The resident, identified as R20, required Sevelamer three times daily to control dangerous phosphate levels in their blood. The medication prevents excess phosphate buildup in dialysis patients with end-stage kidney disease.
Nobody told the family the medication was missing until November 27.
Medication administration records showed staff marked doses as given on November 22, 23, 25, 27, and 28. But nurses' notes for those same dates consistently stated "Medication not available." The Director of Nursing confirmed to inspectors that doses marked as administered "were not accurate, as the medication was never available in the facility."
Family Member I told inspectors the former Director of Nursing called on November 27 to report that R20 "had not received a single dose of the ordered Sevelamer since admission." The family member said they were told the medication "could not be delivered by the pharmacy."
The medication was available at a local pharmacy the same day.
R20 had been admitted with end-stage renal disease and was cognitively intact, scoring 13 out of 15 on a mental status screening. The resident required 2,400 milligrams of Sevelamer daily with meals — three 800-milligram tablets at breakfast, lunch, and dinner.
On November 22 and 23, staff marked two of the three daily doses with "OS" — meaning "see nurses' note" — while documenting the 5:00 PM dose as given. All three doses were marked OS on November 24 and 26.
The pattern continued through the resident's stay. On November 25, two doses were marked OS while the evening dose appeared administered. November 27 showed one dose as OS, two as given. November 28 reflected two doses as administered.
The resident was transferred to a local hospital the afternoon of November 28 due to a change in condition.
Current Director of Nursing B told inspectors he verified on November 28 that "the medication was not in the facility and had not been in-house at any point during R20's admission." He said the facility "experienced difficulty obtaining Sevelamer" and that the Nursing Home Administrator contacted a local pharmacy after the family raised concerns.
The medication was obtained that same day.
According to the National Center for Biotechnology Information, missing doses of Sevelamer can worsen metabolic balance in dialysis patients, particularly when combined with poor nutritional intake. This deterioration may contribute to increased confusion and lethargy.
DON B told inspectors an investigation was initiated regarding falsification of the medication administration record. Staff involved received education.
The inspection report does not identify which staff members falsified the records or specify what education they received. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
R20 no longer resides at the facility.
Sevelamer works by binding to phosphate in the digestive tract, preventing absorption into the bloodstream. For dialysis patients like R20, the medication is essential because their kidneys cannot filter excess phosphate naturally. Without it, phosphate levels can rise dangerously, affecting bone health and cardiovascular function.
The falsified documentation spanned nearly a week of the resident's care. While nurses noted the medication's absence in their clinical notes, the official medication administration record — the primary document tracking whether residents receive prescribed drugs — showed doses as given.
The family learned about the missing medication only when facility administrators made contact on November 27. By then, R20 had missed at least 15 doses of the prescribed medication over six days.
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.