White Dove at Sunrise Mountain Assisted Livinghome

Based on record review and interview, the manager failed to ensure a resident's medical record contained the name and signature of the individual administering medication, for one of two residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of R1's (received medication administration) medical record revealed a signed medication order dated October 2023, for the following medication: -Atorvastatin 20 mg take one tablet daily 2. A review of R1s medication administration record (MAR) for December 2023, listed Atorvastatin. However, the MAR did not contain the name and signature of the individual administering the medication for the 8:00 PM administration on December 25, 2023. 3. In an interview, E1 reported the medication was administered to R1, however, E2 forgot to sign the MAR. E1 acknowledged the medical record for R1 did not include the name and signature of the individual administering the medication. This is a repeat deficiency from the complaint investigation conducted on June 15, 2022.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed Lispro Insulin unlocked in the kitchen refrigerator. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E2 acknowledged medications were stored unlocked. This is a repeat deficiency from the compliance inspection conducted on June 15, 2022.