Print Inspection: SVJ7

Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#6). Findings include, but are not limited to:

A review of Resident 6's Medication Administrator Record (MAR), dated 06/01/24 to 06/30/24, indicated Amlodipine (a blood pressure medication) 2.5 MG tab, one tablet by mouth every evening, for essential hypertension.

A review of a facility incident report, dated 07/02/24, indicated that on 06/30/24, Resident 6 "received in error Amlodipine 5 mg tab instead of 2.5 MG tab."

In an interview on 02/06/25, Staff 1 (Administrator) agreed with the documentation and stated the error did occur.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25.

Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary.

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Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

A review of Resident 4's signed physician orders dated 12/24/23 revealed:

*Sennosides 8.6 mg tablet take 2 tablets by mouth (17.2 mg total at bed time). Hold for diarrhea; and

*Stopped medication: cephalexin 250 mg tablet.

A review of Resident 4's 12/01/23 through 12/31/23 MAR revealed:

*On 12/25/23 Resident 4 received two doses of sennosides, instead of one.

*On 12/25/23 and 12/26/23 Resident 4 received discontinued cephalexin.

During an interview on 02/05/25, Staff 1 (Administrator) stated the medication errors did occur and was reported to Adult Protective Services.

The facility's failure to carry out medication orders as prescribed was substantiated.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25.

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Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

A review of an incident report dated 04/09/23 revealed Resident 5 was given metoprolol (a blood pressure medication) by accident.

Resident 5's MAR dated 04/01/23 through 04/30/23 did not contain any evidence of an order for metoprolol.

Resident 5's progress notes for 04/05/23 through 04/24/23 revealed Resident 4 received metoprolol on 04/09/23 with no negative effects.

During an interview on 02/05/25, Staff 1 agreed with the reviewed documentation.

The facility's failure to carry out medication orders as prescribed was substantiated.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25.

Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

A review of resident 3's progress note dated 07/16/24 revealed Resident 3's eye drops were misplaced by staff and the facility paid for a replacement bottle of the eye drops.

During an interview on 02/05/25, Staff 1 (Administrator) confirmed a facility MT had misplaced Resident 3's eye drop bottle and it was found by another resident's family member.

The facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25.

Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary.