Resident #128 arrived at Albemarle Health & Rehabilitation Center around 2:00 PM on August 1, 2025, with orders for gabapentin 100 milligrams three times daily for nerve pain and sucralfate 1 gram twice daily for ulcers, both related to alcoholic cirrhosis of the liver.
The resident's care plan specifically identified them as at risk for pain, with interventions directing staff to administer medications as ordered and observe for physical indicators of pain.
But Licensed Practical Nurse #15, an agency worker, marked the 9:00 PM doses of both medications with a "9" on the medication administration record — a code meaning "Other / See Progress Notes." No progress notes explained why the medications weren't given.
The pharmacy didn't deliver the resident's medications until 10:04 AM the next morning, August 2. An LPN signed for the delivery at 10:18 AM.
Director of Nursing told inspectors the pharmacy typically delivered medications between 11:00 PM and midnight, with the next delivery the following morning. She said most of Resident #128's medications weren't due until August 2 anyway.
That explanation didn't account for the missed evening doses.
LPN #14 revealed a critical gap during interviews with inspectors. The facility had an automated medication management system containing gabapentin, she said, but "a lot of the agency nurses did not have access to the system."
The Regional Director of Clinical Services confirmed this problem extended beyond just access. After speaking with the pharmacy, she told inspectors that no medication was ever pulled from the automated system for Resident #128.
Inspectors tried repeatedly to reach LPN #15 for comment. They called on September 24 at 12:02 PM and again September 25 at 12:16 PM. No answer. No way to leave a message.
The facility's own policy, revised in August 2020, stated it maintained "sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions."
Gabapentin treats nerve pain, a common complication of liver disease. Sucralfate protects the stomach lining and treats ulcers, another frequent issue for patients with alcoholic cirrhosis.
Both medications were specifically ordered for this resident's liver condition. Both went unadministered on the night of admission.
The inspection found the facility failed to ensure ordered medication was available for administration, violating federal requirements for pharmaceutical services. The violation affected few residents but created potential for actual harm.
Agency nurses present particular challenges for nursing homes. They're brought in to fill staffing gaps but often lack familiarity with facility systems and protocols. At Albemarle, this staffing solution created a medication gap.
The automated medication management system was supposed to provide backup access to essential medications. Instead, it became another barrier when agency staff couldn't use it.
Resident #128's case illustrates how system failures compound. The pharmacy delivery schedule didn't align with admission timing. The automated backup system was inaccessible to temporary staff. And no one documented why prescribed medications for a pain-risk resident went unadministered.
The resident spent their first night at the facility without nerve pain medication for a condition specifically noted in their care plan as requiring pain management interventions.
Federal inspectors completed their investigation on October 25, 2025, finding the facility violated pharmaceutical service requirements designed to ensure residents receive prescribed medications without interruption.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Albemarle Health & Rehabilitation Center from 2025-10-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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