Based on interview and record review, conducted during a site visit on 04/02/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1) was substantiated. Findings include, but are not limited to:

Compliance Specialist (CS) reviewed Resident 1's June 2024 MAR, progress notes and physician orders which indicated the following:

·   Order dated 06/09/25 for Carbidopa/Levo 25-250MG tab 1 tablet by mouth 3 times daily before breakfast, lunch and before evening meal for Parkinson's.

·   MAR indicated resident receive Carbidopa/Levo 25-100 MG 1 tablet by mouth before breakfast and lunch.

In an interview, Staff 2 (RCC) was aware of the issues with Resident 1 not getting the correct medication dosage on 06/10/24. She/he stated the MT received one on one coaching at the time and MT no longer works at facility.

Findings were reviewed with and acknowledged by Staff 1 (ED) on 04/02/25.

The facility's failure to carry out medication and treatment orders as prescribed was substantiated.