Based on interview and record review conducted during a site visit on 05/20/24, it was confirmed facility staff did not visually observe the resident take his/her medication for 1 of 1 sampled residents (# 4). Findings include, but are not limited to the following:

A review of a Facility Self Report dated 10/13/23, revealed that on 10/12/23 Resident 4 missed his/her 5:00 pm dose of Olanzapine 2.5 mg (antipsychotic medication). The report indicated the following: "Resident 4's medications were left in [his/her] apartment dissolved in juice. Medication Tech did not ensure medications were taken by Resident."

On 05/20/24, Staff 1 (Executive Director) acknowledged the incident occurred.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (Registered Nurse) on 05/20/24.

It was determined the facility failed to observe Resident 4 take his/her medication.

Verbal plan of correction: Resident was placed on alert. Physician and Power of Attorney were notified on 10/13/23. Additional training was provided to all Medication Technicians.