Controlled Medication Reconciliation Failure
Summary
The facility failed to have an effective medication reconciliation system in place for controlled medications for 3 residents. Resident 8 had diagnoses including dementia and adhesive capsulitis of the right shoulder, and the MDS indicated moderately impaired cognition and impaired ROM in both upper and lower extremities. Resident 48 had diagnoses including dementia and a wedge compression fracture of the fourth lumbar vertebra, and the MDS indicated a short-term memory problem, moderately impaired cognitive skills for daily decision making, and dependence with all ADLs. Resident 49 had diagnoses including dementia and breast cancer, and the MDS indicated moderately impaired cognition. For Resident 8, the narcotic record showed lorazepam 1 mg was removed from controlled storage for administration, but the MAR for that same dose was not signed-marked as administered. For Resident 48, the narcotic record showed acetaminophen with codeine 300-30 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. For Resident 49, the narcotic record showed alprazolam 0.25 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. During interview, the DON stated the facility did not have a system in place where the MARs were reconciled with the narcotic records and had not investigated the controlled medications that were not accounted for. The DON also stated that signing the MAR indicated the resident received the medication and described the process for controlled medications as requiring licensed nurses to remove the medication, sign the narcotic record, and then sign the MAR once the medication was administered. The facility policy required an accurate reconciliation of controlled drugs and documentation of administration on the accountability record and MAR.
Plan Of Correction
F0755 CFR(s): 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records Root Cause: The root cause of the deficient practice was inconsistent adherence to controlled substance documentation and reconciliation processes, including failure to consistently verify Narcotic Records (NR), Medication Administration Records (MAR), and physical counts, along with lack of a standardized discrepancy resolution process and oversight. The corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/13/2026, for Residents #8, #48, and #49, the Director of Nursing (DON) and designee completed a full reconciliation of Narcotic Records (NR), Medication Administration Records (MAR), and physical controlled substance counts. Documentation was reviewed, staff were interviewed, and all narcotic counts were verified to ensure accuracy. Any discrepancies identified were immediately investigated and resolved. No adverse resident outcomes were identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/31/2026, the DON and designee conducted a 100% audit of all residents receiving controlled medications over the past 30 days, verifying: NR documentation accuracyMAR documentation accuracyPhysical count reconciliationCompletion of required signaturesNo additional unresolved discrepancies were identified. Any discrepancies, if identified, would be immediately investigated, reconciled, and documented, with staff re-education provided. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic controls:Standardized Reconciliation Process: Controlled substance counts will be completed at every shift change by two licensed nurses, verifying: Narcotic Record (NR) Medication Administration Record (MAR) Physical count of controlled medications Both nurses must sign and verify accuracy at each shift change. Real-Time Documentation Requirements: All controlled medications must be documented immediately at the time of removal, administration, waste, or return. Documentation must include date, time, dose, balance remaining, and two licensed nurse signatures for waste. Discrepancy Process: Any discrepancy will be identified immediately and investigated at the time of discovery. The licensed nurse will notify the DON/designee immediately. A discrepancy report will be completed, including documentation of findings and resolution. If diversion is suspected, the facility will initiate escalation procedures, including Administrator notification, Consultant Pharmacist involvement, and reporting per facility policy and regulatory requirements. Education & Oversight: On 3/30/2026, the DON conducted mandatory in-service training for licensed nurses on controlled substance procedures, reconciliation, and documentation requirements. The Consultant Pharmacist will provide ongoing monthly review and oversight of controlled substance practices. How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for controlled substance reconciliation and documentation. Monitoring Plan: The DON or designee will conduct weekly audits of a minimum of 5 residents receiving controlled medications for 4 weeks, followed by monthly audits for 2 months. Audits will include: NR vs MAR vs physical count reconciliation Completion of shift-to-shift narcotic count documentation Presence of required signatures Review of discrepancy identification, documentation, and resolution Corrective Action Loop: Any identified noncompliance will be corrected immediately, including reconciliation of counts and documentation updates. The responsible staff member will receive re-education prior to the end of the shift. A follow-up audit within 24 hours will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the Administrator and DON during the monitoring period. The Consultant Pharmacist will review findings during monthly pharmacy reviews. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Shift-to-shift narcotic counts, real-time documentation, discrepancy identification Director of Nursing (DON)/Designee: Oversight, audits, investigation of discrepancies Consultant Pharmacist: Monthly review and compliance oversight Administrator: Oversight and escalation if needed Completion Date: 4/13/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Not Primed Before Administration: An LVN administered Lantus to a resident with diabetes without priming the insulin pen first. The resident had orders for Lantus 30 units BID, and the LVN stated he was not familiar with priming the pen. The DON stated the pen should be primed before use to ensure the resident receives the appropriate dose.
A resident with restlessness, agitation, pain, palliative care, and a frontotemporal neurocognitive disorder had mismatched Ativan directions across the physician order, narcotic book, EMAR, and bubble pack card. The LPN, pharmacist, and DON all confirmed the entries should have matched, and the pharmacy card lacked notation for the different tablet strength listed in the EMAR.
Incorrect Sertraline Dose Administered: A resident with major depressive disorder and intact cognition was ordered sertraline 150 mg daily, but an MA administered only 100 mg after noticing the order called for 1.5 tablets and not pausing to clarify the discrepancy. The med label also showed 1 tablet, and the DON/VPCS stated staff should check orders against the MAR before administration; the facility policy required verifying the label and dose.
Expired influenza vaccines were found in the refrigerator of The Arbors medication room during an observation. Nurses stated they were responsible for checking medication rooms for expired meds, but the expired vaccines remained in storage despite staff being told to remove them before expiration. The DON, ADON, and Administrator each identified staff responsibility for checking medication rooms, and the facility policy stated multi-dose vials are discarded according to the manufacturer’s expiration date.
Controlled medications awaiting disposal were found stored in a locked cabinet in the med room, including Pregabalin, Lorazepam, Tramadol, Fentanyl patches, and Morphine. An LVN said the meds had been there for about a week, were not counted after placement, and one Morphine count sheet was missing from the cabinet. The DON said discontinued narcotics were supposed to be brought to her immediately for reconciliation and locked storage, but she had forgotten to retrieve them.
A resident with DM, ESRD, bipolar disorder, and autism had an order for Ritalin 20 mg BID for ADHD, but the medication was not administered for five days and nine scheduled doses were missed. Nursing notes repeatedly documented the drug as pending delivery, pending approval, or pending script, and the MAR showed each dose signed off with Code 9. The physician was not aware the resident had not received the medication, and the DON stated the delay occurred because the facility had to fax the hard copy prescription to the pharmacy.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when LVN B administered Lantus insulin to Resident #97 without priming the insulin pen first. Resident #97 was a cognitively intact male with diagnoses that included diabetes, peripheral vascular disease, acquired absence of left toes, and acquired absence of the right leg below the knee. His orders included Lantus 100 unit/mL insulin, 30 units subcutaneously twice daily, and his care plan identified diabetes with interventions for administering medications as ordered. During observation, LVN B obtained the insulin pen from the medication cart, inserted a needle into the rubber seal without cleaning it first, did not prime the pen, dialed the dose to 30 units, and injected the resident. When interviewed, LVN B stated he was not familiar with priming an insulin pen and did not fully know the technology behind priming it, despite having skills training within the year that included insulin use. The DON stated that an insulin pen should be primed before administration and checked for air bubbles because priming ensures the resident receives the appropriate dose. The Lantus package insert also stated to perform the safety test before each injection to ensure an accurate dose.
Medication Transcription Mismatch for Narcotic Order
Penalty
Summary
The facility failed to transcribe medication orders according to standards of practice for medication management for one resident with restlessness and agitation, pain, palliative care, and a frontotemporal neurocognitive disorder. The resident’s physician order for Ativan 0.5 mg solutabs directed that 0.25 mg be given by mouth every 4 hours as needed for restlessness, but the corresponding narcotic book page listed Ativan 5 mg every 4 hours as needed, while the EMAR listed 0.5 mg solutabs with directions to give 0.25 mg by mouth every 4 hours as needed. The bubble pack card for Ativan listed lorazepam 0.25 mg solutab with directions to dissolve 1 tablet by mouth three times a day and dissolve 1 tablet by mouth every 4 hours as needed, and the pharmacy card did not include a sticker or other notation to indicate the different tablet strength listed in the EMAR and not on the card. During observation of the medication cart, the narcotic drawer contained the resident’s Ativan 0.25 mg by mouth card, while the narcotic book page listed Ativan 5 mg every 4 hours as needed and the EMAR listed 0.5 mg solutabs with 0.25 mg by mouth every 4 hours as needed. The LPN confirmed the transcribed locations for the same order did not match and should have. The LPN described the facility process for receiving and transcribing new narcotics, including verification by two nurses and use of the index and narcotic book during counts. The pharmacist confirmed all three areas for the order, narcotic book, and card should match and stated that if there was a change in dose or tablet strength, the card should have had a sticker or other notation, but it did not. The DON stated staff were expected to enter orders received from the pharmacy, have two nurses count and verify the medications, write the correct directions for use in the narcotic book, and compare all areas during narcotic count and medication administration. A policy for medication transcription was requested but not provided.
Incorrect Sertraline Dose Administered
Penalty
Summary
Pharmaceutical services failed to meet the needs of Resident #16 when the facility did not ensure the ordered dose of sertraline was administered. Resident #16 was a [AGE]-year-old female admitted on [DATE] with diagnoses including major depressive disorder, recurrent, unspecified. Her quarterly MDS reflected a BIMS score of 13, indicating intact cognition, and documented that she was prescribed an antidepressant medication. The physician’s order dated 6/25/2026 directed sertraline HCl 100 mg tablets, 1.5 tablets by mouth in the morning for depression, with documentation in the progress notes that the Zoloft dose had been increased from 100 mg daily to 150 mg daily for improved symptom control. During observation on 7/09/2026 at 7:53 AM, MA A prepared medications for Resident #16 and the sertraline package label identified the medication as sertraline HCl 100 mg with instructions to give 1 tablet by mouth in the morning for depression. MA A administered 1 tablet of sertraline 100 mg instead of the ordered 1.5 tablets. In interview immediately afterward, MA A stated she noticed the order said one and a half tablets but was nervous and did not want to pause medication administration to clarify the order before giving the medication. She also stated she was not informed of a change to the sertraline dosage and should notify the nurse if she noticed a discrepancy between the medication order and the label. The VPCS stated staff should check all orders before administering medications and that the potential harm was medication error. The facility policy required staff to check the medication label against the MAR and re-check the dose to confirm the proper dose.
Expired Influenza Vaccines Left in Medication Room Refrigerator
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms reviewed, The Arbors. During an observation on 7/7/2026 at 10:41 am, the refrigerator in the medication room contained 3 boxes of influenza vaccine for the 2025-2026 season, lot #AX615A, that had expired on 6/30/2026. LVN A was present in the medication room and stated nurses were responsible for checking medication rooms daily, but she was not aware the vaccines were expired and said she would discard them. During interviews, RN B stated night shift nurses were responsible for checking medication rooms for expired medications and said she was not aware the expired influenza vaccines were in The Arbors medication room. The ADON stated nurses were responsible for checking medication rooms at night and said she had instructed staff before the end of June 2026 to remove the vaccines, but they were not removed. The DON stated nurses were responsible for daily night shift checks for expired medications and said staff had been told to remove the flu vaccines before they expired, but they did not. The Administrator stated the pharmacist, DON, and ADON were responsible for checking medication rooms and said they should be checked weekly for expired medications. Record review of the facility policy titled Medication Labeling and Storage, revised June 2026, stated that multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.
Controlled Medications Left Unreconciled in Medication Room
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation and an account of all controlled medications. During an observation in the medication room, controlled medications awaiting disposal were found stored underneath a counter in a locked cabinet that all nurses had a key to, including Pregabalin 25 mg tablets, Lorazepam 0.5 mg tablets, Tramadol 50 mg tablets, Fentanyl 50 mcg patches, and Morphine 100 mg/5 ml. LVN B stated the controlled medications had been under the cabinet for about a week and that discontinued narcotics were supposed to be taken to the DON immediately to be logged and locked in the DON's office. She also stated no one counted the medications once they were placed in the medication room and that the cabinet was missing a count sheet for one Morphine bottle, which she found folded in the narcotic count sheet book. The DON stated her locked area for discontinued narcotic medications was in the ADON's office and that she was the only one with keys. She said she intended to retrieve the discontinued narcotic medications on Monday but forgot, and that her expectation was for nurses to bring discontinued medications to her immediately after removal from the medication cart so she could reconcile them and lock them in her double-locked area. The DON also stated she normally checked with nurses on Monday, Wednesday, and Friday mornings to ensure narcotic medications were reconciled properly. The Administrator stated discontinued narcotic medications should be taken to the DON immediately and that the DON was responsible for ensuring no controlled medications were stored in the medication room.
Delay in Obtaining Ordered Ritalin
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure timely acquisition and administration of an ordered CNS stimulant medication for one resident. The resident was admitted with diagnoses including Type 2 diabetes, end stage renal disease, bipolar disorder, and autistic disorder. A physician order for Ritalin 20 mg by mouth twice daily for ADHD was entered with a start date of 06/26/2026, but the medication was not administered through 06/30/2026, resulting in a five-day delay and nine consecutive missed scheduled doses. The June 2026 MAR showed each scheduled dose of Ritalin was signed off with Code 9, indicating other, see progress notes, and no doses were given during the review period. Nursing documentation repeatedly noted the medication was pending delivery, pending approval, or pending script, and one note stated the resident was out for dialysis. The resident's initial MDS assessment was still in progress and the initial care plan assessment had not been completed. During interviews, the physician stated he was not aware the resident had not received Ritalin because it was pending from pharmacy and said the effect would be that the resident would not be able to concentrate. An LVN stated that if a medication was unavailable, the physician should be called for a prescription and the DON notified if doses were missed. The ADON stated staff should check the automated medication dispensing system, obtain a retrieval code from the pharmacy, and notify the physician immediately if the medication was unavailable, and acknowledged there had been miscommunication with the pharmacy. The DON stated the nurses were responsible for verifying admission orders and that the five-day delay occurred because the facility had to fax the hard copy prescription to the pharmacy.
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