Resident 5 was ordered to receive 500 milligrams of Naproxen twice a day starting July 1. The non-steroidal anti-inflammatory medication was prescribed by a physician for a resident who required partial to moderate assistance with daily care needs and already received routine pain medication, according to a July 7 assessment.
But medication records for August showed gaps. No documentation existed that the resident received the 6:00 p.m. dose on August 6. The evening dose was missed again on August 9.
August 21 was worse. The resident missed both the 9:00 a.m. dose and the 6:00 p.m. dose.
Four days later, it happened again. No Naproxen at 9:00 a.m. on August 25. No dose at 6:00 p.m. either.
On August 27, the morning dose was skipped once more.
The Director of Nursing confirmed the violations during a September 5 interview with state inspectors. He acknowledged that Resident 5 did not receive the Naproxen on any of those dates and times, despite the physician's clear orders.
The nursing director explained that Naproxen was stocked in the facility's emergency medication box. He noted it was an over-the-counter medication that could be obtained as stock medication, suggesting the facility had ready access to the drug when needed.
Federal inspectors found the facility failed to follow physician's orders for one of eight residents they reviewed during their complaint investigation. The violation occurred despite the resident's documented cognitive impairment and need for assistance with basic care.
Naproxen is commonly prescribed to reduce inflammation and manage pain, particularly important for elderly residents who may have arthritis or other conditions causing chronic discomfort. For someone already receiving routine pain medication, missing additional prescribed doses could mean prolonged suffering.
The facility's medication administration record served as the primary evidence of the missed doses. These records are supposed to document every time a resident receives prescribed medication, creating a paper trail that ensures continuity of care and regulatory compliance.
State inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The finding was part of a complaint investigation completed September 5, suggesting someone had raised concerns about care at the 119 Industrial Park Road facility.
The missed medications occurred over a three-week period, indicating a pattern rather than isolated oversights. The gaps included both morning and evening doses, suggesting problems with medication administration across different shifts.
For Resident 5, the cognitive impairment documented in the July assessment meant relying entirely on staff to ensure proper medication administration. Residents with cognitive issues cannot advocate for themselves or remind staff about missed medications.
The facility's explanation that Naproxen was available as stock medication raises questions about why doses were still missed. Having medication readily available in an emergency box should theoretically prevent gaps in administration, yet the resident went without prescribed pain relief multiple times.
Federal regulations require nursing homes to provide appropriate treatment and care according to physician orders and resident preferences. The violation at Greene Health & Rehab Center demonstrates how seemingly simple medication administration can fail, particularly for vulnerable residents who depend on staff for basic needs.
The inspection found problems with medication management despite the facility having systems in place, including emergency medication supplies and documentation requirements. The nursing director's acknowledgment of the violations suggests the facility recognized the failures after they were identified.
For Resident 5, each missed dose represented time spent in potentially preventable discomfort, compounded by an inability to understand or communicate about the missing medication due to cognitive impairment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greene Health & Rehab Center from 2025-09-05 including all violations, facility responses, and corrective action plans.