Failure to Account for Controlled Medications
Summary
The facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medications, leading to the loss or potential diversion of controlled medications for seven residents. The medication nurse discovered that a resident's Fentanyl transdermal patch had been tampered with, but no actions were taken at that time. Later, it was found that two residents' Fentanyl patches had been tampered with, indicating possible diversion of the prescribed controlled medication for pain control. The facility did not test or seek expert identification for the tampered Fentanyl patches, and the narcotic count reconciliations for Oxycodone and Hydrocodone were found to be inaccurate, with a total of 509 tablets missing and unaccounted for. The facility's policy required a controlled medication accountability record to be prepared when receiving or checking in Schedule II, III, IV, or V medications, and a physical inventory of all controlled medication to be conducted by two staff members at each shift change. However, the facility failed to ensure that these procedures were followed. The Pharmacy manifest sheets for the delivery of Fentanyl patches and other controlled medications were not signed by a nurse to verify receipt, and the controlled medication accountability records were not accurately maintained. Additionally, the facility did not promptly identify the loss or potential diversion of controlled medications, and the extent of the loss was not timely determined. Interviews with staff revealed that the process for signing the Pharmacy manifest sheets and the controlled medication accountability records was not consistently followed. The DON and other staff members acknowledged that the required procedures were not always adhered to, and the facility's investigation confirmed that multiple narcotic sheets and medication cards were missing. The facility's failure to maintain accurate records and promptly identify and address the loss or potential diversion of controlled medications resulted in Immediate Jeopardy for the affected residents.
Removal Plan
- A reconciliation of controlled medications was initiated for every resident with an order for a controlled medication verifying the disposition of the controlled medications. This was performed by the DON and Regional Signature Care Consultant (SCC). Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities: Health Facilities Commission, Tennessee (TN) Regional Office; TN Bureau of Investigations; Police Department, Ombudsman and Adult Protective Services (APS).
- The DON and SCC reviewed all delivery manifests to ensure all narcotics delivered and signed in by the alleged nurse were added to the narcotic count and narcotic box on the medication cart. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities.
- The affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied increased pain.
- The affected resident with a BIMS of less than 8 was assessed for pain by the DON, there were no complaints or signs of increased pain.
- All residents on hall #3 were assessed for pain by the Unit Managers. No one complained of pain.
- Hall #3 was the only hall identified with controlled medications unaccounted for.
- A secured cabinet with 2 locks was placed in the Four Seasons Medication storage room.
- Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses. The DON and a witness will access the controlled medications and record transactions on a medication reconciliation record.
- A root cause analysis was conducted. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. This process was changed to prevent the nurses/medication technicians from removing completed medication cards or discontinued medication cards. The DON or Unit Managers (UM) will remove controlled medications from the medication cart; completed medication cards/sheets and discontinued medication cards/sheets.
- Education was conducted by the DON and Staff Development Coordinator (SDC) with all staff on the Abuse and Misappropriation Policy. Any staff/agency staff who were not educated will be educated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
Surveyors found that the facility did not consistently reconcile and document controlled drug counts between nursing shifts. Review of narcotic shift count sheets for one hall over an extended period showed that on most days there was a missing signature from either the on‑coming or off‑going nurse, indicating that required shift‑to‑shift narcotic counts were not reliably completed. An administrative nurse confirmed that facility policy required narcotic counts to be reconciled every shift, and the written pharmacy services policy required accurate and safe provision of medications, but documentation showed this process was not consistently followed.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
A resident with CHF, acute respiratory failure, acute kidney failure, and GAD had a new PRN Lorazepam oral concentrate order, with pharmacy records confirming delivery of a 30 mL bottle. The EMAR showed no administrations, and during a narcotic audit the prescription box was found in the narcotic refrigerator without the medication bottle. Interviews with the ADM, DON, LVNs, and a CMA revealed that narcotic counting practices were inconsistent, particularly for medications stored in the narcotic refrigerator, and required narcotic count sheets were missing for several days. Facility policy and verification forms required end-of-shift reconciliation of all controlled substances, but the lack of documented counts and failure to consistently include the refrigerator narcotics resulted in an unreconciled, missing controlled medication for this resident.
A resident with severe cognitive impairment and multiple cardiac diagnoses was admitted with a hospital order for cloNIDine 0.1 mg to be taken PO twice daily PRN for HTN, but the facility entered the drug as a scheduled BID medication with hold parameters in the electronic record. The MAR reflected administration of cloNIDine according to the incorrect scheduled order, and the CMA reported giving all prescribed BP medications without awareness that one was intended as PRN. The admitting RN stated she entered the medications after NP approval and later learned the order had been entered incorrectly, while the NP confirmed the drug should have been PRN to allow dosing based on BP and pulse. The DON acknowledged that admitting nurses are expected to validate medication orders with the physician and that inaccurate order entry could lead to a change in condition, despite a facility policy requiring medications to be administered as prescribed by the attending physician.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Consistently Reconcile and Document Controlled Drug Counts Between Shifts
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate reconciliation of controlled drugs at the end of daily work shifts. The facility had a census of 54 residents and a sample of 14 residents, with four medication carts and two medication rooms reviewed. On review of the Narcotic Shift Count Sheet for the west hall covering an 88‑day period from 01/01/26 to 03/29/26, surveyors found that on 59 of those days there was a missing signature from either the on‑coming nurse or the off‑going nurse, indicating that the required shift‑to‑shift narcotic count reconciliation was not consistently completed. Specific dates with missing signatures included multiple days in January, February, and March. An administrative nurse confirmed that facility policy and expectations required the narcotic count to be reconciled between shift changes daily and every shift, and the written Pharmacy Services Overview policy stated the facility would accurately and safely provide pharmaceutical services, including medications and the services of a licensed consultant pharmacist. These observations and record reviews demonstrated that the facility did not consistently follow its own policy and expectations for controlled drug reconciliation, as evidenced by the frequent absence of required nursing signatures on narcotic shift count sheets over the reviewed period.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Failure to Reconcile and Account for Controlled Medication in Narcotic Refrigerator
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for acquiring, receiving, dispensing, administering, and reconciling controlled medications, specifically Lorazepam Oral Concentrate 2 mg/mL prescribed for one resident. The resident was an adult male admitted with diagnoses including unspecified diastolic congestive heart failure, acute respiratory failure, acute kidney failure, and generalized anxiety disorder. An order dated 03/18/2026 directed that 0.25 mL of Lorazepam oral concentrate be given by mouth every four hours as needed for anxiety, and the pharmacy shipment summary showed that a 30 mL bottle of this medication was delivered to the facility on that date. The Medication Administration Record from 03/18/2026 through 03/31/2026 showed no administrations of this PRN medication during that period. The Administrator reported that on 03/24/2026, following an audit of narcotic medications conducted by the DON and nursing staff, the prescription box for the resident’s Lorazepam was found in the narcotics refrigerator, but the bottle of medication was missing. Interviews with multiple LVNs revealed inconsistent practices regarding narcotic counts, particularly for medications stored in the narcotic refrigerator. Some LVNs stated they counted only the PRN narcotics on the medication carts and did not count the narcotics in the refrigerator, while others stated they believed they were counting all narcotics, including those in the refrigerator. One LVN, who assisted with the narcotic audit, stated that when she removed all items from the narcotic refrigerator, she discovered an empty box labeled for the resident’s Lorazepam without the corresponding bottle inside, and a subsequent search did not locate the medication. Further record review and interviews showed that the facility lacked completed narcotic count sheets for the period from 03/18/2026 to 03/24/2026, despite a policy requiring controlled substances to be reconciled upon receipt, administration, disposition, and at the end of each shift. The DON acknowledged that the narcotic refrigerator was not being consistently counted and that there was no specific system in place to ensure it was included in shift-to-shift reconciliations. The facility’s written policy and the Narcotic Book/EMAR Verification Sheet required that at each shift change both nurses verify all scheduled and PRN narcotics, document the actual number of cards, bottles, and patches, and turn in the form and any empty cards or bottles to the DON every shift without exception. The absence of narcotic count documentation for the relevant dates, combined with staff reports that the refrigerator narcotics were not always included in counts, led to the discovery that the resident’s newly received Lorazepam bottle was missing and could not be reconciled.
Incorrect Entry and Administration of PRN Antihypertensive Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate order entry and administration of medications for a resident with essential hypertension, heart failure, and atrial fibrillation. The resident, who had severe cognitive impairment with a BIMS score of 6/15, was admitted with hospital discharge paperwork indicating cloNIDine 0.1 mg to be taken by mouth twice daily as needed (PRN) for hypertension. However, the facility’s Order Summary Report listed cloNIDine HCl 0.1 mg as a scheduled medication to be given twice daily with specific hold parameters for blood pressure and pulse. The March MAR showed that cloNIDine HCl was administered on one date when the resident’s blood pressure was 142/52 and pulse 58. During interviews, the CMA who administered the medication stated she gave all prescribed blood pressure medications as ordered and was not aware of a PRN blood pressure medication or any parameters on the order. The RN who admitted the resident reported that she sent the hospital medication list to the NP for approval and then entered the approved medications into the electronic record, later learning that one medication had been entered incorrectly as scheduled instead of PRN. The NP confirmed that cloNIDine HCl should have been ordered as PRN to allow it to be held or staggered based on blood pressure and pulse readings. The DON stated that the admitting nurse should validate medication orders with the physician and acknowledged that inaccurate order entry could result in a resident having a change in condition. The facility’s medication administration policy stated that medications shall be administered as prescribed by the attending physician.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
