The resident's family discovered the deception on November 27 when facility staff finally revealed that the medication had never been delivered by the pharmacy. The drug was located at a local pharmacy and available for pickup the same day.
Resident 20 required Sevelamer HCl, a medication that removes excess phosphate from the blood in dialysis patients. The physician ordered 800 milligrams three times daily with meals to treat the resident's chronic kidney disease and phosphorus metabolism disorder.
Medication administration records showed a pattern of falsification from November 22 through November 28. On November 22 and 23, nurses marked two of three daily doses as "OS" (see nurses' note) while indicating the 5:00 PM dose was given. All three doses were marked as "OS" on November 24 and 26.
The records showed the medication was administered twice on November 28, the day the resident was transferred to the hospital due to a change in condition.
Nurses' notes for each date consistently stated "Medication not available."
Family Member I told inspectors the former Director of Nursing explained that the medication could not be delivered by the pharmacy. After the family member made a phone call, the medication was located at a local pharmacy and was available for pickup that same day.
Director of Nursing B confirmed during interviews that the facility experienced difficulty obtaining Sevelamer. He stated the Nursing Home Administrator contacted a local pharmacy and obtained the medication the day after the family raised concerns.
"I reviewed the medication cart on November 28 and verified the medication was not in the facility and had not been in-house at any point during the resident's admission," the Director of Nursing told inspectors.
The Director of Nursing confirmed that doses marked as administered on the medication administration record were not accurate, since the medication was never available in the facility.
The resident scored 13 out of 15 on a cognitive screening test, indicating mental intactness. This means the resident was likely aware of missing their prescribed medication regimen.
Missing doses of Sevelamer can worsen metabolic balance in dialysis patients, particularly when combined with poor nutritional intake, potentially contributing to increased confusion and lethargy according to medical literature.
The facility initiated an investigation regarding falsification of the medication administration record. Staff involved received education, according to the Director of Nursing.
The resident was admitted with end-stage renal disease dependent on dialysis and disorder of phosphorus metabolism. Sevelamer is specifically used to treat hyperphosphatemia, or excess phosphate in the blood, in patients with chronic kidney disease who are on dialysis.
The physician's order for the medication was active from admission through discharge. The resident no longer resides at the facility.
Federal inspectors cited the facility for failing to maintain accurate medical records in accordance with professional standards. The violation was classified as minimal harm or potential for actual harm affecting few residents.
The case illustrates how medication documentation failures can mask serious gaps in care for vulnerable residents requiring specialized treatments. The resident's family only learned about the missing medication after nearly a week, despite the facility's knowledge that the drug was unavailable from the start of the admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascade Senior Care Center from 2025-12-30 including all violations, facility responses, and corrective action plans.