A Golden Retreat Care Home, LLC

Based on documentation review, record review, observation, and interview, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of one resident reviewed. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Opioid/Controlled Substances Administration and Assistance in the Self Administration Policy and Procedure" that stated "...4. The resident's need for the opioid administration will be assessed by the trained caregiver based on the specific parameters defined in the physician's order. 5. A combination of a Wong-Baker FACES scale and numeric rating...will be used to assess pain level prior to administer opioids ...9. Resident relief of pain will be assessed by the trained caregiver between 30 minutes to one hour after administration and response must be documented in the Control Substance Administration record and Inventory flowsheet..." 2. Review of R1's medical record revealed a signed medication order dated July 14, 2023. This medication order stated "Oxycodone HCL 10mg 1T PO TID". 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Oxycodone HCL 10mg 1T PO TID" and indicated one tab was administered at 7am, 12pm, and 7pm August 1st - present. However, documentation was not available showing the identification of R2's need for the opioid and the effect of the opioid administered. 4. During an observation of R1's medications, Oxycodone HCL 10mg was observed and one tab was observed prefilled in the "MORN," "NOON," and "BED" slot of R1's medication organizer. 5. Review of R1's medical record revealed no documentation stating R1 had an end of life condition or an active malignancy. 6. In an interview, E1 acknowledged the caregiver did not document in R1's medical record the identification of R1's need for the opioid and the effect of the opioid administered.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 15, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated July 26, 2022. This medication order stated "Metoprolol Suss ER 25mg 1 tab oral QD Hold is SBP lower than 110mmhg or HR lower than 60". 3. Review of R2's medical record revealed a July 2023 and August 2023 medication administration record (MAR). These MAR's stated "Metoprolol Succ ER 25mg 1T QD (Hold if SBP [systolic blood pressure] below 110mmhg or HR [heart rate] below 60)" and indicated 1 tab was administered July 1st - present. However, R2's HR was below 60 on July 1st-2nd, 4th-11th, 14th-17th, 19th-20th, 24th-25th, 27th-30th, and August 1st. 4. During an observation of R2's medications, Metoprolol 25mg was observed and one tab was observed prefilled in the "Morning" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with the available medication order. 6. This is a repeat deficiency from the compliance inspections conducted August 27, 2021 and August 1, 2022.