§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on interview with resident and staff, review of clinical record and facility provided documentation, it was revealed that facility did not ensure to administer medications according to professional standards of practice for two of five residents reviewed (Residents R1, R12)
Findings include:
Review of facility policy 'Administering Medications,' revised June 1, 2025, states that "the individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication."
Review of medication administration report revealed Resident R1 was administered the following medications at times which were not in accordance with physician orders on, April 9, 2026:
Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol, Powder, breath activated Give 2 puff by mouth two times a day for SOB, Scheduled time at 9:00 a.m.; Administered at 10:41 a.m.; Scheduled time: 5:00 p.m.; Administration Time: 6:47 p.m.
Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT Scheduled time: 9:00 a.m.; Administration Time: 10:37 a.m.
Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduled time: 9:00 a.m.; Administration Time: 10:41a.m.
Mucinex Oral Tablet Extended Release 12 Hour 600, MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days; Scheduled time: 9:00 a.m.; Administration Time: 10:38 a.m.
Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI (urinary track infection) for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 10:37 p.m.
Albuterol Sulfate Nebulization Solution (2.5 MG/3ML), 0.083% 3 ml inhale orally via nebulizer every 6 hours for COPD Supplementary; Scheduled time: 12:00 p.m.; Administration Time: 1:48 p.m.
Review of medication administration report revealed Resident R1 had the following medications administered on April 10, 2026 which were not in accordance to the time frame prescribed by the physician.
Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.
Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder, breath activated Give 2 puff by mouth two times a day for SOB; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.
Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days: Scheduled time: 9:00 a.m.; Administration Time: 11:35 a.m.
Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 11:35 a.m.
Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.
Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale orally via nebulizer every 6 hours for COPD Supplementary; Scheduled time: 12:00 p.m.; Administration Time: 1:14 p.m.
Review of medication administration report revealed Resident R1 was administered the following medications at times which were not in accordance with physician orders on April 11, 2026 (a.m.):
Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.
Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder, breath activated Give 2 puff by mouth two times a day for SOB; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.
Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days: Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.
Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.
Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduledat 9:00 a.m., administered at 11:05 a.m.
Interview with Resident R12 on Monday, April 20, 2026, at 10:00 am, indicated that medications were not administered timely on April 15, 2026, April 16, 2026, and April 17, 2026; Resident R12 expressed concerns for late medication administration since (she/he) takes medications for diabetes and heart issues.
Review of medication administration audit report revealed Resident R12 had the following medications administered on Wednesday, April 15, 2026:
Metoprolol Succinate Extended Release (ER) 25 mg scheduled at 8:00 a.m., administered at 3:21 p.m.
Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 3:33 pm.
Provera 10 mg, scheduled at 9:00 a.m.., administered at 3:21 pm.
Diltiazem HCL ER 120 mg, scheduled at 9:00 a.m., administered at 3:32p.m.
Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 3:21 p.m.
Losartan Potassium 100 mg, scheduled at 9:00 a.m, administered at 3:21 p.m.
Further review of Resident R12 medication administration audit report revealed the following medications were administered on Thursday, April 16, 2026:
Metoprolol Succinate ER 25 mg scheduled at 8:00 a.m., administered at 1:25 p.m.
Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.
Provera 10 mg, scheduled at 9:00 a.m., administered at 1:26 p.m.
Diltiazem HCL ER 120 mg, scheduled at 9:00 am, administered at 1:29 pm.
Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.
Losartan Potassium 100 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.
Further review of Resident R12 medication administration audit report revealed the following medications were administered on Friday, April 17, 2026:
Metoprolol Succinate ER 25 mg scheduled at 8:00 a.m., administered at 2:12 p.m.
Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.
Provera 10 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.
Diltiazem HCL ER 120 mg, scheduled at 9:00 a.m., administered at 2:12 p.m.
Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.
Losartan Potassium 100 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.
Review of medication administration audit report for Resident R13 revealed the following medications were administered on Thursday, April 16, 2026:
Amiodarone HCL 200 mg, scheduled at 9:00 a.m., administered at 2:01 p.m.
Aspirin 81 mg, scheduled at 9:00 a.m., administered at 1:59 p.m.
Magnesium Oxide 400 mg, scheduled at 9:00 a.m., administered at 1:59 p.m.
The above findings were confirmed with Facility Nursing Administrator , Employee E1, and assistant Director of nursing, Employee E2, on Monday, April 20, at 2:30 pm.
28 Pa. Code 211.10(c) Resident care policiies
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 06/05/2026
Medication administration for Residents R1 and R2 was reviewed and assessed. No adverse effects were identified. The attending physician and responsible representative were notified accordingly.
- A review of 10% of the facility population's MARs/TARs was conducted to ensure medications are administered in accordance with physician orders.
- Nursing staff were re educated that the individual administering medications must verify the five rights of medication administration (right medication, right dose, right resident, right time, and right route) by checking the medication label prior to administration.
- The facility's Medication Administration Times Policy was reviewed and revised to support the timely administration of medications.
- The DON Designee will conduct weekly medication administration audits for four (4) weeks in accordance with facility protocol. Audit findings will be reported and reviewed at the Quality Assurance (QA) Committee for ongoing monitoring and follow up.
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