Based on interview and record review, conducted during a site visit on 06/03/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's February through March 2023 MAR, progress notes, and physician orders dated 02/23/23 indicated the following:

·Order to continue Rhopressa 0.02% drops (netarsudil) 1 drop into right eye at bedtime.

·March 2023 MAR indicated Rhopressa 0.02% to instill 1 drop into left eye daily at bedtime.

·03/01/23 through 03/31/23, eye drops had been documented as administered in the left eye.

In an interview with Staff 2 (Wellness Director), s/he stated the pharmacy had indicated they had a different order for the left eye instead of the right eye.

No other documents verifying this had been provided.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2.

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