LAKE PROVIDENCE, LA — Federal inspectors cited Shady Lake Nursing Home for a 7% medication error rate during a May 2025 health survey, exceeding the 5% federal threshold set by the Centers for Medicare & Medicaid Services. The errors involved two residents whose prescribed medications were simply not available anywhere in the facility.
Prescribed Medications Missing From Facility
During a medication pass observation on May 19, 2025, a Licensed Practical Nurse was observed attempting to administer morning medications to residents. In both documented cases, the nurse reported that the prescribed drugs were not on the medication cart — and confirmed shortly after that the medications were not available anywhere in the facility.
One resident had been prescribed Vitamin D-2 at 400 units daily by their physician. The medication was not on the cart at 7:35 a.m., and by 9:10 a.m., the nurse confirmed it could not be located in the building. The second resident was prescribed Farxiga 10 milligrams daily, a medication used to manage Type 2 diabetes. That drug was also confirmed unavailable at the facility by 9:10 a.m.
Both incidents were classified as errors by omission — meaning the medications were ordered by a physician but never administered because the facility failed to maintain its pharmaceutical supply.
Why a 7% Error Rate Raises Concern
Federal regulations under F-Tag 0759 require nursing homes to maintain medication error rates below 5%. Inspectors calculated the facility's rate by reviewing 27 medication administration opportunities and identifying 2 errors, producing a rate of approximately 7.4%.
While a two-error sample may appear small, the federal standard exists precisely because medication errors in nursing home populations carry outsized risk. Elderly residents in long-term care facilities often take multiple medications with narrow therapeutic windows, and even a single missed dose can set off a chain of clinical consequences.
The missed Farxiga dose is particularly notable from a clinical standpoint. Farxiga (dapagliflozin) is an SGLT2 inhibitor prescribed for blood sugar management in patients with Type 2 diabetes. Missing doses of diabetes medications can lead to hyperglycemia — elevated blood sugar levels — which in vulnerable elderly patients may cause confusion, fatigue, dehydration, and in prolonged cases, diabetic ketoacidosis. Consistent administration is essential for maintaining glycemic control.
The missed Vitamin D-2 dose, while less immediately dangerous in a single instance, reflects the same systemic problem: the facility's pharmacy supply chain failed to ensure that physician-ordered medications were physically present and ready for administration.
A Supply Chain Failure, Not a Dosing Mistake
What distinguishes these errors from a typical medication mix-up is their root cause. These were not cases of a nurse administering the wrong dose or giving medication to the wrong resident. The medications were entirely absent from the facility's inventory. The nurse identified the problem during the pass and reported it, but by that point, the residents had already missed their scheduled doses.
Under standard nursing home pharmacy protocols, facilities are required to maintain adequate supplies of all prescribed medications and to have systems in place — including relationships with pharmacy providers — to ensure timely restocking. When a medication runs out or is not delivered, facility staff are expected to take immediate corrective action, including emergency pharmacy orders.
The fact that two different medications for two different residents were simultaneously unavailable suggests a systemic gap in the facility's medication procurement process rather than an isolated oversight.
Facility Identified and Required to Respond
The facility cited in the inspection operates under the name Cypress at Lake Providence, located at 5976 US-65 North in Lake Providence, Louisiana (federal provider ID: 195585). The survey was completed on May 21, 2025, and the facility is required to submit a plan of correction to the state survey agency.
The deficiency was categorized at a level indicating minimal harm or potential for actual harm, affecting few residents. No immediate jeopardy determination was made.
Families and residents seeking additional detail about the inspection findings or the facility's corrective plan can contact the nursing home directly or the Louisiana Department of Health survey agency. The full inspection report, including all cited deficiencies across 39 pages, is available through CMS and provides a more complete picture of the facility's compliance status.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shady Lake Nursing Home from 2025-05-21 including all violations, facility responses, and corrective action plans.
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