Callaway Nursing Home

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician orders for administering medication for 1 (#2) of 4 sampled residents reviewed for following physician orders.

The administrator identified 51 residents resided in the facility.

Findings: Resident #2's hospital discharge papers, dated 08/21/25, showed the resident was diagnosed and treated for bacterial pneumonia during the hospital stay. A health status note, dated 08/21/25 6:24 p.m., showed Resident #2 was re-admitted to the facility on [DATE].The hospital discharge medication list, dated 08/21/25, showed the resident should had received the following new medications which had not been added to the resident's physician orders upon readmission to the facility: a.

Albuterol (bronchodilator) 0.083 % Inhalation Solution, 3 milliliters HHN every 4 hours as needed;b. bumetanide (diuretic) AvPak, 0.5 mg orally twice daily;c.

Cobenfy (antipsychotic) 125 mg-30 mg, one capsule orally twice daily;d. digoxin (used to strengthen the heart) 0.125 mg, 0.25 mg daily at noon;e. divalproex Sodium (anticonvulsant) AvPak 500 mg, extended release, 1500 mg orally daily;f. hydrochlorothiazide (diuretic) 25 mg, 25 mg orally daily;g.

Klor-Con (potassium supplement) 20 meq, extended release, 40 meq orally twice daily;h. lacosamide (anticonvulsant) 200 mg, 200 mg orally twice daily;i. lactobacillus (bacteria to aide in digestion) 0.05 mg-0.05 mg, one tablet orally twice daily;j.

Levalbuterol (bronchodilator) 1.25 mg, 1.25 mg HHN twice daily;k. magnesium Glycinate (magnesium supplement) 100 mg, 400 mg orally twice daily;l. midodrine HCL (antihypotensive) 5 mg, 2.5 mg orally three times daily;m.

Miralax (laxative) 17 gram/1 dose oral powder for solution, orally twice daily;n. tamsulosin HCL (treatment of benign prostatic hyperplasia) 0.4 mg, 0.4 mg orally at bedtime;o. trospium Chloride (treatment of overactive bladder) 20 mg, 20 mg orally daily;p. clozapine (antipsychotic) had been changed from 50 mg, 3 tablets at bedtime to clozapine 25 mg at bedtime; andq. risperidone (antipsychotic) was changed from 3 mg, 2 tablets daily to risperidone 1 mg, give 3 mg daily.A health status note, dated 08/23/25 2:17 p.m., showed Resident #2's physician gave an order for the resident to be transferred to the emergency room due to respiratory concerns. On 10/27/25 at 1:10 p.m., the DON stated the medication additions to Resident #2's physician ordered medication list should have been added and given to the resident.

The DON stated none of the above listed medications had been given as ordered by the physician upon Resident #2's readmission to the facility from the hospital on [DATE] until their discharge to the hospital again on 8/23/25.

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 REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

37E624