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F0658
E

Failure to Provide and Administer Medications per Physician Orders

Holland, Michigan Survey Completed on 12-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were available and administered according to physician orders for two residents. One resident with Parkinson's Disease and Dementia had a physician order for Namenda 10 mg twice daily for Dementia. Documentation showed that the medication was not available from the evening of August 12th until the morning of August 22nd, resulting in the resident missing 19 doses. There was no documentation that the physician was notified about the unavailability of the medication during this period. Another resident with hypertensive heart disease, heart failure, chronic kidney disease stage 3, and aortic valve stenosis had a physician order for Hydralazine 25 mg every 12 hours, to be held if blood pressure was less than 140/90. Despite nursing staff documenting blood pressures prior to administration, the medication was given outside the ordered parameters 16 times. During an interview, the Director of Nursing was unable to explain the medication unavailability and the administration of medication outside physician parameters, acknowledging that these actions did not meet professional standards.

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