The Elms Center

for 1 of 4 residents reviewed for admission orders (Resident identifier is #4).Findings include:Review

[name omitted] was discharged from [hospital omitted] on 5/9/26. [pronoun omitted] discharge summary was not reviewed with the physician on call.Medications had changed and [pronoun omitted] received the wrong dose of some [medications] and omission of others [medications] from 5/9/26 - 5/13/26.Review on 5/27/26 of Resident #4's Hospital Discharge summary dated [DATE] revealed a change in Carvedilol dose from 25mg to 12.5mg twice a day, a new order for Voltaren 1% gel topically to lower back twice a day, and a change in administration time for Divalproex from three times a day to every 8 hours.Review on 5/27/26 of Resident #4's May 2026 Medication Administration Record (MAR) revealed Carvedolil 25mg was administered to Resident #4 from May 9 to May 12 (6 doses).

Further review revealed Divalproex was administered at 8 a.m., 2 p.m., and 8 p.m. from May 9 to May 12 (6 hours between doses).

Further review of MAR revealed no new order transcribed or administered for Voltaren gel.Interview on 5/27/26 at approximately 11:30 a.m. with Staff B (Nurse Practitioner) confirmed Resident #4's medications were not reviewed with a provider or reconciled upon re-admission to the facility on 5/9/26.Interview on 5/27/26 at approximately 12:00 p.m. with Staff A confirmed above findings.Review on 5/27/26 of facility policy titled Medication Reconciliation revised date 9/30/2025 revealed .Policy Explanation and Compliance Guidelines:.4. admission Processes:.b.

Compare orders to hospital records, etc [etcetera] Obtain clarification orders as needed.d.

Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review.5.

Daily Processes:.c.ii.

Perform 24 hour chart checks to verify all new orders have been addressed.Review on 5/27/26 of Quality Assurance Performance Improvement (QAPI) Action Plan, dated 5/13/26, for new admission/readmission medication reconciliation, revealed the following actions/interventions: reorganize admission packet/checklist; reeducate nursing to double check orders for new admissions/readmission; and a monitoring plan to ensure the corrective action was effective.Review on 5/27/26 of facility's revised admission checklist for nursing revealed it included confirming orders with the provider, entering orders into MAR, and second checks for orders.Review on 5/27/26 of nursing training for the new admission process revealed it began on 5/20/26 and was completed 5/26/26.Interview on 5/27/26 at approximately 12:00 p.m. with Staff A revealed that newly admitted or readmitted residents were reviewed each day with the clinical team to ensure all orders and treatments were accurate.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE