The nurse, identified as LPN #1 in the October inspection report, told state investigators that the Breo Ellipta inhaler "was never sent by the pharmacy" and the Triamcinolone cream "took a while." She said she thought she called both the pharmacy and the physician when the medications weren't available.
But she couldn't recall what the physician told her to do.
LPN #1 acknowledged she was supposed to document these conversations in the resident's progress notes. She didn't. State inspectors found no record that she had contacted the pharmacy about the missing medications.
The nurse said there were no backup medications available at CareOne at The Highlands and staff had to wait until the pharmacy delivered the ordered drugs. For this resident, that meant going without a prescribed inhaler and topical steroid for an undetermined period.
The Director of Nursing painted a different picture when inspectors interviewed her the same day. She said backup medications were available at the facility, though not inhalers or steroid creams specifically.
The director explained that when medications weren't available, nurses should call the physician for follow-up orders. The doctor might prescribe a similar available medication or issue a physician's order to hold the original medication until the pharmacy could deliver it.
She said the pharmacy should also be contacted to verify delivery. All of this should happen "the first time a medication was not available" and be documented in the progress notes.
The director described a common scenario that illustrated the problem. When she received a new admission during the 3 PM to 11 PM shift, medications typically wouldn't arrive until noon or 1 PM the next day. The physician should be aware of this timing, she said, and a physician's order would indicate when to start the medication.
Inhalers presented particular challenges because no backup inhalers were available in the facility. But the physician might order something different, nurses could reach out to the family, or a physician's order could indicate holding the medication until the pharmacy delivered the inhaler.
When inspectors and the Director of Nursing reviewed the electronic medication administration record for the resident, she acknowledged there should not be continued documentation showing a medication was unavailable. There should have been documentation showing whether the pharmacy and physician were notified.
The facility's own policy, revised in April 2019, states that medications are administered "in a safe and timely manner, and as prescribed." The policy was provided by the Director of Nursing during the inspection.
The inspection report doesn't specify how long the resident went without the prescribed medications or what health impact, if any, resulted from the delays. Breo Ellipta is typically prescribed for chronic obstructive pulmonary disease and asthma, while Triamcinolone is a topical steroid used to treat various skin conditions.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. But it highlighted a breakdown in the basic systems nursing homes use to ensure residents receive their prescribed medications on schedule.
The case revealed a gap between what the facility's leadership said should happen when medications don't arrive and what actually occurred on the floor. While the Director of Nursing described clear protocols for handling missing medications, the licensed practical nurse either didn't follow them or failed to document that she had.
The resident's electronic medication record became a chronicle of missed doses rather than a record of the facility's efforts to resolve the problem. Each entry showing the medication wasn't available should have triggered the response the director described - calls to the pharmacy and physician, documentation of those conversations, and follow-up orders to address the gap in care.
Instead, inspectors found a nurse who couldn't remember what the physician had told her to do and no written record that she had made the calls she thought she had made. The facility's own policies required both the action and the documentation, but neither happened reliably.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At the Highlands from 2025-10-23 including all violations, facility responses, and corrective action plans.