Litchfield Park Memory Home LLC.

“Based on record review, observation and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, for one of two sample residents who received medication administration.   Findings include:   1. A review of R1's medical record revealed a directed care service plan dated June 2025. The service plan documented R1 was to receive medication administration.   2. A review of R1's medication administration record (MAR) for August, 2025 revealed R1 was administered the following medications August 1, 2025 – August 7, 2025: - Acetaminophen 500 milligram (mg) – 2 tabs by mouth (po) tid – at 8:00AM, 12:30PM, and 5:00PM; - Lorazepam 1 mg – 1 tab po qid – at 8:00AM, 12:30PM, 5:00PM, and 8:00PM; - Quetiapine 50 mg – 1 tab po tid – at 8:00AM, 12:30PM, and 8:00PM; - Mucus 400 mg – 1 tab po tid – at 8:00AM, 12:20PM, and 5:00PM; - Trazadone 150 mg – 1 tab po qhs – at 8:00PM; and - Oxygen – 2 Liters (L) qhs – at 8:00PM.   3. A review of R1's medical record revealed a medication list titled "Medication Review Form" dated June 24, 2025. The form provided the current orders for the following medications: - Acetaminophen 500 milligram (mg) – 2 tabs by mouth (po) tid – at 8:00AM, 12:30PM, and 5:00PM; - Lorazepam 1 mg – 1 tab po qid – at 8:00AM, 12:30PM, 5:00PM, and 8:00PM; - Quetiapine 50 mg – 1 tab po tid – at 8:00AM, 12:30PM, and 8:00PM; - Mucus 400 mg – 1 tab po tid – at 8:00AM, 12:20PM, and 5:00PM; - Trazadone 150 mg – 1 tab po qhs – at 8:00PM; and - Oxygen – 2 Liters (L) qhs – at 8:00PM. However, the orders were signed by a registered nurse. No current orders signed by a medical practitioner was available for review.   4. In an exit interview, E1 reported E1 sent the medication review to the hospice agency for review and they sent the document back. The findings were reviewed with E1, and no additional information was provided.”