The resident at Central Nursing Home told inspectors by phone that twice in September, she didn't receive all her required doses. The missed brimonidine tartrate drops on September 12 and 13 could have increased pressure in her eyes, according to a registered nurse who has worked at the facility for 18 years.
"She does not know why she did not sign the MAR on both days," the nurse told inspectors about the missed 6 a.m. and 10 p.m. doses.
A second resident missed his IV antibiotic three times while battling a serious thumb infection caused by methicillin-resistant staphylococcus aureus. The man's daptomycin doses were skipped on September 28, October 1, and October 2, according to medication records reviewed by the assistant director of nursing.
"He should not miss his antibiotic medication to ensure proper treatment of his infection," the assistant director told inspectors during a December 30 record review.
The resident was eventually transferred to a hospital.
Insurance complications delayed the antibiotic treatment. The facility's nurse practitioner said the pharmacy sent a memo on September 29 stating the patient's insurance wouldn't cover daptomycin without prior authorization. She completed the paperwork that day, but approval never came.
"It was still not approved so she ordered vancomycin as an alternative on 10/2/25 because that was when she was told that daptomycin was not approved," according to the inspection report. The nurse practitioner emphasized the patient "should not miss his antibiotic because it could worsen his infection."
The glaucoma patient, who has anxiety disorder and major depression, was supposed to receive one drop in both eyes every eight hours according to her physician's orders. Her medication record showed clear gaps on consecutive days in September.
Both residents have cognitive scores of 15 on their mental status evaluations. The man with the thumb infection also deals with homelessness and has cardiac implants, making consistent medical care crucial for his complex health needs.
Federal inspectors found the facility's own policies require medications to be "administered in a safe and timely manner, as prescribed." Job descriptions for registered and licensed practical nurses specify they must "carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures."
The 18-year veteran nurse acknowledged the basic protocol during her interview: "The MAR should be signed once medication is given, if MAR is not signed it means the medication was not given." She confirmed working both shifts when the glaucoma patient's eye drops were missed but couldn't explain the oversight.
The missed doses affected two of five residents whose medication administration was reviewed during the complaint investigation. Inspectors classified the violations as causing minimal harm or potential for actual harm.
The antibiotic case revealed systemic problems beyond individual nurse errors. Despite the nurse practitioner's September 29 prior authorization request, the facility continued missing doses while waiting for insurance approval. The gap stretched from September 28 through October 2, when an alternative medication was finally ordered.
The glaucoma patient's experience illustrates how medication errors compound daily challenges for nursing home residents already dealing with multiple chronic conditions. Missing eye pressure medication twice in one month creates unnecessary risk for someone whose vision depends on consistent treatment.
Both cases occurred during routine care periods, not medical emergencies. The missed medications represented failures in basic daily protocols that facilities are required to maintain for all residents, regardless of insurance complications or staffing challenges.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Central Nursing Home from 2026-01-02 including all violations, facility responses, and corrective action plans.