Resident 68 arrived at Best Care Health and Rehabilitation on August 22 needing lactulose solution twice daily. The medication helps prevent constipation, particularly important for elderly patients who may have limited mobility.
Nursing notes from that first day show staff knew about the prescription. At 11:16 a.m., they documented: "lactulose solution 10 grams/15 milliliters give 30 ml by mouth two times daily, awaiting from pharmacy."
The next day brought the same problem. Notes from August 23 at 8:56 a.m. read: "lactulose solution 10 grams/15 ml give 30 ml by mouth two times daily, not available will call the pharmacy for delivery of medication."
But nobody called the doctor.
When federal inspectors interviewed the resident on September 17, he confirmed the medication gap. "When the resident was first admitted he did not receive the medication he takes for his bowels," inspectors noted. The resident said he experienced no adverse effects from missing the doses.
LPN 68, who cared for the patient during those first days, admitted to inspectors that the resident "did not receive scheduled lactulose medication for two days after admission." The nurse said he called the pharmacy about the medication but "was not sure it was documented in nursing notes."
The facility's medication tracking system, called Pixus, keeps some drugs on hand for emergencies. But it didn't have lactulose available, leaving staff dependent on outside pharmacy deliveries.
LPN 21 told inspectors this wasn't an isolated incident. The nurse "confirmed there was a problem getting medications from pharmacy timely especially with admissions." When residents missed medications, facility procedure required staff to call the pharmacy, notify the nurse practitioner or physician, and document everything.
None of that happened for Resident 68.
The facility's Director of Nursing confirmed to inspectors that the resident "did not receive the medication lactulose for three days after admission." More significantly, the DON "confirmed there was no documentation in the nursing progress notes the physician or NP were notified."
This violated the facility's own policy. Best Care's medication administration guidelines, effective since June 2017, specifically required nurses to "contact the pharmacy and document accordingly" when medications were unavailable.
The nurse practitioner, who happened to be on site during the September inspection, told investigators that Resident 68 "had no adverse effects from missing the medication." But that assessment came weeks after the fact, not during the critical first days when the patient needed the prescribed treatment.
LPN 21 mentioned that the facility "was working on a new pharmacy," suggesting ongoing problems with their current medication supplier. For newly admitted residents, who often arrive from hospitals with complex medication regimens, these delays can be particularly problematic.
Lactulose is commonly prescribed for elderly nursing home residents who may struggle with constipation due to limited activity, certain medications, or underlying health conditions. Missing doses for three consecutive days could potentially lead to discomfort or more serious complications, though this particular resident reported no problems.
The inspection found that staff knew about the missing medication from day one but failed to follow their own protocols for handling the situation. Instead of immediately notifying medical providers about the unavailable drug, nurses simply waited for a pharmacy delivery that took three days to arrive.
Federal inspectors classified this as a medication administration violation affecting few residents with minimal harm. The deficiency fell under a broader complaint investigation numbered 2603203, suggesting other issues may have prompted the September inspection.
When inspectors observed Resident 68 on September 17, they noted "no concerns related to not receiving medication upon admission." But the case highlighted systematic problems with the facility's medication management and communication protocols.
The three-day delay represents exactly the kind of breakdown that federal regulations are designed to prevent. Nursing homes must ensure residents receive prescribed medications promptly, especially during the vulnerable transition period following admission.
For Resident 68, the oversight meant starting his stay at Best Care without a medication his previous doctors had deemed necessary. While he suffered no apparent harm, the incident exposed gaps in the facility's systems that could affect other residents facing similar pharmacy delays.
The facility's acknowledgment that they were "working on a new pharmacy" suggests management recognized the problem. But for residents like Patient 68, that solution came too late to prevent missed medications during their first critical days of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Best Care Health and Rehabilitation from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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