The Carlyle At Stonebridge Park

some confusion with her medications at the facility.

The resident said she did not know why, but she did not get some of her medications for a few days.

She stated she did not recall how many, but it included her antibiotic, wound healing powder, and medications for her ADHD. Resident #1 said all she was told was that they were trying to get the medications from the pharmacy.

She recalled she got the first doses on Monday or Tuesday (09/08/25-09/09/25). Resident #1 further stated she did not recall having any unwanted side effects as a result.

Interview on 10/16/25 at 1:21 PM, MA A revealed she worked with Resident #1 on 09/06/25 and 09/07/25 from 6:00 AM to 10:00 PM. MA A said it appeared the pharmacy did not deliver all Resident #1's medications.

She stated some of those medications included the resident's Adderall and Juven.

She stated she did not know why the medications did not get delivered. MA A stated she thought the previous DON and LVN B had attempted to contact the pharmacy during that time.

Interview on 10/16/25 at 3:56 PM, LVN C, who was the nurse who admitted Resident #1, revealed he did not recall who Resident #1 was. He stated many residents come and go on the skilled hall. LVN C stated that if a resident was missing some medications from the pharmacy, they would contact the physician to see if they could substitute it for something else. LVN C further stated it was important for the residents to have all their medications to continue their care.

Interview on 10/16/25 was attempted via telephone with LVN B; however, the attempts were unsuccessful.Interview on 10/16/25 at 5:05 PM, the ADON revealed she was not aware Resident #1 had gone without some of her medications when she was admitted .

The ADON said she only recalled Resident #1's name but no other details surrounding her stay.

She stated the charge nurses were supposed to enter the residents' medication from the hospital discharge paperwork when they admitted to the facility, and they were supposed to verify the medications with the physician. If medications were not available, they were supposed to go to their emergency kit to see if they had them there. If the medications were not in the emergency kit, they were supposed to call the pharmacy and ask for a STAT delivery or call the doctor to see if they could substitute for a different medication.

The ADON also stated it was important for residents to have all their medications available to prevent an adverse event, and the Juven powder was important because it was used for wound healing.

The previous DON was no longer employed at the facility and could not be interviewed during this investigation.

Interview on 10/16/25 at 5:25 PM, the RDCS revealed she did not know how Resident #1's medications were not available for the missing dates.

The RDCS stated the charge nurses were responsible for following up with the physician if they could not obtain a certain medication.

She stated she was not able to get any information as to what occurred with Resident #1's missing medications.

The RDCS further stated it was important to the residents to have their medications to follow the care regime and so there was no lapse in care.

Record review of the facility's Medication Administration policy dated November 2017 reflected the following: PolicyMedications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician a in accordance with professional standards of practice, in a manner to prevent contamination of infection.1.

Upon admission (including readmission) of each Patient/Resident, the physician's orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record.

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