The September incident involved a patient who takes Percocet four times daily for pain management through a specialized clinic. Staff discovered the medication shortage on September 25 but didn't secure a replacement until the morning of September 26.
"I was worried I was going to withdraw," the resident told state inspectors during an October interview. She explained that her longest normal gap between doses is six hours overnight, making the 30-hour period without medication particularly distressing.
The facility had recently switched to a new pharmacy, which staff cited as contributing to the confusion. An anonymous staff member confirmed the transition became official within the month prior to the incident and said they "had an issue with narcotics."
According to the staff member, they believed the narcotic medications were supposed to arrive in one shipment, but when that shipment came, the Percocet wasn't included. Staff were also unable to access emergency stock to bridge the gap.
Medication records show the complexity of the resident's pain management regimen. She was prescribed two different Percocet formulations: a 7.5-325 mg tablet four times daily for regular pain control, plus a separate once-daily dose at 2 a.m. The resident received her 2 a.m. dose on September 25 but then missed every subsequent scheduled dose.
Her regular doses were supposed to be administered at 8 a.m., noon, 4 p.m., and 8 p.m. on September 25. None were given. She also missed her 2 a.m. dose on September 26.
The facility's physician placed a temporary order on September 26 at 9:01 a.m. for Ultram 50 mg every four hours for seven days "until supply arrives of Percocet for pain clinic order." The resident was aware of this substitution, according to nursing notes.
But the communication breakdown extended beyond the facility walls. Pain clinic staff revealed they received a voicemail from Dixon Healthcare on September 24 at 4:29 p.m. requesting the resident's pain medication. Because the call came after hours, it went to voicemail and wasn't retrieved until September 25.
The pain clinic didn't send the prescription to the pharmacy until September 26. Records show the resident's pain medication had last been called in on September 5, more than three weeks earlier.
This wasn't the first time the resident experienced medication delays. She told inspectors "this has happened before" and that staff promised they would start ordering her pain medication seven days before it runs out "due to the frequency she takes it."
During the 30-hour gap, staff offered to send the resident to the hospital, but she declined, not feeling it was necessary despite her concerns about withdrawal.
The Director of Nursing confirmed the timeline during an October 7 interview with state inspectors. The resident's last dose was administered at 2 a.m. on September 25, and she didn't receive medication again until 9 a.m. on September 26.
Federal regulations require nursing homes to ensure each resident receives their medications as prescribed by their physician. The failure to maintain adequate medication supplies represents a breakdown in the coordination between the facility, its new pharmacy, and the resident's pain management clinic.
The resident's fear of withdrawal symptoms highlights the particular vulnerability of patients on controlled substances for chronic pain management. Missing multiple doses of opioid medications can trigger physical withdrawal symptoms, making proper inventory management and pharmacy coordination critical for patient safety and comfort.
State inspectors classified the violation as causing minimal harm with few residents affected, but noted it represented non-compliance investigated under a formal complaint. The inspection was prompted by concerns raised about the facility's medication management practices.
The incident occurred during what staff described as a transition period with their new pharmacy arrangement, suggesting systemic issues with how the facility manages controlled substances during operational changes. The resident's experience illustrates how administrative problems can directly impact patient care and comfort.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dixon Healthcare Center from 2025-11-17 including all violations, facility responses, and corrective action plans.