The facility failed to consistently and accurately reconcile controlled medications, resulting in multiple discrepancies between the EMAR and narcotic logs for three residents receiving PRN narcotic analgesics. One resident with an internal hip prosthesis infection had oxycodone doses documented on the EMAR but not on the narcotic log, and vice versa. Another resident with dementia and a lumbar fracture received oxycodone doses documented only 1 hour and 28 minutes apart despite an order for dosing every 4 hours. A third resident with vascular dementia and spinal stenosis had hydrocodone doses signed out twice within a short interval and twice at the same time on consecutive narcotic log pages, without documentation of waste, while the EMAR reflected only single administrations. The Resident Care Manager confirmed the presence of these documentation discrepancies.
A resident on warfarin with an INR goal of 2–3 had multiple INR tests showing fluctuating and at times critically high results, with corresponding changes in warfarin dosing and eventual bleeding symptoms requiring hospital admission. Surveyors found the INR flowsheet for this resident was incomplete and missing several test entries. Staff reported that INR testing was done in-house using a Coag-Sense meter and that quality control (QC) checks were expected when a new box of strips was opened, but there was no formal process to document QC. An opened box of test strips still contained unused high and low control strips matching the lot numbers of strips in use, and staff acknowledged this meant QC testing had not been performed, despite these strips being used for the resident’s INR monitoring.
A resident admitted with a repaired mid-spine fracture, ankylosing spondylitis, and chronic respiratory failure reported that provider-ordered medications were not available for several days after admission. Review of the MAR showed multiple missed doses of enoxaparin, mirtazapine, cyclobenzaprine, pregabalin, sildenafil, and a Butrans patch. The DON reported the facility was using a new pharmacy and was unsure why the medications were missed, while stating the expectation that resident-specific medications be available for administration on the day of admission.
Controlled drugs in an East 2 med cart were not accurately reconciled. An LPN signed the shift-change log without verifying the controlled drug book against the physical stock, and a review found one 5 mg oxycodone tablet listed for a resident in the logbook but missing from the box. The DON stated controlled meds must be recorded in the logbook and validated during shift-change counts.
Surveyors found that the facility’s use of a broad flex-time medication pass system led to multiple residents receiving APAP, levetiracetam, carvedilol, carbidopa-levodopa, and fosfomycin at times that did not comply with prescriber orders, manufacturer guidelines, or the facility’s own one-hour-before/after policy. One resident’s seizure and pain medications were repeatedly given late or at inconsistent intervals; another resident’s Parkinson’s medication was not coordinated with meals as ordered and APAP doses were given too close together; and a third resident’s APAP and carvedilol were scheduled and administered without regard to ordered meal timing, with some APAP doses only minutes apart and an antibiotic order left unclear between “evening” and “with breakfast.” Staff interviews showed reliance on wide flex-time windows, lack of clear documentation of exact administration times on the MAR, and inconsistent understanding of how to space BID and TID medications, contributing to the cited deficiency for pharmaceutical services.
Medication administration was not done according to professional standards for one alert and oriented resident. A cup with several pills was left on the bedside table while the nurse left to get water, and the resident swallowed the medication without the nurse present. The record did not show approval for the resident to keep meds in the room or self-administer them, and the DON and an LPN stated staff were supposed to observe medication administration and not leave meds in a resident’s room.
A resident with chronic pain and spinal stenosis, who was cognitively intact, had physician orders for scheduled and PRN oxycodone but experienced multiple missed doses due to the medication not being available. The MAR and progress notes documented repeated instances where oxycodone was unavailable in automated dispensing systems, only partial doses were on hand, or doses were pending pharmacy delivery. The resident reported that staff frequently told them the facility had run out of oxycodone and gave varying reasons such as ordering issues, shift mix‑ups, unsigned prescriptions, and insurance problems. A medical provider stated they expected medications to be given as ordered, and the DON reported that the pharmacy had not been sending the full amount of oxycodone requested for refills.
Expired lansoprazole was found in a medication room refrigerator for a resident who was still receiving it, and staff acknowledged it should have been discarded because its effectiveness may be affected. In addition, controlled medications for two discharged residents were destroyed in the narcotic books on the North and South carts by an RN without documentation of a second staff member present, despite staff stating that two nurses were required to verify destruction and help prevent diversion.
Surveyors found that the facility repeatedly failed to administer physician‑ordered medications over multiple days because drugs were not available, affecting numerous residents and a wide range of treatments including respiratory, cardiac, thyroid, diabetic, pain, GI, psychiatric, hormone, and supplement therapies. Review of the Medication Not Available report showed that some medications had been previously delivered in 7‑ to 30‑day supplies or were stocked OTC or in the pyxis, yet were still not given, and refill requests were often submitted after supplies should have run out. RNs, LPNs, and agency staff reported frequent shortages of OTC medications, barriers to pyxis access, confusion over who was responsible for ordering, and management discouraging documentation of unavailable meds. Staff described ongoing problems with pharmacy deliveries, late or missing orders, and high‑cost medications requiring administrative approval, while the consulting pharmacist reported a 5–7 day refill turnaround, noted late refill requests, and identified instances where medications should have been on hand or available in pyxis but were not used, resulting in missed doses, including at admission.
A resident with rheumatoid arthritis and spinal compression fractures, who required extensive assistance with ADLs, had a standing q6h narcotic pain medication order but experienced multiple missed doses when the facility ran out of the medication. The resident reported significant pain and stated staff told them the pharmacy would not refill the narcotic until a new prescription was obtained and that no backup dose was available from the emergency supply. An LPN and the DON confirmed that the established refill process—requesting refills when seven doses remained and using emergency backup narcotics with a pharmacy authorization code if needed—was not followed, and confusion with the pharmacy order prevented timely access to the narcotic medication.
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