Adagio Care LLC

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. Findings include: 1. The Compliance Officer arrived at the facility at approximately 12:00 PM. 2. A review of R1's revealed R1 received medication administration services. R1's medical record contained medication orders signed and dated by a medical practitioner on May 18, 2023, for the following medications: -"Omeprazole 20 mg (milligrams) capsule,delayed release take 1 capsule by mouth 30-60 minutes before meal one time daily at 7:00"; -"Bupropion HCI XL 150 mg 24 hr tablet, extended release take 1 tablet by mouth once daily at 08:00"; -"Furosemide 20 mg tablet take 1 tablet by mouth once daily at 08:00"; -"Metformin 500 mg tablet take 1 tablet by mouth daily before breakfast at 08:00"; -"Sertraline 50 mg tablet take 1.5 tablet by mouth once daily at 08:00"; -"B-Complex tablet take 1 capsule by mouth once daily at 08:00"; -"Eliquis 5 mg tablet take 1 tablet by mouth twice daily at 08:00 and 17:00"; -"Entresto 49 mg-51 mg tablet take 1 tablet by mouth twice daily at 08:00 and 17:00"; and -"Levetiracetam 500 mg tablet take 1 tablet by mouth every 12 hours at 8:00 and 20:00". 3. A review of R1's medical record revealed a medication administration record (MAR) dated June 2023. R1's June 2023 MAR revealed the following medications were administered to R1 on June 1-20, 2023: -"Omeprazole DR 20 mg" at 7:00 AM; -"Bupropion HCL XL ER 150 MG" at 8:00 AM; -"Furosemide 20 mg" at 8:00 AM; -"Metformin 500 mg" at 8:00 AM; -"Sertraline 50 mg" at 8:00 AM; -"B-Complex" at 8:00 AM; -"Eliquis 5 mg" at 8:00 AM; -"Entresto 49MG-51 MG" at 8:00 AM; -"Levetiracetam 500 mg" at 8:00 AM; However, documentation to indicate the aforementioned medications were administered to R1 on the morning of June 21, 2023 was not available for review. 4. In an interview, E1 reported the aforementioned medications were administered to R1, however, staff forgot to document the medications administered on R1's MAR. E1 acknowledged medication administration was not documented in R1's medical record on June 21, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. During the environmental inspection of the facility, the Compliance Officer observed an unlocked kitchen refrigerator. The Compliance Officer observed one bottle of "Latanoprost 0.0005% eye drops" belonging to R2 inside the refrigerator. 3. A review of the facility's policies and procedures revealed a policy titled "Medications Including Opioids and Narcotics" dated January 21, 2022. The policy stated "...2. Medication stored by the facility will be locked in the medication storage area." 4. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.