Complete Care At Harrington Court

x-ray.

Review of the facility policy titled Verbal Orders identified physician orders may be received by

follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).

075253 03/26/2026

Complete Care at Harrington Court 59 Harrington CT Colchester, CT 06415

discharge medications from [DATE] with APRN #2 on [DATE] and APRN #2 approved the orders. RN

PM identified the pharmacy received the orders from the facility electronically.

Upon initial review, a

technician.

After the medication technician was done, they passed the medications on to a different pharmacist for final review.

Neither pharmacist identified the irregularity in medication frequency ordered for the Methotrexate.

Person #1 further identified the pharmacist had the knowledge of the correct medication dosage and attributed the error to human error.

Person #1 identified training was conducted with the pharmacists that filled and checked the medication order as well as all pharmacists the company employs.Interview with RN #2 on [DATE] at 9:50 AM identified it was her responsibility as a supervisor to perform a second check of all admission orders and requirements for Resident #1 to include medication reconciliation against the hospital discharge paperwork. RN #2 further identified she did not identify the error made by RN #1.

Review of the facility contract with Guardian Consulting identified that Guardian Consulting would conduct all pharmacy reviews on newly admitted residents.The facility Medication Error Policy identified a medication error as the preparation or administration of drugs not in accordance with physician's orders.

The policy further identified a significant medication error, in part, as an error that caused the resident discomfort or jeopardized his/her health and safety.Review of facility documentation identified that a Plan of Correction was initiated immediately:All licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers were educated on medication administration including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR. RN #1, RN #2, and pharmacy staff received one-to-one education.Random Audits of residents with Methotrexate, other high-risk mediations, and all newly admitted residents were conducted and ongoing.

There were no additional residents identified with concerns or errors regarding Methotrexate, High-Risk medications or transcription errors.Results were reviewed through QAPI on [DATE] and were ongoing.The Director of Nursing was responsible for the implementation and monitoring with the Administrator maintaining overall regulatory oversight.Alleged compliance as of [DATE].The plan of correction was reviewed on [DATE] during an on-site visit and the facility met all components for past non-compliance.

075253 03/26/2026

Complete Care at Harrington Court 59 Harrington CT Colchester, CT 06415

second check of all admission orders and requirements for Resident #1 to include medication

jeopardy to resident health or the error made by RN #1.The facility Medication Error Policy identified a medication error as the safety preparation or administration of drugs not in accordance with physician's orders.

The policy further identified a significant medication error, in part, as an error that causes the resident discomfort or

Correction was initiated immediately:All licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers were educated on medication administration including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR. RN #1, RN #2, and pharmacy staff received one-to-one education.Random Audits of residents with Methotrexate, other high-risk mediations, and all newly admitted residents were conducted and ongoing.

There were no additional residents identified with concerns or errors regarding Methotrexate, High-Risk medications or transcription errors.Results were reviewed through QAPI on [DATE] and were ongoing.The Director of Nursing was responsible for the implementation and monitoring with the Administrator maintaining overall regulatory oversight.Alleged compliance as of [DATE].The plan of correction was reviewed on [DATE] during an on-site visit and the facility met all components for past non-compliance.

075253 03/26/2026

Complete Care at Harrington Court 59 Harrington CT Colchester, CT 06415

week prior to [DATE] and was unable to recall if Resident #3 had presented with any respiratory

APRN #1 see Resident #3 due to a change in respiratory condition on [DATE] and [DATE].

The ADON

(the [NAME] President of Clinical Services) on [DATE] at 2:20 PM identified the nurse that asked APRN #1 to see Resident #3 for a change in respiratory condition should have documented the assessment in the clinical record.Interview with LPN #4 (the 3:00 PM to 11:00 PM charge nurse) on [DATE] at 12:20 PM identified she recalled Resident #3 having an episode of wheezing in the week prior to [DATE]. LPN #4 further identified she reported the concerns to a supervisor and was told by the supervisor that she was aware of Resident #3's condition. LPN #4 was unable to recall who she reported Resident #3's change in condition to.The facility Documentation Policy identified, in part, that each residents' medical record shall contain an accurate representation of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation and documentation must occur no later than the end of the shift in which the assessment, observation, or care service occurred.