The resident told federal inspectors in September that he didn't receive his lidocaine patch roughly one day out of every five. He said he believed staff were intentionally withholding other medications from him as well.
"He said he felt neglected because he did not get his medication," inspectors wrote after interviewing the resident on September 22.
Medical Assistant B admitted to investigators that she had asked the resident if he wanted only one patch instead of his prescribed two "to make them last longer." The facility's pharmacy wasn't sending the lidocaine patches, though she couldn't explain why.
The medication shortage had persisted for an extended period. Staff sometimes purchased replacement patches from a discount store when they ran out of the prescribed supply.
"She said everyone knew about it, the ADON, DON, and the nurses," inspectors documented. The medical assistant said she informed nurses about the shortage, and "they would get some into the facility, but they would run out quickly."
When the facility's medication administration records showed the number 8 next to a resident's medication, it meant "pending delivery" and that the medication wasn't given because the facility didn't have it in stock.
Licensed Vocational Nurse D confirmed that medical assistants had notified the Director of Nursing about the lidocaine patch shortage "one or two times." The pharmacy had told her the patches were an over-the-counter medication that required a special consent form before they could be automatically delivered to the facility.
She thought she had mentioned this requirement during a morning staff meeting, though she couldn't remember who attended.
"She said it was the responsibility of everyone on the team to make sure that all of the medications for residents were in the building," inspectors noted.
The Director of Nursing acknowledged the medication availability problem during his interview. He confirmed that the resident sometimes received only one patch instead of his prescribed two, calling this "not good medication administration."
Blank spaces on medication administration records meant "the medication was not given or was skipped," he explained to inspectors.
The DON said he saw no documentation indicating that the nurse practitioner had been informed about the lidocaine patch shortage. Facility policy required staff to notify the medical doctor or nurse practitioner, along with the responsible pharmacist, whenever medications weren't available.
"He said all steps and phone calls should be documented in the residents' progress notes," inspectors wrote.
The consequences for the resident were clear to staff. The medical assistant said the possible negative effect of not receiving lidocaine patches "would be that he was in pain."
The Licensed Vocational Nurse agreed that the resident "could have been in pain" without his prescribed medication.
The Director of Nursing provided a more technical explanation, telling inspectors that missing doses meant "the medication did not sustain its sufficiency to maintain the efficiency of the medication or the effects of the medications."
More directly, he said the negative effect for this specific resident was "that he would not get the desired pain management."
The facility's Administrator confirmed during her September 23 interview that the Director of Nursing was responsible for ensuring medications were properly stocked, administered and documented. She acknowledged that residents could "experience pain" when they didn't receive prescribed medications.
"She said if the doctor ordered the medications, Resident #3 needed to be administered the medications," inspectors documented.
The facility's own policies supported this expectation. Nursing policies and procedures from June 2019 stated that the facility would "implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements."
The policy designated the facility's Medical Director as having "an active role in the oversight of medication management."
Yet the resident continued going without his prescribed pain medication while staff improvised solutions. The medical assistant's offer to give him one patch instead of two represented a unilateral change to his prescribed treatment plan.
The practice of purchasing over-the-counter replacements from a discount store raised questions about medication consistency and proper documentation. Staff acknowledged knowing about the shortage but failed to implement systematic solutions.
The Director of Nursing's admission that he saw no evidence the nurse practitioner was informed about the medication shortage violated the facility's own protocols. The policy required notification of prescribing physicians when medications weren't available.
Multiple staff members understood their responsibility to ensure medications were available for residents. The medical assistant said the Director of Nursing was responsible. The Licensed Vocational Nurse said it was "everyone on the team." The Director of Nursing said it was "the person giving the medications." The Administrator confirmed it was the Director of Nursing's responsibility.
Despite this shared understanding, the system failed repeatedly. The resident's 20 percent medication miss rate represented a significant gap in basic care.
The lidocaine patches were prescribed for pain management, making each missed dose a potential source of unnecessary suffering. The resident's statement that he felt "neglected" captured the human impact of the facility's medication management failures.
Staff knew the consequences. They knew their responsibilities. They knew the resident was going without prescribed pain relief.
The resident continued to experience pain one day out of every five while staff debated whose job it was to fix a problem they all acknowledged existed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At the Oak from 2025-11-21 including all violations, facility responses, and corrective action plans.