Failure to Maintain and Account for Ordered PRN Morphine for Hospice Residents
Summary
Surveyors identified a deficiency in the facility’s provision of pharmaceutical services, specifically related to controlled medications for two hospice residents. For one resident, a female with diagnoses including nontraumatic intracerebral hemorrhage, depression, adult failure to thrive, altered mental status, and functional quadriplegia, the record showed an active PRN order for Morphine Sulfate (Concentrate) Solution 20 mg/mL, 0.25 mL by mouth every 4 hours as needed for pain, ordered and started on 12/15/2025. Her MDS and care plan documented that she had a terminal prognosis, was on hospice services, and was receiving pain management with pain medication therapy. However, during observation and interview, the RN confirmed there was no PRN morphine stored in the assigned medication cart, no hardcopy Individual Narcotic Record for this PRN morphine, and she was not previously aware of the active PRN narcotic order. The DON later stated that hospice had dispensed morphine on 12/04/2025, that the PRN morphine order had not been discontinued by the provider, and that she could not locate the medication administration/destruction record or the morphine for this resident. For the second resident, a male with diagnoses including COPD, cognitive communication deficit, rheumatoid arthritis, adult failure to thrive, and muscle wasting and atrophy, the record showed two active PRN morphine orders: Morphine Sulfate (Concentrate) Oral Solution 100 mg/5 mL, 0.25 mL sublingually every 3 hours as needed for pain/shortness of breath, and Morphine Sulfate (Concentrate) Solution 20 mg/mL, 10 mg by mouth every 3 hours as needed for pain. His MDS and care plan documented a terminal prognosis, hospice services, and pain management with a scheduled pain regimen. During observation and interview, LVN A reviewed the medication cart, narcotic binder, and electronic medical record and confirmed there were two active PRN morphine orders but no PRN morphine stored in the cart and no hardcopy Individual Narcotic Record for these orders. LVN A recalled that the resident’s spouse did not want him on morphine and wanted the medication discontinued sometime in January 2026, but she was not aware of any documentation supporting this conversation. The DON stated that this resident had one dose of morphine administered on 11/18/2025 and that the medication was then given to her for destruction on 03/02/2026, while the PRN morphine order remained not discontinued by the provider. Multiple staff interviews confirmed that ordered medications, including narcotics, should be present and readily available in the facility when there are active orders, and that controlled substances must be documented on an Individual Narcotic Record and handled according to policy. The hospice RN, Patient Care Manager, Clinical Team Leader, and Director of Clinical Services all confirmed that there were active PRN morphine orders for these residents and that hospice had dispensed morphine to the facility, with documentation of delivery and expectations for communication between hospice and facility staff regarding refills, discontinuations, and destruction. Facility policies on Medication Administration, Pain Management, Medication Storage and Disposal, and Statement of Resident Rights required that medications be administered as ordered, controlled substances be properly documented and disposed of with appropriate recordkeeping, and that residents receive care necessary to attain their highest possible level of health, including pain management consistent with professional standards of practice. Despite these policies and active orders, the facility did not have the prescribed PRN morphine on hand for the two residents, did not maintain required controlled substance accountability records, and could not locate the medication or related administration/destruction documentation for at least one resident.
Penalty
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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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