Perkins Care Home

The facility failed to maintain readily retrievable records that accurately reconcile the receipt and administration of controlled substances. Specifically, for one resident, the medication on hand did not reconcile with the documented administration of oxycodone following an order change.

The facility failed to accurately document the receipt, administration, and disposition of controlled substances. Specifically, the controlled substance count sheet for Resident #1's oxycodone did not reconcile with the actual medication on hand, and staff admitted that controlled substance counts were not performed daily.

The facility failed to maintain accurate medication administration records (MAR) for Resident #1. Specifically, the facility documented the administration of Humulin R and Lantus insulin even when finger stick blood sugar (FSBS) levels were below the required hold threshold of 110. Multiple instances occurred between December 2017 and February 2018 where medication was administered despite low blood sugar readings.

The facility failed to maintain an accurate medication administration record (MAR) for Resident #1. Specifically, the MAR documented the administration of Humulin R insulin on four separate occasions in December 2017 despite finger stick blood sugar levels being below the required threshold of 110.