The Centers for Medicare and Medicaid Services found four problems with medication administration at Wekiva Springs. First, a patient was given 4 eye drops in one eye when she was supposed to receive only one drop. Second, a nurse dropped papers on the floor while pouring medications, picked them up and did not wash her hands before returning to the task, which created an infection control issue. Third, two out of five patients sampled were allowed to self-administer drugs from home without a physician’s order, instruction in correct usage or reminders. One patient was using three different inhalers and a bottle of liquid Lidocaine without proper help from nurses. Finally, the facility’s monthly medication room inspections had not been effective, and three expired medications were found in a medication room.