Resident 305 and Resident 308 at Laurelhurst Post Acute & Rehabilitation both require Medpass 2.0, a liquid nutritional supplement designed for patients who struggle to eat solid food. The facility ran completely out of the supplement from October 24 through October 27, leaving both residents without their prescribed nutrition.
Resident 308 has lived at the facility since September 2014 with dysphagia, a condition that makes swallowing dangerous, and hemiplegia, which causes loss of motor function on one side of the body. A physician ordered 118 milliliters of Medpass 2.0 three times daily between meals in August 2023. Despite normal cognitive function, the resident told inspectors on November 3 that they couldn't recall receiving any nutritional supplement during the four-day shortage.
The dietary manager, Staff 23, submitted an order for Medpass 2.0 on October 24 but administrative approval didn't come through until October 27. She confirmed to inspectors that this three-day delay left both residents without their prescribed supplements.
An LPN working at the facility painted a more troubling picture. Staff 27 told inspectors on October 31 that Medpass 2.0 had been "unavailable just about every day since the transition of ownership." The nurse said she routinely searched throughout the building trying to locate supplies but usually came up empty.
Medical records documented the shortage with clinical precision. Nurses marked "9" on medication administration records for both residents on October 24, 25, 26, and 27. That notation indicates the medication was unavailable, according to the director of nursing services.
Staff 2, the DNS, confirmed on November 3 that neither Resident 305 nor Resident 308 received their prescribed Medpass 2.0 during those four days.
The supplement shortage reveals deeper supply chain problems at the facility. While the dietary manager blamed administrative approval delays for the October shortage, the LPN's account suggests ongoing inventory failures since new ownership took control.
For residents with dysphagia, missing prescribed nutrition supplements isn't merely inconvenient. These patients already face significant challenges maintaining adequate nutrition due to their swallowing difficulties. Medpass 2.0 provides concentrated calories and nutrients specifically formulated for patients who cannot safely consume regular food or beverages.
Resident 305's case mirrors that of Resident 308, with the same four-day gap in prescribed supplements during the same period. Both residents depend on the facility's dietary staff to maintain adequate supplies of their medically necessary nutrition.
The inspection found that basic medication management systems failed during the ownership transition. While facilities routinely face challenges when changing hands, maintaining prescribed treatments for vulnerable residents represents a fundamental responsibility that cannot lapse.
Staff 27's observation about daily shortages suggests the October incident wasn't isolated. The nurse's description of searching the building for supplies indicates systemic inventory problems rather than a single administrative delay.
Federal inspectors documented these failures as part of a complaint investigation completed November 4. The facility's inability to maintain adequate supplies of prescribed nutritional supplements for residents with serious swallowing difficulties represents a breakdown in basic care coordination.
Both residents experienced the same four-day gap in prescribed nutrition during a critical period when the facility should have been ensuring continuity of care despite ownership changes. The dietary manager's admission about approval delays, combined with the LPN's account of ongoing shortages, reveals management failures that directly affected vulnerable residents who depend on specialized nutrition support.
Resident 308 has lived at Laurelhurst for over a decade, relying on the facility to manage complex medical needs including dysphagia and partial paralysis. Missing four days of prescribed nutrition represents a significant care failure for someone already struggling with adequate food intake due to swallowing difficulties.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laurelhurst Post Acute & Rehabilitation from 2025-11-04 including all violations, facility responses, and corrective action plans.
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