The Timbers of Jasper sent Resident B home on September 19 with medications belonging to a different patient, according to federal inspection records. The facility spent six days trying to contact the resident's family to retrieve the wrong drugs.
Resident B had been recovering from a fractured right lower leg and required substantial assistance with basic activities like toileting and transfers. Their physician had ordered enoxaparin, a blood thinner administered by injection, starting September 5.
But the medication wasn't available when nurses needed it.
The resident's medication administration record showed enoxaparin was marked "unavailable" on September 14 and 15, with a note about "awaiting delivery" on the 15th. It was unavailable again on September 16. On September 18, the day before discharge, the medication record was left blank with no explanation.
The facility had an Emergency Drug Kit machine stocked with the exact medication Resident B needed. When inspectors observed the machine in January, it contained enoxaparin 30 mg syringes. Licensed Practical Nurse 5 told inspectors the machine was kept stocked and that pharmacy would restock within a day if supplies ran low.
Despite having the medication available on-site, Resident B never received the prescribed blood thinner during those final days.
On discharge day, Licensed Practical Nurse 3 signed off that Resident B was "discharged home with all medications." The facility's own policy required two nurses to verify discharge medications and both sign the summary form.
Only one nurse signed.
The Administrator provided inspectors with an incident report showing the medication mix-up was discovered after Resident B had already left. Staff called the resident's representative "several times daily" starting September 19, but couldn't reach anyone until September 25.
The wrong medications were finally returned to the facility that same day, six days after the botched discharge.
LPN 3, who handled Resident B's discharge, no longer works at the facility, the Director of Nursing told inspectors. When asked about discharge procedures, current staff described a two-nurse verification system that clearly wasn't followed in this case.
The facility's medication administration competency form, last updated in April, states medications "should be administered as ordered." Resident B's case violated this basic standard twice - first by failing to give prescribed blood thinners when they were available on-site, then by sending the wrong medications home entirely.
Resident B had no cognitive impairment according to their September assessment, meaning they would have been fully aware their prescribed medications weren't being given as ordered. The blood thinner was discontinued the day of discharge, but only after multiple missed doses in the days leading up to their departure.
The inspection found the facility failed to meet pharmaceutical service requirements for residents. Federal investigators noted minimal harm occurred, but the potential for actual harm was clear - blood thinners prevent dangerous clots, and medication mix-ups can have serious consequences when patients take drugs not prescribed for them.
The facility's Emergency Drug Kit contained the exact medication Resident B needed during those final days, yet staff marked it unavailable and left administration records blank instead of using available supplies.
Resident B's representative eventually retrieved the wrong medications and returned them after nearly a week, but the incident highlighted systemic failures in both medication administration and discharge procedures at the Jasper facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timbers of Jasper The from 2026-01-30 including all violations, facility responses, and corrective action plans.