St Michaels Manor.

“Based on record review and interview, the manager failed to ensure documentation of medication administered to the resident included the correct dosage administered, for one of two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. Record review of R1's medical administration record (MAR) revealed a medication order dated February 5, 2025 for Montelukost Sod. The order instructions were, "take 1 10 MG TAB PO QD" . The MAR instructions were "take 1 15 MG TAB PO QD". 2. The Compliance Officers observed a pill bottle of Montelukost Sod 10 MG tablet stored for administration at the facility. 3. In an exit interview, the findings were discussed with E2 and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure an assisted living facility authorized to provide directed care services provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Documentation review revealed that the facility was licensed at the directed care level. 2. During an environmental inspection, the Compliance Officers observed non-operational door alerts on the front door and back door of the facility. The front door was equipped with a keyed lock, however, the key was stored in the door. 3. During an interview with E2, E2 reported the facility turned on the alerts at night. 4. In an exit interview, the findings were discussed with E2 and no additional information was provided.”

“Based on record review and observation, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a signed medication order dated February 5, 2025, for "Montelukast SOD, 10 MG 1 TAB PO QD". 2. A review of R1's medical record revealed a medication administration record (MAR) that stated "Montelukast SOD, 15 MG 1 TAB PO QD" was documented as administered at 5:00 p.m. on September 3, 2025 (the day of the inspection). However, the documentation was provided to the Compliance Officers at approximately 2:00 p.m. 3. In an interview, E2 reported the medication had not been given yet; however, acknowledged the MAR was signed. 4. In an exit interview, findings were discussed with E2 and no additional information was provided.”