Penda Home Care LLC.

“Based on record review, observation, documentation review, and interview, the manager failed to ensure that a resident’s medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a current service plan dated March 4, 2026. The service plan indicated R1 received medication administration. 2. A review of R1’s medical record revealed a medication administration record (MAR) dated April 2026. The MAR revealed the following medications were administered to R1: · Amoxicillin and Clavulanate Potassium; and · Mupirocin Ointment. 3. The Compliance Officer observed the following medications stored by the facility for administration to R1: · Amoxicillin and Clavulanate Potassium tablets, 500 milligrams (mg); and · Mupirocin Ointment 2%. 4. A review of R1’s medical record did not include medication orders for the following medications: · Amoxicillin and Clavulanate Potassium tablets, 500 mg; and · Mupirocin Ointment 2%. 5. A review of the facility’s policies and procedures revealed a policy titled, “Medications Including Opioids, Narcotics and Schedule 2” which stated the following: "Part III – Medication Regimen, Records and Monitoring: 1. All medications or treatments are administered to the Resident only in compliance with the Doctors Order [sic] and instructions from a Physician or Medical Practitioner.” 6. In an interview, E1 reported that R1’s family member brought the medications into the facility for R1’s use, and the facility has been administering the medications to R1. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”