New Reflections Adult Care Home.

“Based on observation, record review, documentation review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure that policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility.   Findings include:   1. In observation, R2 had Morphine 100/5ml medication (a schedule II-controlled substance) and Lorazepam 2mg/ml medication, (a schdule IV controlled substance) on site and stored by the facility.   2. In record review, R2's medical record (received directed care and medication administration services) included a medication order for the controlled substances. R2's medication administration record included documentation R2 received the medications as ordered, in March and April, 2025. The medical records did not include documentation of an inventory of the medication.   3. In documentation review, a facility policy, titled "Controlled Substance Narcotic Drug Count" page 102, documented, "... The purpose of the policy is to have in place an accountability process for handling all conrolled drugs... 1. All medications received by the pharmacy that are identified as a controlled substance, regardless of the class/schedule of the drug will be counted at each shift change. 2. The pharmacy provides narcotic usage sheets; the staff will be trained by the pharmacy or designee on how to use these sheets. 3. The narcotic count sheet will be signed off by those doing the counts at the end of every shift. (Inventorying each shift)..."    4. During an interview, E1 and E2 acknowledged the facility did not maintain an inventory of controlled substances, per the facility's policy and procedures.”