IOCAM ASSISTED LIVING HOME

Based on documentation review, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy titled "Medications including opioids and narcotics." The policy stated "The trained caregiver will initial in the MAR (Medical Administration Record) and include the date and time the medicene was given to the resident and the medications that were taken." 2. A review of R1's and R2's medical records revealed R1 and R2 received medication administration services. 3. A review of R1's medical record revealed a MAR for January 2024. R1's January 2024 MAR did not indicate the following medications were administered on January 22, 2024 at the following times: -"Acetaminophen" at 8:00 PM; -"Carbidopa-Levodopa" at 12:00 PM, 6:00 PM, and 12:00 AM; -"Famotidine" at 8:00 PM; and -"Trazodone" at 8:00 PM. 4. A review of R2's medical record revealed a MAR. R2's January 2024 MAR did not indicate the following medications were administered on January 22, 2024 at the following times -"Quetiapine" at 10:00 PM; -"Trazodone" at 10:00 PM; -"Acetaminophen" at 2:00 PM and 8:00 PM; -"Busiprone" at 8:00 PM; -"Ferrous Sulfate" (from January 19, 2024 through January 22, 2024) at 8:30 AM; -"Hydroxychloroquine" at 8:00 PM; -"Ipratropium and Albuterol" at 8:00 PM; and -"Diclofenac" at 10:00 PM. 5. In an interview, E1 reported the medication was administered and staff must have forgotten to document in the MARs. E1 acknowledged medication administered to a resident was not documented in the resident's medical record.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer ovserved a glass container of "Lorazepam 2 MG" (milligrams) sitting on a tray in the refrigerator in the kitchen. The refrigerator was not locked. 2. In an interview, E1 acknowledged the aforementioned medication stored by the facility was not stored in a locked area.