Medication Administration Errors
Summary
The facility failed to ensure that physician orders were followed, resulting in a medication error rate of 32%, which is significantly higher than the acceptable threshold of 5%. During observations, interviews, and record reviews, ten medication errors were identified out of 31 opportunities, affecting four residents. The facility's policy on drug administration requires medications to be administered within one hour before or after their prescribed time, but this was not adhered to, leading to the high error rate. The errors were documented during a medication pass observation signed by the Consultant Pharmacist for a Licensed Practical Nurse (LPN).
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable.
Penalty
A resident with a nephrostomy catheter was observed with an old dressing showing bloody drainage that had not been changed since return from a hospital stay, despite existing physician orders and facility policies for catheter and wound care. The resident reported no dressing change since hospital discharge. An APRN and the DON stated that protocols and expectations required nurses to follow nephrostomy care orders, including daily or ordered catheter care. Two LPNs acknowledged they did not perform the documented dressing changes and may have inadvertently checked off the tasks, resulting in the nephrostomy dressing not being changed as ordered and without a recorded reason for not following the physician’s orders.
Surveyors found that staff did not consistently follow physician orders for several residents, including an RN repeatedly holding ordered insulin without required physician notification, and an LPN crushing and administering a delayed-release medication without clarifying its appropriateness. Wound care orders for daily and three-times-weekly dressing changes were not carried out as prescribed, with dressings left unchanged for days and staff unable to account for missed treatments. A resident ordered to wear an AFO during transfers and when out of bed was frequently observed without it, while documentation of application was incomplete and CNAs reported not consistently applying or keeping the device on. Another resident on G-tube feeding had feeding and water setups used beyond the ordered timeframe, and an LPN restarted tube feedings and administered medications without checking gastric residuals as required by the physician order.
Surveyors identified that nursing staff failed to follow physician orders and professional standards for medication administration for two residents. One resident on an anticoagulant had orders to hold and later adjust dosing based on INR results, yet MAR entries showed doses documented as given on days when the drug was ordered held, and the medication was administered despite documented critically elevated INR values without evidence of physician notification or timely completion of ordered follow-up INR labs. Pharmacy records also conflicted with MAR documentation regarding the number of anticoagulant doses actually administered. In a separate observation, a nurse administered six verified oral medications to another resident but then documented on the MAR that a polyethylene glycol dose had been given when it had not; after being questioned, the nurse acknowledged the discrepancy, located the medication in the supply room, and administered it afterward.
A resident with COPD was prescribed oxygen at 3 L/min via nasal cannula with humidifier, but was repeatedly observed receiving 4 L/min without humidification. The resident depended on staff to set the oxygen correctly. Staff confirmed the order was not followed and admitted to not checking the settings during shift changes.
Surveyors identified that staff failed to follow physician orders for three residents, including not applying anti-embolic stockings as prescribed and not obtaining a required lab test. In each case, staff documented that orders were followed when they were not, and there was no documentation explaining the omissions. The DON confirmed that private aides were not responsible for these tasks and that the medical records were inaccurate.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to a failure in obtaining the necessary prescription from the physician. Despite attempts to contact the pharmacy, the medication was not available, and there was no documentation of physician notification. The facility's process for handling new admissions and controlled medications was not followed, leading to the deficiency.
Failure to Follow Physician Orders for Nephrostomy Dressing Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for nephrostomy care for one resident. On observation, the resident was seen in bed with a gauze pad and transparent occlusive dressing over a nephrostomy catheter insertion site on the right lower back. The dressing showed a half-dollar sized area of bloody drainage and was dated several days prior to the observation. The resident reported that she had previously been hospitalized due to blood in her nephrostomy drainage bag and dislodgement of the tube, which was reinserted at the hospital, and that the dressing had not been changed since her return. Her admission record showed an admission date in April 2026 with diagnoses including a fracture of the neck of the left femur. Record review and staff interviews showed that there were physician orders and facility policies in place for catheter and wound care, including daily catheter care or as ordered, and treatment of skin impairments. The APRN stated that protocols for catheter care existed and that nurses were expected to follow nephrostomy care orders. The DON stated that the admitting nurse was expected to obtain nephrostomy care orders and that nurses were expected to follow them. However, two LPNs each confirmed they had not performed the nephrostomy dressing changes on the dates documented and suggested they may have inadvertently checked off the task in error. This resulted in the nephrostomy dressing not being changed as ordered, without a documented reason in the medical record for not following the physician’s orders.
Failure to Follow Physician Orders for Medications, Wound Care, Orthotic Use, and Enteral Feeding
Penalty
Summary
The deficiency involves multiple failures by nursing and therapy staff to follow physician orders for medications, treatments, devices, and enteral nutrition. One resident with diabetes had an order for daily Insulin Glargine with instructions to notify the physician if blood sugar was less than 70 mg/dL. Review of the MAR showed that an RN repeatedly held the insulin on numerous dates when blood sugars were between 60 and 117 mg/dL, including several instances where no blood sugar was documented at all, and the RN stated she misread the order and did not recall notifying the physician. Another resident had an order for a delayed-release oral medication, Zunveyl 10 mg twice daily, with a general order allowing medications to be crushed unless contraindicated. An LPN crushed the delayed-release tablet and administered it without first clarifying with the provider or pharmacy, later acknowledging that the medication was delayed release and that she should have obtained clarification. The deficiency also includes failures to follow wound care orders for residents with skin conditions. One resident who had a dermatology biopsy on the left side of the neck had a physician order for daily wound care on the day shift for seven days, including washing with soap and water, applying petroleum jelly, and covering with a nonstick bandage. Observations on two consecutive days showed the same dressing dated several days earlier still in place, and the resident reported that the dressing had not been changed. Nursing staff interviewed either did not recall the dressing date, stated they did not see dressing change orders, or could not recall what happened on the ordered wound care day. Another resident with a right knee wound from a fall at home had an order for wound care three times weekly on the day shift (Tuesday, Thursday, Saturday). The wound care nurse stated she worked on the relevant Saturday but did not perform the ordered dressing change because the resident was up, and the DON stated staff should follow physician orders and perform wound care as ordered. Additional deficiencies occurred in the implementation of therapy-related and enteral feeding orders. One resident with an order for a right ankle orthosis (AFO) to be applied during transfers and when out of bed was repeatedly observed in a wheelchair and in bed without the AFO, while the device was stored in the closet. The task list showed documentation of AFO application for several days early in the month but no entries on later dates when the resident was observed without the device. Therapy and nursing staff described that restorative aides were to apply the AFO, but a restorative CNA reported they were not applying it and were instead working with a hand splint, and a CNA stated she sometimes removed the AFO when the resident was sitting because she thought he did not like to wear it. Another resident receiving enteral nutrition via G-tube had a physician order for Jevity 1.5 at a specified rate and schedule, with an order to check tube residual prior to feeding, medications, and flushes, and to hold feeding and notify the physician if residual was 100 mL or more. Observations showed the feeding bottle and attached water bag in use beyond 24 hours, and an LPN stated she believed the setup was good for 24 hours and based changes on what was left in the bottle. When restarting the feeding, the LPN set the pump according to the order but did not check for residual, and she confirmed she did not check residuals prior to medication administration or initiation of feeding, despite the physician order and facility policy requiring verification of tube placement and residual volumes.
Failure to Follow Anticoagulant Orders and Accurate Medication Administration Practices
Penalty
Summary
The deficiency involves failure to follow physician orders and accepted standards of practice for anticoagulant management and medication administration documentation for two residents. One resident was admitted with a history that included valve replacement and was prescribed an anticoagulant 5 mg by mouth every other day, with INR labs to be drawn. A subsequent physician order directed that the anticoagulant be held pending INR results, and later an order was given for the resident to receive 5 mg daily and to resume the medication. The MAR showed nurses initialed administration of 2.5 mg on one date and 5 mg on three dates, even though the physician’s order indicated the 5 mg dose was on hold on two of those dates. Nursing documentation reflected elevated INRs of 3.38 and then 9.12, yet the 5 mg dose was still administered when the INR was 9.12, and there was no evidence that the physician was contacted for guidance when the INRs were elevated. Further review of lab results for this resident showed critically elevated coagulation values, including a prothrombin time of 94.9 seconds with an INR of 9.12, and later a prothrombin time of 180 seconds with an INR of 17.63. When the INR was critically elevated at 17.63, the physician ordered vitamin K 10 mg injection and INR labs to be drawn for two days. The record did not show that these ordered labs were drawn as prescribed, nor that staff followed up with the lab to ensure completion; the labs were not completed until a later date, by which time the resident’s condition had changed and deteriorated, requiring transfer to the hospital for further evaluation. Pharmacy dispensing records showed that 21 tablets of the 5 mg anticoagulant were dispensed and 20 tablets were returned at discharge, while the MAR contained four documented doses, raising questions about whether the medication was actually administered as charted. The DON confirmed that the ordered labs were not drawn on the specified days and that there was no evidence nurses contacted the physician before administering the anticoagulant when the INR was elevated. A second deficiency involved inaccurate medication administration and documentation for another resident. During an observed medication pass, a licensed nurse prepared and administered six oral medications, which were verified by the surveyor, and confirmed that no additional medications were to be given at that time other than an insulin dose that was held due to a blood glucose of 109. However, on the MAR, the nurse documented that she had also administered polyethylene glycol 3350 powder, 17 g by mouth twice daily for constipation, even though this medication had not been given during the observed pass. When questioned, the nurse acknowledged she had not administered the polyethylene glycol but had signed for it, then searched the medication cart, found none available, went to the supply room to retrieve a bottle, and subsequently administered the dose. She stated she must have retrieved the medication from another cart previously, despite its absence on the current cart at the time of the observation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. On [R] Physician was notified of prior events and current conditions for resident discharged to Lawnwood Regional Medical Center on [R]. No additional residents were affected at this time. C. On [R], comprehensive medication and lab review for resident #1 was completed to ensure all physician orders are current and being followed; resident transferred to hospital prior to additional interventions being implemented. D. As of [R], the licensed nursing staff identified in the deficient practice are no longer employed by the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R], the Director of Nursing/Designee identified and reviewed current residents receiving [R]. The review included [R] verification of current physician orders, review of [R]/INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of the review, there were no residents in the facility receiving [R]/ however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R], the facility implemented system changes, including the establishment of an [R] Management Protocol outlining INR critical value parameters, required interventions for elevated INR levels, and mandatory physician notification guidelines. A Lab Tracking Log was also implemented to ensure all ordered laboratory tests are completed as scheduled, reviewed in a timely manner, and escalated appropriately when not obtained. In addition, High-Risk Medication Audits Tool for [R] was put into place to monitor compliance and medication safety practices. Education was completed with licensed nursing staff regarding the administration, monitoring, management of [R]/ including therapeutic INR ranges, timely physician notification, documentation requirements, and appropriate interventions for abnormal lab values. B. By [R], Licensed Nursing Staff will have been educated by Director of Nursing/Designee on the components of N0054 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. C. Newly hired licensed nursing staff will receive education by the Director of Clinical/Designed on the components of N0054 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: (A) The Director of Nursing/Designee will conduct audits on 5 residents on [R] weekly x 4 weeks, then biweekly x 4 weeks, then monthly x 1 month. Audits will include medication administration accuracy, lab completion and follow up, physician notification compliance. The findings of these quality monitoring's to be reported to the quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Physician's Oxygen Order for Resident with COPD
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who was prescribed oxygen at 3 liters per minute via nasal cannula with humidifier. Multiple observations revealed that the resident was receiving oxygen at 4 liters per minute without the required humidification. The resident reported being unable to check the oxygen settings and relied on staff to ensure accuracy. Staff interviews confirmed awareness of the correct order but acknowledged that the oxygen was set incorrectly and the humidifier was not in use. One LPN admitted to not checking the oxygen settings upon starting her shift.
Plan Of Correction
On 06/18/2025, resident #60 was assessed by the DON/Designee, confirming oxygen delivery is being provided in accordance with physician orders. All residents residing in the facility requiring supplemental oxygen have the potential to be affected. The DON/Designee will review all current residents requiring supplemental oxygen by 07/18/2025 to ensure that oxygen is delivered in accordance with physician orders, with corrective action immediately upon discovery. Licensed nurses will be re-educated by the DON/Designee regarding the delivery of oxygen in accordance with physician orders. This re-education will be completed by 07/25/2025. The DON/Designee will audit ten residents requiring oxygen weekly for four weeks, and then five residents requiring oxygen weekly for eight weeks, to ensure that oxygen delivery is provided in accordance with physician orders. The results of these audits will be submitted to the QAPI committee monthly for review and further recommendations. The overall completion date for these actions is 07/25/2025.
Failure to Follow Physician Orders and Inaccurate Documentation
Penalty
Summary
Surveyors found that the facility failed to follow physician orders for three residents regarding the application of anti-embolic stockings and the timely collection of a laboratory test. For one resident with moderate cognitive impairment and dependent on staff for lower body dressing, there was an active physician order for anti-embolic stockings to be worn during the day. Observations on multiple occasions showed the resident was not wearing the stockings, and both the resident and her private duty aide confirmed that the stockings were not applied and that no one had instructed them to do so. Nursing staff documented in the Medication Administration Record (MAR) that the stockings were applied, but later admitted uncertainty about whether this was done, and the Director of Nursing (DON) confirmed that private duty aides are not responsible for applying such treatments. Another resident with a history of joint replacement and vascular disease had an active order for anti-embolic stockings to be applied every shift. Observations repeatedly showed the resident was not wearing the stockings, and the resident stated he had not been asked to wear them since admission. Nursing staff documented in the MAR that the stockings were applied, but admitted during interviews that they had not applied them nor instructed others to do so. The DON acknowledged that the medical record was inaccurate in this regard. A third resident had a physician order for a specific laboratory test to be drawn in the morning, but the test was not obtained as ordered, and there was no documentation in the medical record explaining the omission. The DON confirmed that the order was not followed and that the expected documentation was missing. In all three cases, the facility failed to follow physician orders as prescribed and did not document reasons for non-compliance in the residents' medical records.
Plan Of Correction
Resident #13 had order for discontinued on Resident #133 had physician order reviewed and placed on resident for remainder of his stay. Resident discharged on Resident #29 had lab order incorrectly entered on level drawn on and results required no change in orders. Education provided to licensed nurses and ARNPs on staff responsibility of resident to receive treatment and care in accordance with professional standards of practice in regards to following physician orders with and lab orders. Audit other physician orders for and labs to ensure professional standards of practice are being followed. Audits to be conducted to ensure compliance with professional standards of practice by DON/designee of physician orders for and labs daily for four weeks, and three times a week for eight weeks thereafter. Results to be taken to monthly QAPI meeting for three months. N 054 N 054 N 054
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, who was admitted with a medical diagnosis that included subcortical and flaccid conditions affecting the right dominant side. The resident was prescribed Pregabalin 75 mg to be administered three times a day, starting from the day of admission. However, the resident did not receive the medication during five administration opportunities, as documented in the medical records. The deficiency arose because the prescription for Pregabalin was not sent to the pharmacy, and the medication was not available in the emergency drug kit. Despite the nurses' attempts to contact the pharmacy, they did not have the prescription, and there was no documentation indicating that the physician was notified to provide the necessary prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dosage was not administered. Interviews with the nursing staff and the Director of Nursing revealed that the facility's process for handling new admissions and controlled medications was not followed. The nurses were expected to notify the physician and document the need for a prescription, but this was not done. The Director of Nursing confirmed that the medication should have been administered as prescribed, and the nurses should have continued to contact the physician until the medication was delivered.
Plan Of Correction
Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is 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.
