G & I Adult Care Home

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated September 16, 2025, which included “Levetiracetam 500 mg - take one tab PO twice a day.” 2. A review of R1’s medication administration records (MAR) for January 2025 revealed that R1 was administered one tablet of “Levetiracetam 500 mg” once daily. However, the medication order directed that Levetiracetam 500 mg be administered twice daily. 3. A review of R1’s medication organizer revealed that R1 is being administered “Levetiracetam 500 mg” in the morning and evening slots. 4. In an interview, E2 acknowledged that “Levetiracetam 500 mg” is only being documented in the evening as being administered. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.