Park Senior Villas at Houghton - Villa Dd

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances, which posed a health and safety risk. Findings include: 1. A review of the facility's policies and procedures covering medication administration, reviewed August 21, 2023, revealed a policy covering inventorying controlled substances, which stated, "Controlled substances will be inventoried and verified at the end of each shift by two caregivers or designee." 2. A review of R1's medical record revealed a signed order for Morphine Sulfate (Concentrate) [20MG/ML] ...Take 0.25mL (5mg) Morphine in side of cheek or under tongue every four hours as needed for pain", dated June 6, 2024. 3. The Compliance Officer reviewed a Medication Administration Record (MAR) for June 2024. The MAR revealed administration of Morphine 0.25ML, on June 17, 18, 19, 23, and 24, 2024. However, no daily inventory record of the medication was provided. 4. E3 telephoned O1, who ordered the medication. The Compliance Officer heard O1 state, the initial order normally includes 5 syringes of Morphine. O1 further stated, R1's representative declined the medication and understood it was destroyed, though O1 was not present or witness to the destruction. 5. E3 telephoned O2, and was advised the pharmacy verified delivery of 10 syringes of Morphine 0.25ML on June 6, 2024 at 8:47pm to E7. 6. A search of the facility revealed additional Morphine 0.25ML dated July 15, 2024 and July 19, 2024. The syringes included a count sheet that was completed daily until R1's discharge, when the medications were sent to the safe for storage until destruction. 7. In an interview, E1 acknowledged the controlled substance log had not been updated each shift as required by the facility's policy regarding inventorying controlled substances.

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 two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan for directed care level of services and medication administration. 2. A review of R1's medical record revealed a signed order to change the Risperidone 1mg tab to .5mg tab on May 16, 2024 at 4:03 pm, with new dosing instructions. 3. A review of R1's Medication Administration Record (MAR) revealed Risperidone 1mg continued to be administered to R1 as previously ordered through May 20, 2024. The dosage was changed to Risperidone 0.5mg on May 21, 2024. 4. In an interview, E1 acknowledged the medication was not administered as ordered. E2 reported, E2 usually updated the medication orders and was out sick at the time the new order was received.