Deficiencies in Medication Management and Accountability
Summary
The facility failed to properly account for controlled substances and non-controlled medications, leading to deficiencies in medication management. Specifically, one dose of a controlled substance, diazepam, was unaccounted for in the medication cart for Resident 23. The discrepancy arose because the Licensed Vocational Nurse (LVN) administering the medication did not sign the Controlled Drug accountability log after giving the dose, which is against the facility's policy. This oversight was confirmed during an interview with LVN 3, who acknowledged the failure to document the administration of the medication. Additionally, the facility did not include the necessary verifying signatures on the Controlled Drug accountability logs for medications awaiting disposal. Six logs lacked signatures from either the Director of Nursing (DON) or a Registered Nurse (RN), alongside the LVN, as required by the facility's procedures. The DON admitted to not consistently signing and dating the logs upon receipt of controlled substances, which is crucial for maintaining accountability and preventing medication diversion. Furthermore, the Medication Disposition log for 16 non-controlled medications disposed of on a specific date did not contain witness signatures or the quantity of medication destroyed. The DON sometimes disposed of these medications without a witness, which is contrary to the facility's policy. These practices indicate a lack of adherence to established procedures for medication management, increasing the risk of medication errors and potential harm to residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to administer ordered medications to three residents despite medications being available on site and clear physician orders. One resident with diabetes, CKD, and hypertension did not receive multiple antihypertensives, psychotropics, and insulin doses on admission and the following day, and blood glucose monitoring was not performed as ordered. Another resident with Parkinson’s disease did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal, even though the drug was in stock. A third resident with acute systolic heart failure and hypertension did not receive an ordered evening dose of carvedilol, despite vital signs not meeting hold parameters and the medication being available. The DON confirmed in each case that medications were not administered per physician orders, contrary to facility policies requiring adherence to written orders and use of on-hand medication supplies.
A resident admitted with a lumbar compression fracture and significant back pain had a PRN oxycodone order, but staff were unable to obtain the medication from the emergency supply machine due to repeated malfunctions. The nurse verified orders with the on-call provider, faxed prescriptions to the pharmacy, and administered Tylenol while the resident continued to report moderate to severe pain. Despite multiple attempts to access the emergency supply and arranging for pharmacy delivery, no oxycodone was administered, and the physician was not notified that the ordered pain medication was unavailable, contrary to facility policy requiring prescriber contact when controlled substances are delayed or not available.
A resident with anxiety and other medical conditions, care planned for safe medication use, had multiple scheduled doses of clonazepam 0.5 mg PO BID not administered as ordered, with MAR entries coded to see nurses’ notes and incomplete documentation, including one missed dose with no corresponding progress note and no narcotic sign-outs for the omitted doses. Progress notes on some days cited waiting for pharmacy supply or a new prescription. Additionally, clonazepam 1 mg tablets were available while the order was for 0.5 mg BID, and on two occasions RNs documented wasting 0.5 mg of clonazepam with only a single nurse signature and no second witness, contrary to facility policy requiring two licensed nurse witnesses and signatures for controlled substance destruction.
Surveyors determined that the facility failed to consistently follow its policy requiring two nurses to count and sign for controlled substances at shift change. Review of narcotic count sheets for several medication stations over multiple weeks showed repeated instances where a second nurse’s signature was missing, indicating that the required dual-nurse verification of narcotic counts was not documented. This issue involved all residents receiving narcotic medications during the review period and was confirmed by the facility Administrator.
A resident with ESRD on hemodialysis, HTN, and prior MI had an order for daily diltiazem ER 120 mg that was not administered as prescribed, with the MAR indicating the drug was unavailable. Nursing documentation stated medications had not yet arrived and some were pulled from the emergency medication bank, while the pharmacy confirmed it received the order early that morning and delivered the medications, including diltiazem, that afternoon with staff signature. The resident, cognitively intact, twice contacted law enforcement/911 reporting not receiving medications, and later vital signs showed elevated BP. The DON verified that nursing staff did not notify the physician that the ordered diltiazem dose was not given and was unaware the medication had been delivered but not administered, and the facility’s medication administration policy did not address holding medications pending pharmacy delivery.
Surveyors found that staff failed to accurately and timely document both controlled and routine medications. A resident receiving PRN tramadol had doses recorded on the narcotic log that were not entered on the EMAR. Another resident with leukemia and chronic pain had PRN oxycodone signed out on the narcotic log at a time not aligned with scheduled passes and with no corresponding PRN entry on the EMAR. In addition, an LPN administered ordered antihypertensive, anticoagulant, cardiac, and GI medications to a resident with multiple comorbidities but did not document these doses in the EMAR for more than two hours after administration, despite facility policy requiring proper documentation of all and PRN medications.
Failure to Administer Ordered Medications Despite Availability
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders for multiple residents, despite medications being available on site. One resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia was admitted from the hospital with a history of chronically elevated systolic blood pressure up to the 190s and severe cognitive impairment, dependent on staff for activities of daily living. Hospital discharge orders and subsequent physician orders included multiple antihypertensives, insulin aspart on a low-dose sliding scale, and several other medications. On the evening of admission, the resident did not receive ordered doses of amlodipine, hydralazine, and trazodone, and blood sugar was not monitored and insulin was not administered. The following day, the resident did not receive hydrochlorothiazide, lisinopril, morning doses of amlodipine and hydralazine, atenolol, fenofibrate, pantoprazole sodium, pregabalin, and sertraline, even though the facility’s Medication Inventory on Hand report showed these medications were available. The DON confirmed the medications were not administered per physician orders and that the nurse should have used medications on hand and clarified which medications the resident had been receiving prior to leaving the hospital. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait and mobility abnormalities, and with severe cognitive impairment, was admitted with hospital orders for carbidopa-levodopa 25/100 mg three times daily. The physician orders at the facility also reflected carbidopa-levodopa 25/100 mg three times daily. Review of the MAR showed that the resident did not receive the evening and bedtime doses of carbidopa-levodopa on one day, and did not receive the bedtime dose the following day. The Medication Inventory on Hand report indicated that carbidopa-levodopa was available for administration, and nursing notes contained no documentation that the resident refused the medication. The DON verified that the medication was not administered as ordered, despite being available in the facility. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension, and with intact cognition, was admitted with hospital discharge orders for carvedilol 6.25 mg twice daily. The facility’s physician order mirrored this, specifying carvedilol 6.25 mg twice daily for hypertension, to be held only if systolic blood pressure was less than 100 or pulse was less than 60 beats per minute. On the evening of admission, the resident’s vital signs showed a blood pressure of 116/59 and heart rate of 84, which did not meet the hold parameters. However, the MAR indicated that the evening dose of carvedilol was not administered, and nursing notes did not document any refusal. The Medication Inventory on Hand report showed carvedilol was available, and the DON confirmed that the medication was not administered per physician orders. Facility policies required medications to be administered according to written physician orders and allowed use of on-hand medication supply when pharmacy medications were not yet delivered, but these procedures were not followed in the cited instances.
Failure to Ensure Availability of Prescribed Pain Medication and Notify Prescriber of Delay
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed pain medication was available for administration to a resident with significant back pain. The resident was admitted with osteoporosis and a wedge compression fracture of the first lumbar vertebra and reported lower back pain rated as six out of ten shortly after admission. A baseline care plan documented that the resident was alert and oriented with short-term memory problems, required supervision for mobility and toileting, and was independent with eating. A physician’s order was in place for oxycodone 5 mg by mouth every four hours as needed for moderate pain, and one to two 5 mg tablets every four hours as needed for moderate to severe pain, for up to twenty doses in total. On the evening of admission, the nurse verified admission medication orders with the on-call provider and faxed the medication list and prescriptions, including oxycodone, to the pharmacy. The Medication Administration Record showed that the resident received Tylenol 600 mg for a pain level of six out of ten, but no oxycodone or other pain medications were documented as administered. Pain assessments documented pain levels of six out of ten at 8:30 p.m. and 9:55 p.m., and seven out of ten at 11:24 p.m. The nurse contacted the pharmacy at 9:20 p.m. to verify receipt of the oxycodone prescription and was given a code to obtain two 5 mg oxycodone tablets from the facility’s emergency supply machine. When the nurse attempted to retrieve the oxycodone from the emergency supply machine with a second nurse, the drawer malfunctioned and would not open despite multiple attempts. The nurse called the pharmacy again to report the problem and was advised to contact the DON or the machine’s support number. The nurse notified the ADON and DON and continued unsuccessful attempts to access the medication, then requested immediate delivery of oxycodone, which the pharmacy indicated would arrive in the early morning hours. The resident was informed of the situation and offered Tylenol while continuing to report pain at a level of seven out of ten. The Administrator and DON later confirmed that the nurses did not notify the resident’s physician that the oxycodone was not available, despite a facility policy stating the prescriber would be contacted when delivery of a controlled substance would be delayed or the medication would not be available.
Failure to Administer and Reconcile Clonazepam per Orders and Controlled Substance Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer and reconcile a controlled medication, clonazepam, according to physician orders and facility policy for one resident. The resident was admitted with diagnoses including encephalopathy, low back pain, cervical spinal stenosis, and anxiety, and had a care plan identifying increased risk of adverse reactions related to opiate use, with interventions to administer medications as ordered and monitor for side effects. The admission MDS showed intact cognition. Physician orders for February directed clonazepam 0.5 mg PO BID for anxiety. Review of the MAR/TAR showed that multiple scheduled doses (one morning dose on the first day of the month, both morning and evening doses on the second day, and both morning and evening doses on the sixteenth day) were marked with a code indicating “Other/See Nurses Notes,” and the narcotic sign-out sheet showed no corresponding sign-outs for these doses. Progress notes lacked any entry for the missed dose on the first day, while notes on the second and sixteenth days documented that clonazepam was not administered due to awaiting medication from the pharmacy or a new prescription. The Interim DON confirmed that five doses were missed, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed. The deficiency also includes improper handling and documentation of controlled substance wasting for the same resident’s clonazepam. The narcotic sign-out sheet showed clonazepam 1 mg available with an order for 0.5 mg BID, and entries on two consecutive days documented that RNs each wasted 0.5 mg of clonazepam but signed the waste with only a single signature and no second witness, despite facility policy requiring all controlled substance destruction to be witnessed by at least two nurses with both signatures recorded. The Interim DON confirmed that only one signature appeared for each waste event. One RN stated she always had a witness and speculated the other nurse may have walked away without signing, while the other RN reported she had not been aware at the time that two nurse witnesses and signatures were required. The facility’s controlled substance policy specified adherence to state and federal laws and required two licensed nurse witnesses and a record for each drug destruction, which was not followed in these instances.
Failure to Consistently Complete Dual-Nurse Narcotic Count Verification
Penalty
Summary
Surveyors found that the facility did not consistently ensure proper reconciliation of narcotic medications in accordance with its Controlled Substance Shift to Shift Count Policy, which required all narcotic medications to be counted and verified by two nurses at each shift-to-shift handoff, with both nurses signing the count sheet. Review of narcotic Controlled Substance Count Sheets for multiple medication stations over a period from early February to late March showed missing second nursing signatures on several dates, indicating that the required dual-nurse verification was not documented. Specifically, Station #1’s count sheet lacked a second nurse signature on one date, Station #2’s count sheet lacked a second nurse signature on three dates, and Station #4’s count sheet lacked a second nurse signature on three dates. This deficiency had the potential to affect 17 residents who received narcotic medications from the facility. During an interview, the Administrator confirmed these findings. No additional resident-specific medical histories or conditions related to this deficiency were described in the report.
Failure to Administer Ordered Cardiovascular Medication and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed cardiovascular medication was administered as ordered for one resident. The resident had diagnoses including end stage renal disease with hemodialysis, essential hypertension, and a history of myocardial infarction, and had intact cognition with minimal assistance needs. The care plan included administering medications per physician orders and monitoring cardiovascular status. A physician’s order dated 12/27/25 directed that the resident receive diltiazem extended-release 120 mg orally once daily. Review of the December 2025 MAR showed that this medication was not administered as ordered and was marked as unavailable by the nurse. An electronic MAR note on 12/27/25 at 11:36 A.M. documented that the diltiazem was not given because medications had not yet arrived from the pharmacy. Progress notes showed that the resident was readmitted to the facility on 12/26/25 after hospitalization for altered mental status, and on 12/27/25 at 4:24 P.M. the resident called the police reporting that he had not received his medications. The same note stated that the pharmacy had not delivered that morning, the nurse pulled available medications from the emergency medication bank, and that medications were delivered shortly afterward and the resident was reminded he did receive his medications. However, the pharmacist reported that the pharmacy did not receive the medication orders until 12/27/25 at 4:21 A.M. and that the medications, including diltiazem, were delivered at 3:30 P.M. and signed for by facility staff. A nurse’s note on 12/28/25 at 2:45 A.M. documented that the resident called 911 via cell phone to be transferred to the hospital, with vital signs including blood pressure 154/87. The DON confirmed that the nurse did not notify the physician that the diltiazem had not been administered as ordered and stated she was not aware the medication had been delivered and not given. The facility’s medication administration policy was silent regarding holding medications until arrival from the pharmacy.
Failure to Accurately and Timely Document Controlled and Routine Medications
Penalty
Summary
Surveyors identified a failure to maintain accurate and timely medication records for controlled substances and other medications, including discrepancies between the EMAR and the facility’s narcotic log, and failure to document medications at the time of administration. One resident with arthritis and chronic pain had a PRN tramadol 50 mg order for moderate to severe pain every eight hours; the EMAR showed multiple administrations during the month, while the narcotic log for the same period showed additional tramadol doses that were not documented on the EMAR. Another resident with leukemia and chronic pain had orders for scheduled oxycodone 5 mg twice daily and PRN oxycodone 5 mg every 24 hours; the EMAR for the review period showed no PRN oxycodone administrations, but the paper narcotic log showed an oxycodone dose signed out at a time that did not correspond to the scheduled AM or PM medication passes and was not documented as PRN on the EMAR. In both cases, the DON confirmed that controlled substances should be documented on both the EMAR and the narcotic log. Surveyors also observed a failure to document routine medications at the time of administration for another resident admitted with multiple diagnoses including peripheral vascular disease, partial foot amputation, stroke, liver disease, and chronic kidney disease. This resident had orders for amlodipine 10 mg daily, apixaban 2.5 mg daily, metoprolol 25 mg twice daily, and pantoprazole 40 mg daily. During a medication pass, an LPN administered these medications but did not sign them as given in the EMAR at the time of administration. More than two hours later, the EMAR still did not show documentation of the morning medications, and the LPN was observed sitting at the nurse’s station talking with coworkers rather than charting. The LPN verified that the medications administered earlier remained undocumented. Facility policy required staff to document administration of controlled substances in accordance with law, document when medications are given, and document PRN medications on appropriate forms.
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.
