Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1's February 2023 Medication Administration Record (MAR) and progress notes, indicated the following:

* fixed order for Novolog 100 u/ml flexpen 13 units 3x daily before meals. Hold scheduled insulin if BG level at mealtime is less than 120.

* order Novolog 100 u/ml flexpen 0-11 sliding scale <100-no insulin, 101-150- 6 units, 151-200- 7 units, 201-250- 8 units, 251-300- 9 units, 301-350- 10 units, BS>350 give- 11 units. Give in addition to fixed units

*Resident 1 missed his/her 2:00 pm dose of Lactulose 10gm/15ml SOLN on 02/19/23 with a noted exception of "awaiting med from pharmacy";  

*Progress note on 2/24/23 at 3:19 pm indicated on 02/23/23, Resident 1 was ordered to recieved an additional 6 units of Insulin Novalog 100U/ML per sliding scale order (101-150= 6 units) for CBG of 105 at 5:00 pm. Staff gave the base 13 units and did not give the additional 6 units; and

*On 02/09/23 and 02/10/23, there was no evidence of the 11:30 am CBG, or units given for Insulin  Novalog 100U/ML Flex pen.

* On 02/21/23 at 4:30 pm CBG was 99 and 13 units were given. Order was to hold if less than 120.

* On 02/24/23 at 4:30 pm CBG was 171 and only 13 units were given.

* On 02/18/23 and 02/24/23, there was no evidence of the 11:30 am CBG, or units given for Insulin Novalog 100U/ML Flex pen.

Resident 2's February 2023 MAR and progress notes indicated Resident 2 missed his/her 8:00 pm dose of Melatonin 5mg Tab due to med not being available.

During an interview, Staff 1 (ED) stated most medications are on cycle fill. S/he also stated that they had been doing a lot of re-training on medication administration since s/he started in August 2023.

The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a  "boot camp"  for the med techs. Training will be provided on ordering/re-ordering medications and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.