Failure in Controlled Drug Record-Keeping
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for one resident. The facility's policy on controlled substances management requires strict handling, storage, disposal, and record-keeping, including signing off each dose on the control sheet and electronic medication administration record (eMAR). However, a review of the records for a resident revealed discrepancies in the documentation of controlled medication administration. Specifically, there was no documentation on the eMAR for doses of a controlled medication that were removed from the supply at 1:30 AM and 7:00 AM on a particular day. Interviews with nursing staff revealed inconsistencies in the process of documenting the administration of controlled medications. A registered nurse and a licensed practical nurse both described the procedure of removing medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this, the records for the resident in question did not reflect the administration of the medication as per the facility's policy, indicating a failure in the system of record-keeping for controlled substances.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4, screening completed, resident's level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Penalty
Two LPNs at the facility were observed signing off medications for two residents before administration, contrary to the facility's policy. One LPN claimed unfamiliarity with the rule, while the other cited the simplicity of the task as a reason. The DON confirmed that all nurses had been trained on proper procedures.
A facility failed to timely reorder and receive a routine breathing medication for a resident, resulting in the medication being unavailable at the prescribed time. An LPN confirmed the inhaler was not in stock, and records showed discrepancies in reorder and delivery dates. The resident expressed that the medication occasionally ran out, and the facility's policy on timely medication receipt was not followed.
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. A resident did not receive evening and morning doses due to pharmacy closure and lack of follow-up. Another resident did not receive prescribed medications due to unavailability and incorrect substitutions. A third resident experienced delays in receiving medications, with no emergency kit available and reliance on Omnicare for delivery. The facility did not document efforts to obtain medications promptly.
A LTC facility failed to administer medications as ordered for two residents. One resident received an incorrect dosage due to a discrepancy between the physician's order and the medication label. Another resident did not receive scheduled medication for high blood pressure, leading to a physician-ordered dosage adjustment. These incidents highlight a failure to adhere to medication administration policies.
The facility failed to secure a medication lock box and administered medication in the wrong form to a resident. The lock box in the medication refrigerator was found unlocked due to a warped lock, and a resident received a tablet instead of a capsule as per the EMAR. The LPN planned to verify the order with the pharmacy, and the Consultant Pharmacist suggested the error was likely human. These issues indicate non-compliance with the facility's pharmaceutical procedures.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to pharmaceutical procedures during medication administration for two residents. During an observation at 8:00 AM, an LPN was seen signing off medications for a resident before they were actually administered. Similarly, at 9:50 AM, another LPN signed off on a medication for a different resident prior to its administration. Both instances were confirmed through interviews with the involved staff members, who admitted to signing off medications prematurely. The LPNs involved provided explanations for their actions. One LPN stated that she was not informed that signing off medications before administration was not allowed and did so to familiarize herself with the resident's medication. The other LPN mentioned that he signed off on the medication early because it was only one medication being administered via a tube. The Director of Nursing confirmed that all nurses had received training on medication administration policies, which clearly state that medications should only be signed off as given after they are administered.
Plan Of Correction
Staff nurse A and B were immediately reeducated during the survey on pharmaceutical procedure and the facility's policy during medication administration and on signing the Medication Administration Record after administration of medication. Residents #4 and #50 are receiving medications as ordered according to pharmaceutical procedure and the facility's policy and have exhibited no negative outcome. An audit was conducted of current residents by the Director of Clinical Services to ensure that medications were administered prior to the administration record being signed. No issues were identified. Staff nurse A and B were immediately reeducated during the survey by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration. Licensed Nurses were reeducated starting on by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration and not signing the medication record until medications have been administered. The Director of Clinical Services or Designee will conduct random audits of the medication administration record for 10 residents to determine if the medication administration record was signed prior to the administration of medication, daily x 4 then weekly for 4 weeks, then quarterly x 4. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Failure to Timely Reorder and Receive Breathing Medication
Penalty
Summary
The facility failed to ensure the timely reordering and receipt of a routine breathing medication for a resident, leading to the medication being unavailable at the prescribed time. During an observation, a Licensed Practical Nurse (LPN) confirmed that the inhaler for the resident was not in stock. The LPN stated that the inhaler had been reordered, but records showed discrepancies in the reorder and delivery dates. The Medication Administration Record (MAR) confirmed the inhaler had not been administered, and a progress note indicated that the physician was contacted to order the medication once it was received. The resident, who had been admitted and re-admitted with certain diagnoses, expressed that the medication occasionally ran out. The Care Plan for the resident included giving medications as ordered and monitoring side effects and effectiveness. During an interview, the Director of Nursing (DON) explained that inhalers should be reordered before they run out, depending on the type of inhaler. The facility's policy on medication ordering and receiving from the pharmacy emphasized timely receipt and accurate record-keeping, which was not adhered to in this instance.
Plan Of Correction
1. What corrective action will be accomplished? Resident #48 received ordered inhaler @ 5:59pm on. Resident #48 was assessed by ARNP and found to have no adverse effect related to delayed administration of inhaler. The licensed nurses caring for resident #48 were re-educated on the facility policy for re-ordering medication. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: An audit was conducted of current residents who have physicians order/receives inhalers to ensure all are stocked and re-ordered timely. 3. Measures/systematic changes put into place: The licensed nurses were re-educated by the DON/Designee on the facility policy for re-ordering medications (including inhalers). Re-ordering medication (including inhalers) was added to new nurse hire orientation and annual education. 4. How Corrective action will be monitored: The DON/Designee will conduct a daily audit (for 5 weeks) of residents with a physician order for inhalers to ensure the inhaler is available and re-ordered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. Resident #2 was admitted with several medication orders, but did not receive the evening doses on the day of admission and the following morning due to the unavailability of drugs. The facility's pharmacy was closed for a holiday, and although a request was faxed to Omnicare, there was no follow-up or documentation of physician notification. Resident #5 did not receive prescribed medications on multiple occasions due to unavailability. The facility had Acidophilus instead of the prescribed Rhamnosus, and some nurses administered a pill form of a medication instead of the prescribed liquid form. There was no documentation of efforts to clarify or obtain the correct medications. Resident #6 also experienced delays in receiving medications. Despite being a new admit and expressing concern about the unavailability of medications, the facility did not have an emergency kit and relied on Omnicare for delivery. Progress notes indicated communication with Omnicare and hospice, but there was no documentation of a STAT request for prompt delivery. The facility's failure to follow procedures for acquiring and administering medications in a timely manner led to these deficiencies.
Plan Of Correction
Resident #2 was not negatively affected by the findings. Resident #5 was discharged to home on 3.5.25. Resident #6 was discharged to hospice house on 2.10.25. All residents have the potential to be affected. On [date], an audit was conducted by the Director of Nursing of all resident medications administration records from 3.13.2025 to 3.25.25 for missed doses. Education was provided by Staff Development Coordinator/Designee to the nurses on the facility protocol regarding pharmaceutical services related to acquiring and administering medications in a timely manner. The DON/Designee will conduct a weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.
Medication Administration Deficiency in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to a deficiency in compliance with pharmacy policies and procedures. For one resident, a registered nurse administered 15 ml of a medication, despite the physician's order indicating a dosage of 10 ml daily. This discrepancy was noted during an observation of the medication administration process, and the nurse referred to a physical chart that confirmed the physician's order for a lower dosage. The Director of Nursing later clarified that the order should have been 10 ml daily, and an incident report was completed. Another resident experienced a failure in medication administration when a scheduled medication for high blood pressure was not administered. The resident's son expressed concern about the medication causing low blood pressure, and the nurse contacted the physician to discuss the issue. The physician then ordered a reduced dosage of 2.5 mg daily, which the son agreed to. The resident required substantial assistance for daily activities and had a history of hypertension, which was relevant to the medication management. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing practices. However, the incidents involving these two residents demonstrate a failure to adhere to these standards, resulting in the administration of incorrect dosages and missed medications. These deficiencies were identified through observations, record reviews, and interviews with staff members.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 is no longer at the facility. Resident's #6 order was corrected. The physician was called and was advised of the incorrect dosage being administered, and no new orders were given. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All resident's with orders were reviewed, any deficiency found were corrected immediately. An audit was conducted which reviewed a sample of new orders for accurate transcription and if any deficiencies were found, they were addressed immediately. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Standard parameters will be established through the therapeutic and pharmacy committee. All nursing staff will be educated on utilizing the standard parameters for orders, unless, the physician ordered otherwise. An audit will be conducted to review orders daily by the nurse managers and pharmacist for 7 days, then weekly for 30 days and then monthly for 3 months. If any deficiency is found, it will be corrected immediately. Nursing staff will be educated on accurately administering medications per physicians orders by following the Five Rights. A sample of new orders will be randomly audited on all units by the unit manager or designee daily for 7 days, then weekly for 30 days, and then monthly for 3 months. Additionally, the pharmacy representative will be conducting random medication administration pass observations weekly for 3 months; if any deficiencies are observed, education will be provided to the nurse immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmaceutical procedures, as evidenced by two key observations. During an inspection of the medication storage room on the second floor, the lock box within the medication refrigerator was found unlocked. This lock box contained an emergency kit with several vials, and the Assistant Director of Nursing (ADON) was unable to secure it due to a warped lock. The ADON admitted that this issue had not been reported prior to the survey. This oversight indicates a lapse in the facility's policy that requires all compartments containing drugs and biologicals to be locked when not in use. Additionally, there was a discrepancy in the administration of medication to a resident. The Electronic Medication Administration Record (EMAR) indicated that the resident was to receive a 7.5 mg capsule twice a day, but the resident was being given a 7.5 mg tablet instead. The Licensed Practical Nurse (LPN) involved stated they would contact the pharmacy to verify the order. The facility's Consultant Pharmacist noted that the tablet could be administered with physician authorization, suggesting the documentation error was likely human error. This incident highlights a failure to follow the facility's policy of verifying medication orders and ensuring the correct form of medication is administered to residents.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On the lock box was repaired. On lock box was replaced lock box. On the 17, 2025, the physician ARNP was contacted, and order was revised: medication was received matching revised order for Resident #180 on the same day. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. Facility conducted an audit of all orders to ensure physician order matched the type of medication provided by the pharmacy. 3. The Director of Nursing, or designee(s) will educate all staff on Pharmacy Services, Procedures, Pharmacist, Records CFR(s): 483.45(a)(b)(1)-(3), 59A-4.112(1), FAC Pharmacy Policies and Procedures and facilitys Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
