The medication gap occurred at Wood Aven Health and Rehabilitation, where federal inspectors found that staff knew the resident's seizure medication wasn't available but took no action to secure a replacement or inform her doctor about the missed doses.
The facility's Director of Nursing told inspectors she was unaware that Resident 1 had missed her scheduled Lyrica for 48 hours. When questioned about proper protocol, the DON said staff should have contacted the pharmacy and notified the physician to request an equivalent medication.
"RN1 should have followed through with the pharmacy and notified the physician about R1's missing dose," the DON told inspectors during the December 23 complaint investigation.
Lyrica is commonly prescribed to prevent seizures and treat nerve pain. Missing doses can trigger breakthrough seizures or withdrawal symptoms in patients who depend on the medication for neurological stability.
The nursing staff responsible for medication administration knew the prescription wasn't available but failed to take the basic steps outlined in the facility's own policies. Those policies require licensed nurses to "report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician."
The same policies mandate that nurses "reorder and crossmatch medications according to facility policy to assure accurate and adequate supply of medications."
None of that happened.
The medication shortage wasn't an isolated incident. The DON revealed that Wood Aven had experienced similar problems with their pharmacy provider not delivering medications on time. The pattern of delayed deliveries became so problematic that the facility terminated its contract with the pharmacy.
"The facility discontinued services with the pharmacy related to similar issues of not receiving medications in a timely manner," the DON explained to inspectors.
Wood Aven switched to a new pharmacy provider on December 1, 2025, just three weeks before the federal inspection. But the medication policies that could have prevented the two-day gap remained unchanged.
The facility's medication monitoring policy, implemented in November 2024, clearly outlines the responsibilities that nursing staff ignored. Licensed pharmacists are supposed to review each resident's medication regimen at regular intervals and "whenever changes in condition that could be related to medications are noted."
The policy states that "irregularities are reported and addressed in accordance with facility policy for medication regimen reviews and addressing irregularities."
But when inspectors asked about the facility's written procedures for requesting and obtaining medications, they discovered a critical gap. The DON admitted that Wood Aven had no written policy governing "the process by which a facility requests and obtains medication."
The absence of clear procurement procedures may explain why nursing staff didn't know what to do when the pharmacy failed to deliver a resident's prescription. Without written protocols, individual nurses were left to make judgment calls about medication shortages.
The December inspection was triggered by a complaint, suggesting that someone — possibly a family member or staff member — reported concerns about medication management at the facility. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
However, the two-day medication gap reveals systemic problems beyond one missed prescription. A facility that lacks written policies for obtaining medications and employs nursing staff who don't follow existing protocols for medication irregularities poses ongoing risks to residents who depend on consistent medication schedules.
The resident who missed her Lyrica doses for 48 hours relied on nursing staff to ensure her medications arrived on time and were administered as prescribed. That basic expectation of nursing home care failed twice — first when the pharmacy didn't deliver, and again when staff didn't respond to the shortage.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wood Aven Health and Rehabilitation from 2025-12-23 including all violations, facility responses, and corrective action plans.