The resident, who scored 15 on a cognitive assessment indicating mental clarity, told federal inspectors on Christmas Eve that staff repeatedly said they were waiting for the medication to be delivered from the pharmacy. The patient had been ordered to receive Rivaroxaban 10 milligrams each morning to prevent deep vein thrombosis following joint replacement surgery.
"I went four days without receiving my blood thinner medication in the facility," the resident told inspectors. "I had asked about my blood thinner and one of the nurses told me that they were waiting for the medication to be delivered from the pharmacy."
The patient said they had to continuously ask about the blood thinner because they understood the risks. "I was concerned about getting a blood clot and understand the importance of receiving my blood thinner. Apparently it was not important to them because no one made sure that I received my medication."
Medical records show the resident missed doses on November 22, 24, 25, and 26. Each day, nursing notes documented the same explanation: "waiting for pharmacy delivery," "waiting for medication delivery from pharmacy," or "awaiting medication."
The resident expressed concern about other patients who might not be able to advocate for themselves. "I'm just glad that I'm able to advocate for myself, but what if I was not in the position to advocate for myself? I could have gotten a blood clot."
A licensed practical nurse at the facility told inspectors that missing medications should not happen for days. "If a resident is missing a certain medication, we can usually have the medication pulled from the basement. Otherwise, we can request a rush delivery for a medication," the nurse said. "A resident should not have to go days without a prescribed medication."
The facility's Director of Nursing acknowledged the importance of blood thinners for post-surgical patients. "All medication should be administered as ordered unless the medication is being held per Doctor's order," the director said. "Blood thinner medication is important to prevent blood clots especially after a person has had surgery and has decreased mobility."
The administrator told inspectors that the facility operates a medication dispensing machine that nurses normally use to retrieve medications not available on individual units.
The resident had been diagnosed with multiple conditions including aftercare following joint replacement surgery, presence of an artificial hip joint, polyosteoarthritis, long-term use of anticoagulants, and abnormalities of gait and mobility. The physician had ordered Rivaroxaban from November 21 through December 27 specifically for deep vein thrombosis prevention.
Federal inspectors found that facility policy requires drugs to be administered according to written physician orders and approved protocols. The policy states that orders written by prescribing practitioners must follow approved written protocols.
The inspection, conducted as a complaint investigation on December 24, found the facility failed to ensure appropriate treatment according to physician orders. Inspectors reviewed three residents for medication administration and found problems affecting one patient.
Blood thinners like Rivaroxaban are critical for patients recovering from joint replacement surgery, when reduced mobility increases the risk of dangerous blood clots that can travel to the lungs or brain. The medication works by preventing blood from clotting too easily, reducing the risk of deep vein thrombosis and pulmonary embolism.
The facility's failure occurred despite having multiple backup systems in place, including basement medication storage and rush delivery options that staff acknowledged were available but apparently did not use during the four-day period when the patient went without the prescribed blood thinner.
The resident's case highlights the vulnerability of nursing home patients who depend on staff to administer life-saving medications on schedule, even when backup systems exist to prevent dangerous gaps in treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Lakeland Rehab & Hcc from 2025-12-24 including all violations, facility responses, and corrective action plans.