Woodstock Valley Health and Rehabilitation could not provide Ziprasidone, prescribed for schizophrenia, and Flomax, prescribed for prostate enlargement, to Resident 7 on multiple dates between July and September 2025. The medications were simply not in the facility's medication carts or backup supply machine.
The resident had been prescribed Ziprasidone 60 milligrams twice daily since March 14, taking one capsule each morning and at bedtime. He also received Flomax 0.4 milligrams once daily since May 6 for an enlarged prostate gland.
Medication administration records showed the morning Ziprasidone dose was missing on July 21, 22, 23, 24, and 26, plus August 11. The bedtime dose was unavailable on July 21, 22, 23, 24, 26, and 28, as well as September 15, 16, 17, and 18.
The daily Flomax dose was not given on July 21, 22, 23, 24, 26, and 27, and again on August 11.
Licensed Practical Nurse 2 explained to inspectors on September 24 that nurses document medication administration by marking it on the medication administration record. When asked the following day about procedures when medications are unavailable, the nurse said staff should first check the Omnicell machine that contains various backup medications.
If the needed drug is not in the Omnicell, nurses should contact the pharmacy, the nurse told inspectors.
But neither Ziprasidone nor Flomax were available in the facility's Omnicell machine, inspectors confirmed by reviewing the supply list.
The gaps in medication delivery occurred repeatedly across a two-month period. For Resident 7's morning Ziprasidone alone, the medication was unavailable on six separate days. His bedtime dose was missing on ten different dates.
Ziprasidone is an antipsychotic medication used to treat schizophrenia and bipolar disorder. Suddenly stopping the medication can cause withdrawal symptoms and potentially worsen psychiatric conditions. Flomax helps men with enlarged prostates urinate more easily by relaxing muscles in the prostate and bladder neck.
The inspection records show no explanation for why the medications were unavailable or what steps staff took to obtain them during the extended periods when doses were missed. The facility's executive director was notified of the medication availability problems on September 25 at 4:59 p.m.
Federal regulations require nursing homes to ensure each resident receives the correct medications at the right times. Facilities must maintain adequate medication supplies and have systems in place to prevent interruptions in prescribed treatments.
The medication failures affected what inspectors classified as "some" residents, though the report details problems only for Resident 7. Inspectors rated the violation as causing "minimal harm or potential for actual harm."
No information was provided about whether the facility had addressed the medication supply problems or implemented new procedures to prevent future gaps in essential treatments. The inspection was completed on September 26, one day after administrators were made aware of the concerns.
The medication administration records that documented the missing doses span from July through September, indicating the supply problems persisted for months without resolution. Each missed dose represented a failure in the facility's medication management system.
For a resident with schizophrenia, consistent medication adherence is critical for managing symptoms and preventing psychiatric episodes. The repeated unavailability of both psychiatric and urological medications suggests broader issues with the facility's pharmaceutical supply chain and staff protocols.
The inspection found that basic nursing procedures for obtaining unavailable medications were not followed, despite the nurse's knowledge of the correct steps. Staff knew they should check backup supplies and contact the pharmacy, but the medications remained unavailable across multiple shifts and weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodstock Valley Health and Rehabilitation from 2025-09-26 including all violations, facility responses, and corrective action plans.
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