PREMIER 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 June 16, 2023. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed a signed medication order dated September 18, 2023. This medication order stated "Gabapentin 100mg 2 tabs po three times daily".

3. Review of R2's medical record revealed a December 2023 medication administration record (MAR). This MAR stated "Gabapentin 300mg 1 tab PO TID" and indicated one tab was administered at 8am, 2pm, and 8pm December 1st - present.

4. During an observation of R2's medications, Gabapentin 300mg was observed and one tab was observed prefilled in R2's medication organizer three times a day.

5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with the available medication order.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed Fabuloso, Kroger bleach, and Bona multi surface floor cleaner unlocked in a cabinet in the kitchen sink. This cabinet had a locking device, however the device was not locked.

2. During an observation, the caregivers were not accessing the toxic materials at the time of arrival.

3. In an interview, E1 acknowledged toxic materials were stored unlocked.