Elmwood Senior Living

Based on record review and interview, the manager failed to ensure that medications were administered in compliance with a medication order and failed to accurately document the administration of medications in the medical records, for two of two sampled residents who received medication administration services. The deficient practice posed a risk to residents if medications were not administered according to the medication orders and if the documentation of medication administration was inaccurate. Findings include: 1. A review of R1's and R2's medical record revealed a service plan reflecting R1 and R2 received medication administration services. 2. A review of R1's medical record revealed a progress note dated which reflected R1 was admitted to Chandler Regional Medical Center on January 8, 2025 and the facility was notified on January 28, 2025, R1 would no longer return to the facility. 3. A review of R1's medical record revealed a medication administration record (MAR) dated February 2025, which reflected R1 was administered Methenamine 1 mg and Centrum 15 ml tablet on February 4, 2025 at 8 am. However, R1 was unadmitted from the facility and could not have recieved the above medications. 4. In an interview, E1 acknowledged R1's medication was documented as administered although R1 has not been in the facility since January 8, 2025. 5. A review of R2's medical record revealed a medication order dated December 5, 2025 for Furosemide 20 mg give one tablet two times a day for diuretic, hold if systolic blood pressure is below 100. 6. A review of R2's MAR dated January 2025, which reflected R2 was administered Furosemide 20 mg at 7 am and 4 pm from January 1, 2025 through January 17, 2025, without documenting R2's systolic blood pressure before administration. 7. In an interview, E1 acknowledged and reviews R2's medical record did not reflect R2's Furosemide was administered according to R2's medication order.