Based on interview and record review, conducted during a site visit on 04/28/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

A review of Resident 4's May 2024 MAR, progress notes, and incident report dated 05/15/24 indicated the following:

·Resident 4 was given another resident's medications in error on 05/15/25 at 8 pm; and

·Resident 4 was given Prazosin HCI 2 mg caps and Lamictal 200 mg.

·Resident 4 did not have a physician's order for either medication.

The findings were reviewed with and acknowledged by Staff 1 (ED) on 04/28/25.

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

Based on interview and record review, conducted during a site visit on 04/28/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the ABST and Specific Needs Contract (SNC) indicated the following:

·Day shift: House 2617- 2.17 hours; House 2619- 2.89 hours; House 2623-1.56 hours; and House 2625- 2.43 hours required;

·Night shift: 2617- 1.42 hours; House 2619- 1.52 hours; House 2623-1.56 hours; and House 2625- 0.94 hours required; and

·SNC contract required one to four staffing ratio for day shift and one to six staffing ratio for night shift.

A review of the posted staffing plan and staffing schedule for 04/22/25 through 04/28/25 indicated the following:

·Day shift: three staff required for each house;

·Night shift: two staff required for each house; and

·The facility was not staffed per the posted staffing plan for six of 14 shifts reviewed.

In an interview, Staff 1 (Executive Director) stated the facility recently had new move-ins and had updated the ABST.

Findings were reviewed with and acknowledged by Staff 1 on 04/29/25.

The facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated.