The resident, suffering from brain cancer, lung cancer, chronic obstructive pulmonary disease and chronic pain, consistently rated her pain between four and six on a scale of ten during the six-day period when staff had no pain medication to give her.
Her doctor ordered Tramadol 50 mg on September 10, but the facility didn't request the opioid pain medication from the pharmacy until September 15. The medication finally arrived September 21.
"I was always in pain due to a bad hip and back," the resident told inspectors. "There were a few days, but I cannot recall the exact dates, sometime over the past week I was told they were out of my pain medication."
She said nurses told her "they were out, and they were trying to make phone calls and get something in to relieve the pain."
"My pain got worse and I felt sick," she said.
Pain assessments documented her suffering throughout the delay. On September 15 at 1:39 a.m., she rated her pain six out of ten. Two days later, she reported six out of ten pain at 2:22 a.m., then again six out of ten that morning at 10:21.
The ratings continued: four out of ten on September 17 at 5:44 p.m., four out of ten the next morning at 1:23 a.m., four out of ten that evening. September 19 brought three separate pain assessments, all rating four out of ten.
By September 20 at 2:24 a.m., her pain had worsened to six out of ten again.
The facility's Director of Nursing confirmed to inspectors that Tramadol was ordered September 15 but not received until September 21, creating a seven-day gap between order and delivery. The DON acknowledged no alternative pain management methods were documented during the resident's suffering.
When inspectors asked why the Tramadol order wasn't sent to the pharmacy when the physician first prescribed it on September 10, the facility was unable to provide an explanation.
The resident also had a prescription for acetaminophen ordered the same day as the Tramadol, but inspection records don't indicate whether this less powerful pain reliever was available or administered during the gap.
Stellar Care Center's own policy, reviewed in August 2022, states that pain management is "based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents' choices related to pain management."
The 35-bed facility violated federal requirements to provide safe, appropriate pain management for residents who require such services. Inspectors found the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and comprehensive care plans.
Federal investigators classified the violation as causing minimal harm or potential for actual harm. The deficiency was investigated under two separate complaint numbers, suggesting multiple concerns about the facility's pain management practices.
The resident's complex medical conditions, including type two diabetes, heart failure and weakness in addition to her cancers, made adequate pain control particularly important for her overall care and quality of life.
Staff documented her pain ratings consistently during the medication gap, creating a clear record of her suffering while unable to provide the prescribed relief. The facility's pharmacy audit report confirmed the timeline of the delayed order and delivery.
The case illustrates how administrative failures in medication ordering can directly impact resident comfort and wellbeing. Despite having a physician's order and a documented need, the resident endured days of preventable pain due to the facility's failure to promptly request her prescribed medication.
The resident's description of feeling sick as her pain worsened demonstrates how untreated pain can cascade into broader health impacts for vulnerable nursing home residents with multiple serious medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stellar Care Center from 2025-09-30 including all violations, facility responses, and corrective action plans.