Villas at Green Valley, Villa I.

“Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.    Findings include:   1. A review of R1’s medical record revealed a service plan dated August 1, 2025, which indicated R1 received a variety of assisted living services, including medication administration.  2. A review of R1’s medical record contained a medication order dated October 4, 2025, for the following medication to be administered as indicated:   Morphine Sulfate 100mg/5ml-0.25ml (5mg) by mouth every 4 hours for pain and/or shortness of breath   A review of R1’s medical record contained a medication order dated October 9, 2025, for the following medication to be administered as indicated: Lorazepam 2mg 1ml, give 0.25 ml (0.5mg) by mouth every four hours for anxiety 3. Further review of R1’s medical record revealed a Medication Administration Record (MAR) which included sections for documenting the administration of Morphine Sulfate and Lorazepam; however, the documentation revealed Morphine Sulfate and Lorazepam were not administered on the following days and times:   -October 10, 2025 at 12:00 a.m. and 4:00 a.m.    4. In an interview, the findings were reviewed with E1. E1 advised E2 was new to the facility and was not aware of R1’s medication change. E1 stated E2 did not administer the medication as ordered and an investigation was conducted.”