Failure to Ensure Timely Provision and Documentation of Controlled Medications
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquisition, receipt, dispensing, and administration of medications for two residents, including an antiepileptic drug for a resident with epilepsy and dementia. Facility policy required that Schedule II medications be delivered only upon receipt of a faxed or original prescription, allowed emergency use of medications from the emergency supply with pharmacist authorization, and directed that Schedule II medications be reordered when a seven-day supply remained. For Resident 1, who had orders for lacosamide 100 mg by mouth every 12 hours for seizure management, the Controlled Substance Record showed 30 tablets received on December 29, 2025, with administration beginning January 1, 2026, and the last documented dose given on January 15, 2026, at 8:00 PM. The January 2026 MAR documented lacosamide doses on January 16 and 17 as “Hold/See Nurses Note,” and medication administration notes on January 16 and 17 indicated the lacosamide was on order, on back order, and not available, with repeated calls to the pharmacy. On January 17, nursing progress notes documented seizure activity for Resident 1. One note by an LPN at 10:40 PM described a seizure from 10:20 PM to 10:26 PM and stated that the pharmacy had earlier indicated the lacosamide would be sent, but later reported that a prescription was needed to dispense it. Another note by an RN at 11:20 PM documented a seizure lasting approximately 20–25 minutes, notification of the physician, and that the ordered lacosamide was not available, leading to an order to send the resident to the hospital for evaluation and treatment. A written statement from an LPN dated January 28, 2026, indicated that on January 16 the LPN called the pharmacy to report that the resident was out of lacosamide, that it had been ordered days prior, and that the pharmacy said it would be on the next delivery. On January 18, a nurse’s note recorded another seizure for Resident 1 lasting from approximately 7:06 AM to 7:23 AM, physician notification, review of medication concerns with the physician, a new order for Ativan 1 mg IM every 12 hours as needed for seizure activity, and a second transfer to the emergency room. The same note documented that EMS staff were informed of concerns regarding lacosamide, that a voicemail was left for the on-call pharmacist, and that prescriptions for lacosamide and Ativan were later signed and faxed to the pharmacy. Subsequent progress notes indicated that the pharmacy reported the last lacosamide delivery as December 28, 2025, with a 15-day supply, that the pharmacy already had a script for lacosamide, and that lacosamide and Ativan would be included in the next delivery. Resident 1 received a dose of lacosamide from the emergency medication supply on January 18 at 8:00 PM, and a new supply of 60 tablets was received on January 19, with administration resuming that morning. The record showed that Resident 1 had no seizure activity between August 3, 2025, and January 17, 2026, while receiving medications as ordered, and then experienced two seizures with two hospital transfers when lacosamide was not administered as ordered due to the pharmacy’s failure to provide the medication or timely communicate why it could not be supplied when initially ordered. Interviews with the Regional Director of Clinical Services and the DON confirmed that nursing staff had reordered lacosamide on January 12, 2026, that the pharmacy had an active prescription but overlooked filling it, that there was no documentation of pharmacy communication between January 12 and 17, and that staff could not access lacosamide from the emergency supply because the pharmacy would not provide an authorization code while stating there was no current script. For Resident 2, who had dementia and anxiety disorder and an order for Xanax 0.5 mg every 8 hours, a medication administration note on January 26, 2026, documented that Xanax was not administered while awaiting pharmacy delivery. A nurse’s note later that day recorded that an RN contacted the pharmacy about retrieving Xanax from the emergency medication supply and questioned whether two 0.25 mg tablets could be used to equal the ordered 0.5 mg dose; the pharmacy responded that medications must be dispensed as written. The RN then contacted the physician for further orders, and the pharmacy indicated the medication would be on the next delivery. Another note documented that the physician gave a one-time order for Xanax 0.25 mg, two tablets now. The Controlled Substance Record for Xanax showed the prescription was filled on January 25, 2026, but the Receipt Verification section was blank, and the first dose from that package was not administered until January 26 at 6:30 PM. In an interview, the DON stated she expected medications to be reordered when down to a five-day supply, expected timely dispensing and delivery or immediate notification of issues from the pharmacy, and expected staff to complete the Receipt Verification on controlled substance records. No additional information was provided regarding when staff reordered Xanax or the reason for the delivery delay.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to reconcile liquid controlled narcotics during a shift change count. An RN counted only the pill narcotics in the locked med cart box and left 7 bottles of liquid controlled meds uncounted, stating liquid morphine was hard to count. Other staff, including the DON and consulting pharmacist, confirmed that all controlled meds, including liquids, should be reconciled shift to shift per policy.
Incorrect Medication Route Transcribed on MAR: A resident with cerebral infarction, dysphagia, and gastrostomy status had an order for acetaminophen 650 mg by mouth PRN pain, but the MAR reflected the route incorrectly. During observation, the resident received medications through the G-tube, and the LVN stated she had transcribed the wrong route into PCC even though the resident was NPO. The DON stated new orders are transcribed by the charge nurse and reviewed by nurse managers.
A resident with cognitive intactness, wheelchair use, and multiple diagnoses had groin redness and a provider order for nystatin powder, but staff also kept an unlabeled bottle of 2% miconazole nitrate at the bedside without a provider order. Staff and the resident described self-administration, yet the TMA documented the ordered nystatin as given even though she later said it remained in the cart and was not administered, and staff were unclear about which antifungal powder was being used.
Failure to Monitor Controlled Narcotics in E-kit: The facility failed to monitor controlled narcotic medications in an E-kit stored in a med cart. RN-A stated the plastic numbered tag on the E-kit was not checked daily or documented, and both RN-A and TMA-A said there would be no way to know if the kit had been opened and narcotics removed until the kit was accessed for needed meds. The E-kit contained controlled meds including tramadol, hydrocodone/APAP, lorazepam, and morphine solution, and the DON stated staff should have been monitoring the tag number.
A resident with diabetes had insulin glargine documented as held on multiple occasions even though the DON stated it was administered as ordered, and a second resident's PRN Norco was signed out on the controlled drug record but not documented on the MAR. Facility policy required medications to be given per MD order and controlled meds to be documented on both the accountability record and MAR.
An LVN prepared medications for two residents on one tray and intended to administer them one after the other, rather than for one resident at a time. One resident had osteoarthritis and the other had liver cancer; both were cognitively intact and required substantial to maximal assistance with ADLs. During observation, the LVN carried two medication cups and water into the roommates’ room, gave one resident’s medication while the other was busy, and stated she saw no issue with preparing and administering both residents’ medications together. The DON stated medications should be prepared and given to one resident at a time, and facility policy said medications are administered when prepared and are not pre-poured.
Failure to Reconcile Liquid Controlled Narcotics During Shift Change
Penalty
Summary
The facility failed to reconcile liquid controlled narcotic medications in 1 of 2 medication carts during the shift change narcotic count. During observation and interview, RN-B counted the narcotic pills in the locked box of the medication cart while LPN-A confirmed the pill count, then RN-B locked the box and cart without picking up or confirming the amounts of 7 bottles of liquid narcotic medications also stored in the locked box. RN-B stated the liquid morphine was not counted because it is hard to tell as a liquid, although the facility documented administration of the liquid narcotics in the narcotic book. The unreconciled medications included liquid morphine, codeine solution, and lorazepam solution for residents R7, R8, R23, R26, R36, and R53. Interviews with other nursing staff, the DON, the regional clinical service director, and the consulting pharmacist confirmed that all controlled medications, including liquid narcotics, should be reconciled shift to shift. Staff stated that everything in the locked box should be counted to confirm the correct amount remained, and the DON identified that nurses should count all narcotics between two staff members. Review of the facility's controlled medication policy stated that all controlled medications are to be verified when delivered and that each time the keys secure the controlled medication locked box, the oncoming and off-going nurse or medication aide should reconcile all controlled medications to ensure the count matches the remaining amount listed.
Incorrect Medication Route Transcribed on MAR
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #35 by inaccurately transcribing a physician-ordered medication onto the Medication Administration Record. Resident #35 was an adult male admitted with diagnoses including cerebral infarction, dysphagia of the oropharyngeal phase, and gastrostomy status, and his care plan identified that he required tube feeding related to stroke. His orders included NPO status and an order for acetaminophen 325 mg tablets, 2 tablets by mouth every 6 hours as needed for pain. During observation of medication administration, the resident did not receive acetaminophen, and scheduled medications were administered through the gastrostomy tube. Record review showed the MAR documented acetaminophen 650 mg as given, but the route was reflected incorrectly. The LVN who received the original order stated she had accidentally marked the wrong route when transcribing it into PCC and that she administered the dose through the gastrostomy tube because the resident was NPO. The DON stated the charge nurse is responsible for transcribing new physician orders into PCC right away and that the incorrect route was missed during review.
Medication Given and Documented Without Proper Order
Penalty
Summary
The facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for one resident who was cognitively intact, used a wheelchair, and had diagnoses including bilateral subdural hematomas related to a fall, congestive heart failure, and chronic kidney disease. The resident was occasionally incontinent of urine and required moderate assistance with lower body dressing and toileting. A nursing progress note documented redness in the groin related to moisture, and the provider later ordered nystatin external powder to the groin three times daily for 14 days for candidiasis related to rash and other nonspecific skin eruption. Despite that order, the resident’s record did not contain a provider order for 2% miconazole nitrate powder. Surveyors observed a container of 2% miconazole nitrate antifungal powder on the resident’s bedside table on two occasions, and the container did not have a pharmacy prescription label. The resident stated staff had given him the powder and that he could use it as needed, while a nursing assistant stated staff were supposed to help apply it but the resident preferred to do it himself and refused staff assistance or removal of the medication from the room. During interviews, nursing staff stated orders should be in the system for all medications, including topicals and self-administered medications. A review of the MAR showed the nystatin powder was documented as administered, but the TMA later stated it had remained in the cart that morning and was not given, and that she charted it as administered after the resident said he would do it later and later told her he had done it himself. The TMA also produced a separate bottle of 2% miconazole nitrate from the medication cart and confused it with the nystatin order, while the DON stated no medications should be administered without a provider order and that medication administration should be documented accurately.
Failure to Monitor Controlled Narcotics in E-kit
Penalty
Summary
The facility failed to monitor controlled narcotic medications in 1 of 1 emergency kits (E-kits) to prevent potential diversion. During observation and interview, the E-kit was found stored in the medication cart, with a small plastic E-kit box inside a locked box on the cart containing controlled narcotic medications. RN-A stated the nurses did not monitor the plastic numbered tag on the E-kits daily, and the tag was not documented anywhere to confirm the correct tag remained in place. Both TMA-A and RN-A stated there would be no way to know if someone had opened the E-kit and removed narcotics until the nurse accessed it for needed medication, and RN-A acknowledged the kit and the smaller box were not opened regularly, so medication could be missing for quite some time before anyone would notice. Review of the E-kit medication list showed controlled narcotics including Tramadol 50 mg, Hydrocodone/APAP 5/325 mg, Lorazepam 0.5 mg, and Morphine solution 20 mg/ml. The DON stated staff should have been monitoring the number on the plastic tag of the E-kit and the E-kit located inside the locked box on the medication cart, and a policy on monitoring controlled narcotic medications was requested but not provided.
Medication Administration and Controlled Drug Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for two residents. For one resident with diabetes mellitus, the physician ordered insulin glargine 27 units subcutaneously at bedtime and regular human insulin before meals and at bedtime per sliding scale. The order summary did not include any hold parameters for insulin glargine, yet the MAR showed the insulin glargine dose was held on multiple dates in July 2026. On those same dates, the regular human insulin was held appropriately based on the documented blood sugar values. During interview and record review, the DON acknowledged the insulin glargine doses were shown as held on the MAR but stated the medication had been administered as ordered. For another resident, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for severe pain, not to exceed 3 g in 24 hours. The facility's controlled medication record showed one tablet was dispensed and signed out, but the MAR did not show documentation that the dose was administered. The resident's H&P indicated the resident had the capacity to understand and make decisions. An LVN and later the DON reviewed the record and verified that the medication had been pulled and that there was no documented evidence on the MAR. Facility policy required medications to be administered according to physician orders and required controlled medications to be documented on both the accountability record and the MAR at the time of administration. The survey findings showed that insulin glargine was documented as held on the MAR despite the DON stating it had been given, and that a controlled pain medication was signed out but not documented as administered on the MAR.
Medication Prepared for Two Residents on One Tray
Penalty
Summary
The facility failed to ensure that an LVN did not prepare medication for two residents on one tray with the intent of administering the medications sequentially. Resident 4 had osteoarthritis, intact cognition, and required substantial to maximal assistance with ADLs; his physician’s order included hydrocodone-acetaminophen 10-325 mg, one tablet every 4 hours as needed for severe pain. Resident 5 had liver cancer, intact cognition, and required substantial to maximal assistance with ADLs; her physician’s order included oxycodone HCl 5 mg every eight hours for pain. During a medication administration observation, the LVN was seen carrying two medication cups, each with one pill, and two cups of water on one tray to the roommates’ room. When Resident 5 was being transferred from a wheelchair to the bed, the LVN stated she would administer Resident 4’s medication first and return later for Resident 5’s medication. The LVN stated she knew both residents well and saw no issue with preparing and administering their medications together. The DON stated medications should be prepared and given to one resident at a time because preparing medication for multiple residents simultaneously could result in giving the wrong medication to the wrong resident. The facility policy stated medications are administered at the time they are prepared and are not pre-poured, and medications are administered without necessary interruptions.
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