Resident 20 was admitted with end-stage renal disease and a disorder of phosphorus metabolism. The patient scored 13 out of 15 on a cognitive screening test, indicating mental clarity. Doctors ordered Sevelamer HCl, taken three times daily with meals to prevent dangerous phosphate buildup in dialysis patients.
The medication was never available in the facility.
From November 22 through November 28, staff marked doses as "administered" on the medication record while writing "medication not available" in nursing notes. On November 22 and 23, two of three daily doses were marked as given. Staff documented administering the 5:00 PM dose both days.
All three doses were marked as administered on November 24.
Two doses were documented as given on November 25. Staff marked the evening dose as administered while noting the morning and afternoon doses were unavailable.
The pattern continued through November 26, when all three doses were marked as unavailable, and November 27, when staff documented giving two of three doses.
On November 28, staff marked two doses as administered on the medication record.
The family discovered the deception on November 27. Family Member I told inspectors the facility informed her that day that Resident 20 "had not received a single dose of the ordered Sevelamer since admission." The former Director of Nursing blamed the pharmacy, saying the medication could not be delivered.
After a phone call, the medication was located at a local pharmacy and available for pickup the same day.
Resident 20 was transferred to the hospital on the afternoon of November 28 due to a change in condition.
Director of Nursing B confirmed during the inspection that doses marked as administered were "not accurate, as the medication was never available in the facility." The director stated he reviewed the medication cart on November 28 and verified the drug had not been in the facility "at any point during R20's admission."
The nursing home administrator contacted the local pharmacy and obtained the medication the day the family raised concerns.
According to the National Center for Biotechnology Information, missing doses of Sevelamer, particularly when combined with poor nutritional intake, worsen metabolic balance and may contribute to increased confusion and lethargy in dialysis patients.
Director of Nursing B told inspectors an investigation was initiated regarding falsification of the medication record and staff involved received education.
The falsified documentation occurred over seven consecutive days while the cognitively intact patient went without medication designed to prevent dangerous phosphate accumulation. The drug was available at a local pharmacy throughout the period but was never obtained until the family intervened.
Federal inspectors found the facility failed to maintain accurate medical records in accordance with professional standards. The violation affected few residents but carried potential for actual harm.
Resident 20 no longer lives at the facility.
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.