The resident, identified as R2 in the October inspection report, missed doses of three prescribed medications between September 18 and September 21. The missed medications included nateglinide for diabetes management, pregabalin for nerve pain, and D-Mannose, a supplement used for various health conditions.
R2 had been admitted to the facility following left knee replacement surgery and was diagnosed with diabetes, osteoarthritis, and cellulitis. Mental status testing showed the resident had intact cognition and was responsible for their own healthcare decisions.
The medication failures began September 18, when R2 missed the 9:00 PM dose of nateglinide because the drug was unavailable. The next day brought a complete medication blackout. R2 received none of the three daily nateglinide doses scheduled for 9:00 AM, 2:00 PM, and 9:00 PM. The resident also missed all three pregabalin doses and the morning D-Mannose supplement.
On September 20, the facility changed R2's nateglinide prescription from 120 mg tablets to 60 mg tablets, but the medication problems persisted. R2 missed the morning nateglinide dose, then missed the noon and 5:00 PM doses of the new prescription. Two more pregabalin doses went unadministered.
The pattern continued September 21, when R2 missed the noon nateglinide dose.
Federal inspectors reviewed a medication audit report that documented each missed dose with the same explanation: "medication was unavailable." The facility's own policy, dated May 2025, requires medications to be administered "in a safe and timely manner and as prescribed" and within one hour of their scheduled time.
Director of Nursing B told inspectors on October 8 that when the pharmacy fails to deliver a medication, staff should call with a "stat" or immediate order to obtain the drug promptly. The nursing director acknowledged this is standard procedure when medications are missing.
No evidence in the inspection report indicates staff made such emergency calls during the four-day period when R2's medications were unavailable.
Nateglinide is prescribed specifically for type 2 diabetes management and helps control blood sugar levels. Missing multiple doses over several days can lead to dangerous blood sugar spikes. Pregabalin, an anticonvulsant medication used for nerve pain, requires consistent dosing to maintain effectiveness.
The facility's medication administration policy explicitly states that drugs "must be administered in accordance with the orders, including any required time frames." The policy makes no exceptions for pharmacy delivery failures.
R2's case illustrates a breakdown in the medication management system that nursing homes are required to maintain. Federal regulations mandate that facilities either employ licensed pharmacists or contract for pharmaceutical services to meet each resident's medication needs.
The inspection found that Samaritan Nursing and Rehab failed to provide adequate pharmaceutical services for R2, despite having policies in place that should have prevented the medication gaps. The facility's own audit system documented each missed dose but apparently triggered no corrective action during the four-day period.
R2's medical record showed physician orders dating back to September 18 for all three medications. The D-Mannose was ordered as a morning supplement, while nateglinide was prescribed three times daily and pregabalin was ordered for three daily doses to manage nerve pain.
The inspection classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. However, the systematic nature of the medication failures over multiple days suggests problems with the facility's pharmaceutical services that could affect other residents.
Inspectors found the facility violated federal requirements for providing pharmaceutical services to meet residents' needs. The violation occurred despite having a licensed pharmacy arrangement and written policies governing medication administration timing and procedures.
The medication audit report reviewed by surveyors covered September 18 through September 25, suggesting the facility has systems to track missed doses. However, the tracking system apparently failed to trigger the emergency procedures that the Director of Nursing described as standard practice when medications are unavailable.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Samaritan Nursing and Rehab from 2025-10-16 including all violations, facility responses, and corrective action plans.