Sanctuary Assisted Living LLC

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated November 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated December 5, 2023. This medication order stated "Metoprolol 25 mg tablet take 1 PO twice a day hold for SBP [systolic blood pressure] <110 or heart rate is <55". 3. Review of R2's medical record revealed a January 2024 medication administration record (MAR). This MAR stated "Metoprolol 25 mg tablet take 1 PO twice a day". The MAR documented a blood pressure reading of 107/51 on January 16, 2024 and that the medication was administered instead of being held per physician orders. 4. During an observation of R2's medications, Metoprolol 25mg was observed. 5. In an interview, E1 acknowledged R2's medication was not administered in compliance with the available medication order.