F0755

E

Failure to Accurately Account for and Document Controlled Substances

Wexford, Pennsylvania Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to ensure accurate accounting and documentation of controlled substances for nine of twelve reviewed residents. Facility policy required that the individual administering a medication record the dose on the MAR immediately after administration. For multiple residents receiving PRN and scheduled opioid analgesics, including oxycodone, Endocet (oxycodone/acetaminophen), Tramadol, and hydrocodone/acetaminophen, there were discrepancies between the controlled substance records and the MARs. Specifically, numerous doses were signed out on the controlled substance records on various dates in February 2026 without corresponding documentation of administration on the residents' MARs.

For one resident with an order for oxycodone 5 mg every six hours PRN, 15 additional doses were signed out beyond the 10 administrations documented on the MAR. Another resident with Endocet orders for moderate and severe pain had six extra doses signed out without matching MAR entries, while a third resident on Endocet for severe pain had 10 such undocumented doses. Additional residents with PRN oxycodone, Tramadol, and hydrocodone/acetaminophen orders each had multiple doses signed out on the controlled substance records that were not documented as given on the MARs. During an interview, the Nursing Home Administrator and the DON confirmed that controlled substances were not accurately accounted for for these nine residents.