Federal inspectors found that Cherrelyn Healthcare Center ran out of multiple medications for Resident #2 throughout November and December 2025, creating gaps in treatment that lasted up to six days.
The most serious lapses involved Xifaxan, an expensive medication used to treat bacterial infections and hepatic encephalopathy. The resident missed evening doses on November 24 and 25 when the facility's 14-day supply ran out and staff had not yet ordered a refill. Nursing notes documented the medication was "not available in the facility and was on order from the pharmacy."
But the facility had options it didn't use.
The resident's representative had brought in 30 to 60 pills of Xifaxan when the resident was admitted and again on November 5. Registered Nurse #1 told inspectors the nursing staff "would have administered the medication Resident #2's representative brought into the facility if the facility did not have the medication stocked."
They didn't. The nursing home administrator said he "did not know why the nursing staff had not provided the evening medication doses to the resident from the family provided medications on November 24 and 25."
The medication gaps continued in December. The resident missed both doses of Xifaxan on December 12 and 14, and one of two doses on December 13. Again, nursing notes blamed pharmacy delays.
Other medications went missing too. The resident was prescribed lotilaner ophthalmic solution, an anti-parasitic eye drop, to be administered twice daily. She missed doses on November 5, 6, 7, 15, 25, and 30 because the medication wasn't delivered from the pharmacy.
On December 12, she missed her midodrine, a medication used to prevent low blood pressure.
The physician's assistant who worked with the resident told inspectors that Xifaxan was "a difficult medication to get insurance approval for because it was expensive." When the facility runs out of a medication, she said, nursing staff was supposed to notify the provider on duty.
That didn't happen either. The physician's assistant said "there was no record of the provider group being notified when Resident #2 did not receive her Xifaxan on November 24 and 25."
The facility's medication management revealed a pattern of poor planning. Pharmacy records showed the facility filled a 14-day supply of Xifaxan on November 6, which would have lasted through November 20. The next refill didn't arrive until November 26, creating a six-day gap.
The administrator acknowledged the timing problem. He said the facility asked for a refill on November 24, four days after the previous supply was exhausted, and the medication was delivered two days later.
Throughout the inspection period, the facility had backup medication available from the family but repeatedly failed to use it. The administrator confirmed that "Resident #2's family brought in medication from home for the facility to use" and said "the nurses probably administered Resident #2's home medication during the time the facility did not have the medication from the pharmacy."
The medication administration records told a different story. They documented multiple missed doses with nursing notes citing unavailable medications, not successful administration of family-provided supplies.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to few residents. But for Resident #2, the gaps in hepatic encephalopathy treatment and other medications created unnecessary health risks during a vulnerable period of nursing home care.
The inspection was conducted on December 30, 2025, in response to a complaint about the facility's medication management practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cherrelyn Healthcare Center from 2025-12-30 including all violations, facility responses, and corrective action plans.