The resident at East Park Care Center told federal inspectors she had to call her own physician to get help after facility staff ignored her repeated complaints about the infection she knew would develop from antibiotic treatment.
"She got a yeast infection every time she was on an antibiotic," according to the October inspection report, "but they did not do anything so she called her doctor."
The 48-bed facility's medication failures affected a cognitively intact resident who served as her own responsible party and clearly understood her medical needs. She had been admitted with multiple diagnoses including Parkinson's disease, dementia, and major depressive disorder.
Her ordeal began March 12 when she complained to staff about vaginal pain and burning that kept her awake most of the night. No one notified the physician.
For 12 days, the resident continued experiencing discomfort while staff documented nothing about her complaints or any attempts to address them.
On March 24, the facility's nurse practitioner finally examined the resident and ordered miconazole antifungal cream for seven days to treat the vaginal itching. The resident had managed to get the doctor's attention herself.
Then the medication problems began.
Staff couldn't give the resident her prescribed cream on March 24, 26, 27, or 29 because "it was not available," according to medication records. Pharmacy delivery sheets from the entire month of March showed no evidence the miconazole cream was ever delivered to the facility.
The resident remained untreated for her yeast infection while the cream sat somewhere other than where it needed to be.
By April 4, nearly a month after her initial complaint, the resident was still suffering vaginal discomfort. She told staff directly: "she had a yeast infection." The nurse practitioner ordered a different approach — one dose of Diflucan oral medication and Monistat vaginal cream for seven days.
When inspectors interviewed the resident in October, she described the facility's systematic failure to respond to her medical needs.
"She had told the nurses several times she had vaginal itching and it was from the antibiotic," the inspection report states. The resident explained she "never got the cream because the staff could never find it."
Licensed Practical Nurse #300 admitted during interviews that she wasn't sure why the resident didn't receive her medication. The nurse confirmed the documentation showed the resident first complained March 12, but "the physician was not notified until March 24 by the resident herself."
The nurse said she would investigate why the cream wasn't delivered.
The facility's administrator revealed a striking detail about the medication mix-up. Because miconazole was available over-the-counter, staff had gone out and purchased it for the resident's use. But this apparently happened much later in the timeline.
"The previous Administrator went out and purchased it," the current administrator told inspectors, though she couldn't explain why the medication administration records still showed gaps in treatment on multiple dates.
The administrator confirmed there was no documentation the medication was given on March 24, 26, 27, or 29 — a span when the resident was supposed to receive daily treatment for her infection.
East Park Care Center's own medication policy, dated April 28, states that "medications would be administered in a safe and timely manner and as prescribed."
The facility's approach to the resident's yeast infection violated both parts of that standard. The treatment was neither safe — leaving an infection untreated for weeks — nor timely, with a 12-day delay before even notifying a physician.
For a cognitively intact resident who understood her own medical patterns and tried repeatedly to communicate her needs, the facility's response demonstrated a fundamental breakdown in basic nursing care. She knew from experience that antibiotics would trigger a yeast infection, told staff about her symptoms as they developed, and ultimately had to bypass the facility's care system entirely to get medical attention.
The resident spent weeks in unnecessary discomfort because staff couldn't manage the simple task of obtaining and administering an over-the-counter antifungal cream. Her case illustrates how medication management failures can leave even the most self-aware residents vulnerable to prolonged suffering in facilities that fail to follow their own policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Park Care Center from 2025-10-14 including all violations, facility responses, and corrective action plans.