F760 · Significant medication errors

Based on record review and interviews, the facility failed to prevent a significant medication error for one (#1) of three residents out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of cerebral infarctions due to an embolism (stroke) and a prosthetic mechanical heart valve.On 7/8/26 the facility entered the following physician's orders from Resident #1's admission orders:Coumadin (a blood thinning medication) 3 milligram (mg) tablets, give 9 mg every day for five days. Recheck the international normalized ratio (INR - a test to measure if the blood thinner is within the therapeutic level to prevent blood clotting) on day five and obtain new physician's orders for Coumadin, scheduled to start on 7/9/26 and end on 7/13/26. …

Larchwood Health and Rehab LLC · Colorado

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors which resulted in a resident requiring hospitalization for multiple nights in 1 of 3 residents reviewed for unnecessary medications. (Resident identifier is #1.)Findings include:Review on 8/27/26 of Resident #1's progress note, dated 8/11/26, revealed Resident #1 was sent to the emergency room because a medication error had occurred and nursing staff were concerned about his electrolyte levels.Review on 8/27/26 of Resident #1's laboratory results, dated 8/11/26, revealed that Resident #1's Blood Urea Nitrogen (BUN) was 112 mg/dL (milligrams per deciliter) and creatinine was 6.80 mg/dL. …

Country Village Center, Genesis Healthcare · New Hampshire

Based on observations, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #126) of 3 residents reviewed for medication administration.The facility failed to ensure CMA E did not crush Resident #126 Finasteride Oral Tablet 5 MG (Finasteride- used to treat enlarge prostate) and Potassium Chloride ER 10 MEQ on 9/16/2026.This failure could place residents at risk of not receiving the full therapeutic effects of their medication and can result in a decline of their health conditions. The Findings include:Record review of Resident #126's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. …

Lamun-Lusk-Sanchez Texas State Veterans Home · Texas

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the significant medication errors. * The facility failed to administer Resident 1's ketotifen (an antiallergic medicationto help prevent asthma attacks) as ordered by Resident 1's physician. This failure had the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Medication Administration revised 4/2025 showed the medications shall be administered as prescribed by the resident's physician. Medical record review for Resident 1 was initiated on 4/15/25. …

Garden Grove Post Acute · California