Terrace Post Acute

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact.

The MDS indicated Resident 1 was totally dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for morphine sulfate oral solution 10 milligrams/5 milliliters (mg/mL- units of measurement), give five (5) ml by mouth every eight (8) hours as needed for leg/knee pain give for severe pain level 7-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered [DATE].During a concurrent observation and interview on [DATE] at 2:25 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1's morphine sulfate bottle. LVN 1 stated that Resident 1's morphine sulfate expired on [DATE].During a review of Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2025, the MAR indicated morphine sulfate was administered to Resident 1 on [DATE], [DATE], and [DATE].During a concurrent interview and record review on [DATE] at 3:26 p.m., with the Director of Nursing (DON), reviewed Resident 1's MAR for 7/2025.

The DON stated Resident 1 was administered morphine sulfate on [DATE], [DATE], and [DATE].

The DON stated that morphine sulfate should not have been administered because Resident 1's morphine sulfate expired on [DATE].

The DON stated that before licensed nurses administer any medication, licensed nurses should always check the expiration date of all medications being administered.

The DON stated if licensed nurses find that a medication is expired during medication administration, the medication found to be expired should be removed from the medication cart and reordered from the pharmacy.

The DON stated the expired medication should not be administered to the residents because an expired medication may not have the potency the medication needs to be effective.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, review date [DATE], the policy indicated medications are administered in a safe and timely manner, and as prescribed.

The expiration/beyond use date on the medication label is checked prior to administering.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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