The Elms of Lynchburg LLC

1. Corrective Action for Affected Residents Immediate audit of MARs completed. Reviewed narcotic logs, pharmacy refills, physician orders, and communication logs. Interviewed staff responsible for medication administration. Completed late entries where verification supported administration. Filed incident reports where doses could not be verified. Notified physicians and responsible parties where omissions occurred. Completed clinical assessments for adverse outcomes. 2. Identification of Other Residents at Risk Conducted 100% audit of all resident MARs for June 2026. Reviewed initials/signatures, PRN documentation, controlled substances, and treatment records. Corrected discrepancies immediately. 3. Systemic Changes Revised medication administration policy. Mandatory re-education for all medication staff. Competency testing with 90% passing requirement. Implemented end-of-shift MAR reconciliation. Incoming shift verification process. Supervisor daily MAR review. 4. Monitoring Process Daily MAR reviews x 30 days. Weekly MAR audits x 8 weeks. Monthly QA review x 3 months. Monthly staff competency checks. Findings reviewed in clinical and QA meetings. Progressive discipline for repeat noncompliance. 5. Compliance Date Facility alleges compliance by: July 19th, 2026 Additional Accountability Measures Repeat omissions result in written disciplinary action. Three occurrences in 90 days may result in suspension or termination of medication administration privileges. Administrator Attestation I certify that this Plan of Correction constitutes the facility's credible allegation of compliance and that all corrective actions will be completed by the date indicated.

The facility immediately initiated the criminal history background check for Staff Person #6 on 02/24/2026.Documentation of submission was obtained and placed in the employee personnel file. Upon receipt, the completed criminal histo1y report will be filed in the employee record and reviewed by the Administrator for compliance. Human Resources Hiring and Onboarding Policy requires: Background check submission prior to first day of work whenever possible. Tracking of submission and receipt dates in a centralized onboarding checklist. The Personnel File Compliance Checklist requiring verification of criminal history record receipt within 30 days will be reviewed The Business Office Manager/HR designee will continue to maintain Background Check Tracking with due dates and status indicators. The Administrator or designee will conduct: Weekly review of all new hires for required documentation for 90 days. Quarterly personnel record audits thereafter. Findings will be documented on the Personnel Record for survey review.

On 2/25/2026, the Administrator/designee reviewed Resident #3's record and verified the presence of the valid DDNR order. The ISP was immediately updated to include: Confirmation of DDNR status Location of DDNR documentation in record Emergency response protocol consistent with DDNR status Staff awareness and care coordination instructions Updated ISP was reviewed with resident/representative and signed. On 2/25/2026, the Administrator/designee completed a 100% audit of all resident records to identify residents with: DDNR orders Advance directives POST/DNR documentation Any ISP lacking documentation of advance directive status was immediately corrected and updated. The facility reinforced the requirement that all DDNR and advance directive documentation trigger ISP review/update within 7 days of receipt or identification. Admission checklist reviewed and included: Advance directive verification. DDNR presence ISP documentation confirmation Implementation Advance Directive Tracking implementation reviewed: Resident directive status Date obtained ISP update date Responsible staff DDNR orders will be maintained in: Resident chart designated advance directive section. ISP reference section Emergency information binder per facility policy Administrator/designee will conduct: Monthly audits for 3 months, then quarterly Random ISP audits verifying directive documentation Results will be reviewed through the facility QAPI process. On 2/26/2026, staff received education regarding: Virginia assisted living requirements for DDNR implementation ISP documentation expectations Emergency response consistent with advance directives Documentation location and accessibility Education attendance maintained in staff training records.

Resident #1: The UAI dated 02/18/2026 was immediately reviewed by the Administrator/designee. The mobility section was revised to specify mechanical assistance required. The stair climbing section was clarified to reflect independence/no assistance required. The updated UAI was reviewed with care staff and incorporated into the resident record and service planning process. Resident #2: The UAI dated 01/2026 was immediately reviewed. The bowel and bladder sections were corrected to reflect independence/no assistance required. The corrected UAI was signed, dated, and filed in the resident record. All corrections were completed prior to submission of this Plan of Correction. To prevent recurrence, the facility will reinforce the following measures: A full audit of all private pay resident UAls was conducted to verify,Assistance levels are clearly specified (independent, supervision, physical, mechanical, etc.) All AOL domains, including stair climbing and elimination, are completed. Documentation reflects current functional status. The facility reviewed its UAI completion protocol which requires: Documentation of the type and level of assistance whenever assistance is indicated Completion verification using a standardized UAI review checklist Administrator or designee secondary review prior to filing The facility integrated UAI review into the Individualized Service Plan (ISP) development workflow to ensure consistency between assessment and care planning. The Administrator or designee will conduct: Monthly UAI audits for 3 months, then quarterly thereafter Review of newly completed or updated UAls within 72 hours of completion. Findings will be tracked on a UAI audit tool and reviewed through the facility Quality Assurance and Performance Improvement (QAPI) process. Any identified discrepancies will be corrected immediately and used for targeted staff coaching. Staff responsible for assessment completion and review received in-service education on: 22VAC30-110 UAI requirements Documentation of assistance levels. Alignment between UAI and ISP. Education included case examples and competency verification. Training documentation will be maintained in the facility education file.

On 2/26/2026, the Administrator/designee conducted a 100% audit of all residents receiving hospice or home health services to verify ISP documentation accuracy. Any identified discrepancies were corrected immediately through ISP updates and interdisciplinary review. The facility reviewed the policy to ensure the process was followed for hospice determinations. Care Coordination Process Any initiation, discontinuation, or change in external healthcare services (hospice, home health, therapy) will trigger an ISP review within 7 days or sooner if clinically indicated to hospice services will be communicated by: Administrator RMA DRC, RN Nurse Consultant Memory Care Coordinator Notification documented in resident chart and ISP. Tracking review to be completed by DRC or designee: Service start date Service type ISP update due date Responsible staff The Administrator or designee will conduct monthly audits for 3 months, then quarterly thereafter, of residents receiving external healthcare services to ensure ISP accuracy. Audit results will be reviewed in QAPI meetings and corrective action taken as needed. On 2/26/2026, education was provided to licensed staff, RMAs, and care coordination personnel regarding ISP regulatory requirements Documentation of hospice involvement Interdisciplinary communication expectations Timelines for ISP revision

On 2/26/2026, the Administrator obtained a completed and dated Virginia Department of Health TB Screening and Risk Assessment form for Staff Person #3_ The form was reviewed for completeness and placed in the employee health file_ Staff Person #3 was verified to be free from communicable tuberculosis symptoms at time of review. On 2/26/2026, the Administrator and Business Office Manager/designee completed a 100% audit of all active employee health files to verify: Presence of TB screening documentation Completion of required sections Date of screening Screening within required timeframe prior to hire or within seven days of start. Any missing, incomplete, or undated TB documentation identified during the audit was immediately corrected by obtaining new completed screening forms. No additional staff were found without TB screeninq; however, no staff required replacement forms due to incomplete dating. The facility will continue with the following measures: Hiring Process Controls. A TB screening checklist I in the New Hire Orientation Packet. No employee will begin work without verification of completed TB documentation unless obtained within the regulatory 7-day window. A standardized Employee Health Record Checklist is in place TB screening completion and date verification continue to be mandatory checklist items. The Business Office Manager/HR designee is responsible for initial verification. The Administrator conducts secondary verification prior to completion of orientation. The facility will continue to utilize: Virginia Department of Health TB Screening Tool OR Equivalent form containing all required elements and date fields. On 2/26/2026, re-education was provided to administrative staff regarding TB screening regulatory requirements Acceptable documentation elements. Dating requirements Employee health record compliance. Attendance records for this in-service are maintained. The Administrator or designee will complete: Weekly new hire record audits for 4 weeks. Monthly employee health file audits for 3 months Results will be reviewed during QAPI meetings. Any variances will result in immediate corrective action and staff re-education.

On 02/24/2026, staff, Removed the two Latanoprost bottles from use. Replaced them with new bottles. Labeled new bottles with open date and discard date. Residents #6 and #7 continued to receive medication without interruption. The facility revised the ECP (EMR) Medication Management Plan to include Mandatory labeling of all medications with manufacturer-specified beyond-use dating once opened. Identification of medication categories requiring open-date labeling (eye drops, insulin, inhalers, creams, etc.). A standardized Medication Open Date Labeling Protocol is in effect. It requires, Documentation of open date, Calculated discard date, Verification during medication cart checks. Medication aides and nurses received education on manufacturer expiration guidance and documentation expectations. The RMA Director of Resident Care: Conduct weekly medication cart audits for 90 days focusing on open-date compliance. Transition to monthly audits thereafter. Results will be documented on the Medication Cart Audit Tool and reviewed during QAPI. RMA Director of Resident Care Administrator Medication Aides will be responsibleOn 02/24/2026, staff immediately: Removed all identified completed and discontinued medications from medication carts. Verified no further administration occurred after order completion discontinuation Reconciled medication carts against current physician orders. Medications were disposed of in accordance with facility medication destruction procedures. The facility revised the Medication Management Plan of the ELMS Extended Care Professional MAR SOFTWARE (ECP) to include the following procedures: Automatic Stop/ Completion Process Medications ordered for a defined duration (e.g., 7-day therapy) will be: Tracked using the eMAR stop date Removed from medication carts within 24 hours of completion Discontinued Medication Removal Process Upon receipt of a discontinuation order: Medication aide will immediately flag medication in eMAR. Medication will be removed from medication cart prior to next medication pass Medication will be stored in designated discontinued bin pending destruction using the ECP process Medication Cart Reconciliation Process Daily shift-to-shift cart check Weekly formal medication cart audit comparing: Physician orders eMAR Medication cart contents Policy Revision Medication Management Plan updated to include Completion date monitoring Discontinuation removal procedure Short-term medication tracking Documentation expectations ECP Medication administration staff received in-service training on: Short-term medication stop dates Discontinuation removal process Medication cart reconciliation expectations eMAR utilization for stop dates MONITORING RMA Clinical Director /RN Consultant will Conduct weekly medication cart audits for 90 days. v\udit will include verification of no expired, completed, or discontinued medications present. Results will be documented on the Medication Cart Audit Tool and reviewed in QAPI audit 90 days, audits will continue monthly. Administrator RMA Clinical Director, RN Medication Administration Staff

On 3/12 2026, the Administrator/designee and RN, DRC conducted an immediate review of the records for Residents #5, # 6, 7, and #10. Verification of current Physician/NP orders for blood glucose monitoring and insulin administration. Immediate implementation of blood glucose monitoring as ordered, with documentation recorded on the current MAR. Review of insulin orders and sliding scale parameters to ensure safe medication administration. Physician/NP notification was completed if any irregularities or safety concerns were identified. No adverse outcomes were identified during the review. On 3/12/ 2026, the Administrator/designee conducted a 100% audit of all residents with Physician/NP orders for blood glucose monitoring and insulin administration to ensure: Blood sugar monitoring is performed according to Physician/NP orders. Documentation is present on the MAR or blood glucose monitoring record. Insulin administration is documented according to sliding scale parameters. Any missing documentation or discrepancies identified during the audit were addressed immediately through staff follow-up and corrective documentation where appropriate. The facility reinforced the following procedures: Blood glucose monitoring will be documented immediately after the reading is obtained on the MAR or approved blood glucose monitoring record. Insulin administration will not occur without a documented blood glucose reading when required by Physician/NP order. Medication administration staff must verify that required blood glucose monitoring has been completed before insulin administration. Medication administration staff must review the MAR at the end of each shift to ensure: All blood glucose checks ordered were completed. All insulin administration was properly documented. The RN, DRC or/ Administrator designee will review blood glucose monitoring documentation during routine medication audits. The Administrator or designee will conduct weekly MAR and blood glucose documentation audits for 4 weeks, followed by monthly audits for 3 months. Audit results will be reviewed through the facility Quality Assurance and Performance Improvement (QAPI) program. On 3/12 / 2026, medication administration staff (including RMAs, nurses, and other authorized medication staff) received ongoing education regarding: Physician/NP order compliance requirements Blood glucose monitoring procedures Sliding scale insulin protocol Proper documentation requirements on the MAR Resident safety risks related to undocumented glucose monitoring Training attendance records will be maintained in ECP electronic education files

On 3/12/2026, the RN, DRC Administrator/designee immediately reviewed the electronic medication records for Residents #6, #8, and #15. Verification of current Physician/NP orders for all medications and treatments. Immediate correction of the MAR to accurately reflect current Physician/NP orders. Discontinued medications and treatments were removed from active MARs. Medication administration staff were instructed to follow updated orders immediately. Physician/NPs were notified where appropriate to review medication status. A clinical review was conducted to ensure no adverse effects occurred. On 3/12/2026, the Administrator/designee conducted a 100% audit of all resident medication records and Physician/NP orders to ensure: Discontinued medications were removed from active MARs. PRN medications were correctly listed as PRN. Frequency changes were accurately reflected on MARs. Medication administration instructions matched Physician/NP orders. Any discrepancies identified were corrected immediately. The facility’s electronic newly implemented Physician/NP order verification procedure requires: All new or changed Physician/NP orders to be reviewed and transcribed to the MAR within 24 hours. A second verification is completed by the RN/DRC or Administrator designee. When a medication is discontinued, staff must: Immediately remove the medication from the active MAR. Remove the medication from the medication cart if applicable. Document the discontinuation in the resident record. Any change in medication frequency, dosage, or administration instructions must be verified during the next medication pass. Medication carts and MARs will be reconciled weekly to ensure accuracy between Physician/NP orders and documentation. The Administrator or designee will implement the following monitoring process: Weekly medication administration audits for 4 weeks. Monthly medication record audits for 3 months. Audits will verify: Physician/NP orders match MAR instructions. Discontinued medications are not administered. Frequency and PRN orders are followed correctly; Audit results will be reviewed during the facility Quality Assurance and Performance Improvement (QAPI) meetings. On 3/12/2026, medication administration staff received training regarding: Physician/NP order transcription and verification procedures. Discontinued medication removal process. Proper documentation on MARs. PRN vs scheduled medication administration requirements. Resident safety risks associated with medication order errors Attendance records are maintained in ECP electronic staff training files.

On 3/13/2026, the Administrator/designee, the RN consultant and director of resident care conducted a review of the MARs for all residents identified in the citation. Staff responsible for medication administration were interviewed to determine whether medications were administered as ordered. When administration could be verified through supporting documentation (shift notes, medication cart review, or Physician/NP orders), a late entry was completed according to facility documentation policy indicating the medication was administered and explaining the missing initials. Any medications that could not be verified were reviewed with the Physician/NP/NP and pharmacist as appropriate to ensure resident safety. No adverse outcomes were identified. On 3/13/2026, the facility conducted a 100% audit of all resident MARs for the previous 60 days to identify any additional documentation omissions. Any missing initials were addressed through appropriate late entry documentation and staff follow-up. The facility reinforced the following procedures: Staff administering medications must initial the MAR immediately after administration. Medication administration will not be considered complete until documentation is recorded on the MAR. End-of-Shift MAR Reconciliation Medication staff are required to review the MAR at the end of each medication pass to confirm all medications administered are documented/DRC Medication Documentation Audit The RN/DRC Administrator designee will perform daily spot checks of MAR documentation. The Medication Management Plan has been revised to include: MAR documentation expectations Late entry procedures End-of-shift MAR reconciliation requirement The RN/DRC or Administrator or designee will conduct electronic weekly MAR audits for 4 weeks, then monthly audits for 3 months to verify compliance with medication documentation requirements. Audit results will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings. On 3/13/2026, medication administration staff (RMAs, LPNs, and other authorized staff) received continuing education regarding: MAR documentation requirements Proper medication administration procedures Importance of Immediate Documentation Late entry documentation protocol. Training attendance is maintained in the facility Extended Care Professional (ECP)education records.

1. Corrective Action Taken for the Affected Resident (Resident #1) Corrective actions completed immediately to protect Resident #1: Resident #1 was returned to the facility and medically evaluated per emergency response and follow-up. The facility initiated enhanced supervision immediately upon resident return: Increased rounding frequency (minimum every ___ minutes) while awake Continuous observation during high-risk timeframes (shift change, evenings, activity transitions) The Administrator/Designee initiated an immediate care plan/ISP revision to include: Elopement risk status: High Specific interventions for exit-seeking and wandering Individual triggers and redirection techniques The facility completed an Immediate Post-Incident Risk Review including: Timeline reconstruction Door integrity and alarm function verification Staff assignment verification Resident #1’s family/Responsible Party was notified, and a care conference was done: Incident details Updated supervision plan Prevention measures moving forward If clinically indicated, the facility contacted the resident’s provider regarding: Behavioral monitoring Dementia progression Safety recommendations ¿ Date Completed:1 /19/2026 Responsible Party: Administrator / RN Consultant/Director of Resident Care ________________________________________ 2. How the Facility Will Identify Other Residents Who May Be Affected The facility will conduct a facility-wide audit to identify all residents at risk for wandering/elopement, specifically those who: Reside in the safe secure unit Have dementia or serious cognitive impairment Have “wandering,” “exit-seeking,” “unable to recognize danger,” or “unable to self-preserve” documented in UAI/ISP Have prior incidents, near-misses, or exit attempts Audit actions: Review UAIs, reassessments, and ISPs for all safe secure unit residents (and any others with wandering risks). Confirm each resident has: Clear documentation of wandering/elopement risk Supervision plan tied to behaviors Specific interventions and monitoring frequency Verify all identified residents have updated: ISP interventions Shift-to-shift communication tools (behavior alert, assignment sheet, care cards) ¿ Date Completed: 1/19/2026 Responsible Party: Administrator / Designe________________________________________ 3. Systemic Changes / Measures Implemented to Prevent Recurrence To prevent recurrence, the facility will implement the following policy, supervision, and safety controls: A. Safe Secure Unit Supervision Protocol Effective 1/19/2026: Staff will conduct documented resident checks at minimum: Every ___ minutes for high-risk residents Every ___ minutes for all other secure-unit residents Checks must include verification of resident location and engagement/safety. B. Elopement Prevention Policy Implementation The facility will implement/revise a policy titled: “Wandering, Exit-Seeking, and Elopement Prevention & Response” including: Risk identification criteria Required interventions (redirection, structured activity, escort protocols) Monitoring requirements and documentation Immediate actions when a resident cannot be located (Code/Alert procedure) 911 notification, family notification, and incident reporting expectations C. Door/Alarm/Environmental Safety Controls Effective immediately: Facility will inspect and document functionality of: Door alarms Magnetic locks / delayed egress systems Wander management devices Cameras Daily shift checks will be added to confirm alarm integrity. D. Staffing Workflow During High-Risk Timeframes The facility will implement additional safeguards during: Shift change Dinner service Activity transitions Visiting hours (due to limited character space, the facility's full POC will not appear on this notice)

1. Corrective Action Taken for Resident #1 (Immediate Action) What actions were taken to correct the specific deficiency for Resident #1? On 10/29/2025, upon identification that Resident #1 was missing, staff initiated an immediate building sweep and grounds sweep, notified leadership, and proceeded with resident search actions per facility procedure. Upon Resident #1’s return to the facility at approximately 1:00 PM, Resident #1 was assessed for injury, and staff documented the fall and injuries (left pinky and ring fingernail area). Resident #1 was reassessed for cognitive status and elopement risk, including contributing causes such as increased confusion, grief reaction, and change in mental status. Resident #1 was placed on heightened supervision until care plan updates and interventions were implemented, including: Increased observation rounds Staff-to-staff communication at shift change and throughout the day Immediate alert for exit-seeking behaviors Facility ensured Resident #1 had a clinical review following the elopement and change in mental status. Resident #1’s family/Responsible Party was contacted and informed of the incident and interventions. Staff Responsible: Administrator / RN CONSULTANT / Director of Resident Care 2. Systemic Changes to Ensure the Deficiency Does Not Recur What actions will be taken to correct the root cause and prevent recurrence for all residents? The facility will implement the following systemic corrective measures: A. Updated Elopement Risk Identification & Monitoring The facility will revise the Admission Review and Ongoing Assessment process to ensure that any resident with: confusion, dementia, decreased orientation, supervision needs, exit-seeking history/behaviors, is immediately identified as an elopement risk and placed on appropriate precautions. B. Individualized Service Plan (ISP) and Care Plan Updates For any resident with mental status changes, exit-seeking behaviors, or wandering risk, the facility will ensure: ISP reflects supervision level required Behavior monitoring interventions are clearly written Staff responsibilities are assigned (who, when, how often) Interventions include prevention and response actions C. Increased Supervision and Structured Rounding Implement enhanced rounding procedures for residents identified as elopement risks: Minimum rounding frequency: every 30 minutes (or more often as assessed) Documented resident location checks Increased monitoring during known high-risk periods (meal transitions, shift change, afternoons, evenings) D. Exit Door Safety Procedures Facility will verify and reinforce: exit door alarms functioning properly staff response expectations for door alarms monitoring entrances during high-traffic periods visitor accountability procedures to prevent “tailgating” through secured doors E. Change in Condition Protocol When a resident displays acute confusion, agitation, or exit-seeking: the facility will notify the licensed nurse/RN CONSULTANT provider will be notified promptly (same day) assessment will include possible causes such as UTI, dehydration, grief reaction, medication effects, or dementia progression interventions must be added to the care plan immediately F. Incident Reporting and Timely Family Notification The facility will ensure consistent documentation and timely notification including: incident report completion the same day physician/NP notification responsible party notification with time documented interventions documented and implemented immediately following the incident Staff Responsible: Administrator / RN CONSULTANT/ Director of Resident Care (due to limited character space, the facility's full POC will not appear on this notice)

PLAN OF CORRECTION Deficiency Statement: The UAI for Resident #1 dated 09/04/2025 allegedly states on page 2 the resident is “disoriented some spheres some of the time,” however there is no documentation identifying which spheres are affected. Staff interview confirmed the spheres affected are time and place, but this was not reflected in the UAI documentation. ________________________________________ 1. Corrective Action Taken for Resident #1 On 9/18/2025, the Administrator/Designee reviewed the UAI for Resident #1. The facility ensured documentation was updated to clearly specify the cognitive spheres affected as time and place, consistent with staff observation and interview findings. The resident’s Individualized Service Plan (ISP) was reviewed and updated (if applicable) to reflect the correct cognitive status and support needs related to disorientation. ________________________________________ 2. How the Facility Will Identify and Correct Other Residents Potentially Affected The Administrator/Designee will conduct an audit of all current resident UAIs to verify: If cognition is marked as “disoriented,” the UAI specifies which spheres are affected (person, place, time, situation). Supporting documentation exists in the resident record (progress notes, nursing notes, assessments, care notes, etc.). Any UAI found with incomplete cognitive sphere documentation will be corrected immediately and reflected in the ISP as needed. Completion Date:1 /19/2026 ________________________________________ 3. Measures to Prevent Recurrence The facility will implement the following process changes: A. UAI Documentation Standard Effective 1/19/2026, staff completing or updating UAIs will ensure: If “disoriented some spheres some of the time” is selected, staff must document the specific sphere(s) affected: Time Place Person Situation Staff must also document the source of information supporting the selection (assessment observation, prior documentation, care team input). B. New UAI Verification Step The Administrator/Designee will review all UAIs for completeness before filing, using a checklist to verify cognitive sphere documentation is included when applicable. C. Policy/Procedure Update The facility will revise or implement a policy titled: “UAI Completion and Supporting Documentation Requirements” to include cognitive sphere clarity as a required element. Implementation Date: 1/19/2026 (due to limited character space, the facility's full POC will not appear on this notice)

Upon notification of the violation the facility immediately conducted a review of the referenced individual's criminal background documentation. All applicable background screening records were verified to determine applicability under the current barrier crime statutes. No resident safety threat was identified. If the citation applied to the staff the individual was immediately removed from duties. The staff person was immediately removed. Future compliance will be ensured as follows: All leadership and hiring personnel will be retrained on the barrier crime definition. Training will be documented and retained in facility training files. Monthly audits of 10% of personnel files and Quarterly compliance reviews with Human Resources will be conducted.

TEOL implemented the following system wide corrections: Policy Revision The Medication Management Policy was revised explicitly to state: The RMA licensed to administer medications is responsible for timely reporting of: Medication refusals ineffectiveness of PRN or routine medications Adverse reactions Medication errors Communication timelines were immediate, samesday,24-hour reporting requirements. All medication staff completed mandatory retraining on: Medication observation responsibilities signs and symptoms requiring prescriber notification Competency validation was completed and placed in personnel files

An immediate clinical review was completed for all affected residents. The prescribing physician /nurse practitioner were notified of any identified medication issues,observations,side effects or administration concerns discovered during record review Each residents Medication Management Plan was updated to clearly identify: The RMA licensed to administer medications as the responsible party for: Reporting medication refusals Side effects Effectiveness issues Adverse reactions Notifications and updates were documented in: Resident clinical notes Medication communication logs Prescriber contact records

A 100% audit of all current residents' medication management plans was completed to verify: Clear identification of the responsible medication staff Proper communication pathways to the prescriber Any resident records missing this designation were corrected immediately Pharmacy service consultant/RN consultant verified alignment between: Physicians' orders MAR documentation Medication Management plans