Our Home on Rosewood, LLC

Based on observation, record review, documentation review, and interview, for two of two resident records reviewed, the manager failed to ensure medication administration was documented in a resident's medical record. The deficient practice posed a health and safety risk to a resident if a medication administered to a resident was not documented, as required. Findings include: 1. In observation, R1 had Oxycodone oral solution; (a schedule II controlled substance), on site and stored by the facility. The medication bottle indicated Oxycodone oral solution; 240ml was dispensed on November 28, 2023. The Compliance Officer observed approximately 75ml of Oxycodone solution remained in the bottle. 2. In record review, R1's medical record (received directed care and medication administration services) included a medication order: Oxycodone oral solution; take 1 teaspoonful (5ml) per tube every 4 hours as needed. The record did not include documentation of the administration of the Oxycodone medication to R1. 3. During an interview, E2 reported the Oxycodone was administered to R1 for pain; however, E1 and E2 acknowledged the medication administration was not documented on the resident's medication administration record. 4. In observation, R2 had Morphine medication (a schedule II controlled substance), on site and stored by the facility. The morphine medication indicated 30 syringes were dispensed on July 3, 2023, and 13 syringes remained. 5. In record review, R2's medical record (received directed care and medication administration services) included a medication order for Morphine 20mg/ml, take 0.25ml by mouth under the tongue every 1 hour as needed for pain. The record did not include documentation of the administration of the morphine medication to R2. 6. During an interview, E2 reported R2 was administered the morphine medication occasionally. E1 and E2 acknowledged the medication administration was not documented in the resident's medical record.

Based on observation, record review, documentation review, and interview, for two of three residents reviewed, who received controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation R1's medications were observed to include the following controlled substances: - Lorazepam; 30 pills were dispensed on December 5, 2023, and 20 pills were observed in the bottle. - Oxycodone oral solution; 240ml was dispensed on November 28, 2023, and approximately 75ml of Oxycodone solution was observed in the bottle. 2. In observation R2's medications were observed to include controlled substances: - Lorazepam syringes; ten syringes were dispensed on September 7, 2023, and ten syringes remained. - Morphine syringes; 30 syringes were dispensed on July 3, 2023, and 13 syringes remained. 3. In record review, the medical records for R1 and R2 did not include an inventory of the controlled substances. 4. In documentation review, a facility policy, titled "Medications..." documented on page 2, "...3. As soon as possible, medication will be inventoried and placed in the resident's labeled medication bin... B... 4. The opioids and narcotic medications will be inventoried and placed in the medication storage area. 5. Daily narcotic administration will be recorded on each resident MAR or Narcotic Administration Record..." 5. During an interview, E1 and E2 acknowledged an inventory of the residents' controlled substances was not maintained.

Based on observation, record review, and interview, for two of two residents reviewed, and receiving opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if the resident's level of pain was not documented, as required. Findings include: 1. In observation, R1 had Oxycodone medication (a schedule II controlled substance), on site and stored by the facility. The Oxycodone bottle indicated the Oxycodone 240ml was dispensed on November 28, 2023. The Compliance Officer observed approximately 75ml of Oxycodone solution remained in the bottle. 2. In record review, R1's medical record (received directed care and medication administration services) included a medication order; Oxycodone, take 1 teaspoonful (5ml) per tube every 4 hours as needed. The record did not include documentation of the administration of the Oxycodone medication to R1, including an identification of the need for the medication, and the monitoring of the effect. 3. During an interview, E2 reported the Oxycodone was administered to R1 for pain; however, E1 and E2 acknowledged the medication administration was not documented on the medication administration record as administered, and there was no documentation of an identification of the need for the medication, and the monitoring of the effect. 4. In observation, R2 had Morphine medication (a schedule II controlled substance), on site and stored by the facility. The morphine medication indicated 30 syringes were dispensed on July 3, 2023, and 13 syringes remained. 5. In record review, R2's medical record (received directed care and medication administration services) included a medication order for Morphine 20mg/ml, take 0.25ml by mouth under the tongue every 1 hour as needed for pain. The record did not include documentation of the administration of the morphine medication to R2, including an identification of the need for the medication, and the monitoring of the effect. 6. During an interview, E2 reported R2 received the morphine occasionally. E1 an E2 acknowledged the medication administration was not documented on the medication administration record, as administered, and there was no documentation of an identification of the need for the medication, and the monitoring of the effect.