Resident #1 told federal inspectors in October that she experienced "some confusion with her medications at the facility" following her September admission. She said she didn't know why, but she went without several medications for multiple days, including her Adderall for ADHD, an antibiotic, and Juven wound healing powder.
"All she was told was that they were trying to get the medications from the pharmacy," according to the inspection report. The resident recalled finally receiving her first doses on Monday or Tuesday, September 8th or 9th.
Medical assistant MA A worked with the resident on September 6th and 7th from 6:00 AM to 10:00 PM. She confirmed to inspectors that "it appeared the pharmacy did not deliver all Resident #1's medications," specifically mentioning the resident's Adderall and Juven powder.
The medical assistant said she didn't know why the medications weren't delivered. She believed the previous director of nursing and another nurse had tried contacting the pharmacy during that period.
When inspectors interviewed LVN C, the nurse who admitted the resident, he said he didn't recall who Resident #1 was. "Many residents come and go on the skilled hall," he told investigators.
The nurse explained the standard protocol when medications are missing: contact the physician to see if they could substitute something else. He acknowledged "it was important for the residents to have all their medications to continue their care."
Inspectors attempted to reach LVN B by telephone but were unsuccessful.
The assistant director of nursing revealed she wasn't aware the resident had gone without medications after admission. She only recalled the resident's name but no other details about her stay.
According to the ADON, charge nurses are supposed to enter residents' medications from hospital discharge paperwork when they're admitted and verify those medications with the physician. If medications aren't available, nurses should check the emergency medication kit first.
"If the medications were not in the emergency kit, they were supposed to call the pharmacy and ask for a STAT delivery or call the doctor to see if they could substitute for a different medication," the ADON explained.
She emphasized that having all medications available was crucial "to prevent an adverse event." The Juven powder was particularly important because it's used for wound healing.
The facility's registered director of clinical services said she didn't know how the resident's medications became unavailable for those missing dates. She confirmed that charge nurses were responsible for following up with physicians when they couldn't obtain specific medications.
"She was not able to get any information as to what occurred with Resident #1's missing medications," inspectors noted.
The clinical director stressed it was important for residents to have their medications "to follow the care regime and so there was no lapse in care."
The facility's medication administration policy from November 2017 requires that "upon admission (including readmission) of each Patient/Resident, the physician's orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record."
The previous director of nursing was no longer employed at the facility and couldn't be interviewed during the investigation.
Federal inspectors found the facility failed to ensure the resident received all prescribed medications as ordered by her physician. The violation was classified as causing minimal harm or potential for actual harm, affecting some residents.
The resident told inspectors she didn't recall experiencing unwanted side effects from going without her medications. But the missing drugs included critical treatments: Adderall for managing ADHD symptoms, an antibiotic for fighting infection, and specialized wound healing powder.
Nobody at the facility could explain to investigators why the pharmacy delivery was incomplete or why backup protocols apparently weren't followed to obtain the missing medications more quickly.
The case highlights gaps in medication management during the vulnerable admission period when residents transfer from hospitals to nursing facilities and their medication regimens must be seamlessly continued.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Carlyle At Stonebridge Park from 2025-12-01 including all violations, facility responses, and corrective action plans.
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