Ortiz Sunnyside Assisted Living, LLC

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s medical record revealed R1 received medication administration. 2. Review of R1’s medical record revealed a signed medication order for the the following medications: Insulin Lispro KwikPen 100 units/ mL injectable solution; inject 100 units injectable 3 times a day (Before Meals) for diabetes; Inject 40 units subcutaneously 1X daily at bed time for diabetes. 400 notify medical director” Hydralazine 50 mg oral capsule; take 1 tab(s) orally 3 times a day for hypertension…; Hold for SBP less than 110 or HR less than 55.” 3. Review of R1’s March 2025 medication administration records (MAR) revealed Lispro KwikPen units were not documented at 11am and 5pm on March 28th, 29th, 30th, and 31st of 2025. The 7am documentation of the units was not documented on March 29th, 30th, and 31st of 2025. 4. Review of R1’s MAR revealed Hydralazine HCL 50mg was not documented on March 31, 2025 at 2pm and 8pm. 5. In an interview, E2 reported that the medication was administered, however it was not documented on the MAR.