Inge's Uniquely Warm Assisted Living - II

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of one resident sampled. Findings include: 1. A review of R1's medical record revealed R1 received directed care and medication administration services. 2. A review of R1's medical record revealed a medication order dated December 19, 2024 for: Gabapentin 100 mg, 1 tab by mouth, once daily to be discontinued and Gabapentin 300 mg, one tab by mouth, once daily to begin 4. A review of R1's medication administration record (MAR) for December 2024 revealed Gabapentin 100 mg was administered to R1 daily from December 19-31, 2024 and Gabapentin 300 mg was not administered until January 1-8, 2025. 5. In an interview, E1 acknowledged E1 failed to ensure medication administered to R1 was administered in compliance with a medication order.

Based on observation, 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 one sampled resident who received medication administration. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1 at the facility during the time of inspection. 2. A review of R1's medical record revealed R1 received directed care and medication administration services. 3. A review of R1's medical record revealed a medication order dated November 22, 2024 for: Trazadone 100 mg, one tab by mouth, once a day at hour of sleep 4. A review of R1's medication administration record (MAR) for December 2024 revealed Trazadone 100 mg was properly administered per the medication order; however, the MAR for January 1-8, 2025 did not document that Trazadone 100 mg was administered to R1. 5. In an interview, E1 stated, E1 is "not sure why Trazadone is not documented on the MAR but Trazadone is given every night" to R1. 6. In an interview, E1 acknowledge E1 failed to ensure a medication administered to a resident was documented in the resident's medical record.