Resident CL1, admitted with a T11-T12 compression fracture, was prescribed Lyrica 25 mg three times daily to treat nerve pain. On November 27, 2025, the resident missed all three scheduled doses at 9:00 a.m., 1:00 p.m., and 9:00 p.m.
Nursing notes documented the problem throughout the day. At 10:39 a.m., staff wrote "Lyrica medication not yet in from pharmacy." Two hours later: "Lyrica medication Not here from pharmacy, not available in Pixis," referring to the automated medication dispensing system.
By 11:07 p.m., nurses were still documenting "Lyrica medication waiting for pharmacy to deliver."
The medication didn't arrive until November 28, causing the resident to miss three consecutive doses. Clinical records show the physician was never notified about the missed medications.
The same resident experienced another medication delay in December. On December 8, a prescribed hydrocodone-acetaminophen tablet for back pain wasn't administered at the scheduled 8:00 a.m. time. Nursing notes show the medication was finally given around 11:15 a.m., more than three hours late "due to unavailability."
Director of Nursing confirmed during a January 2 interview that both medications were unavailable due to pharmacy issues.
The inspection found Park Lane Post Acute failed to ensure pharmaceutical services met residents' needs, specifically failing to make pain medications available for a resident with a spinal fracture. Federal regulations require nursing homes to employ or obtain services from licensed pharmacists to ensure medications are accessible when prescribed.
The facility received a minimal harm citation affecting few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Lane Post Acute LLC from 2026-01-02 including all violations, facility responses, and corrective action plans.