Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:

A review of Resident 2's March 2024 MAR and progress notes, and suspected abuse or unexplained injury reporting form dated 03/25/24, indicated the following:

·MAR showed Nifedipine ER 90 MG TB24 to be given 1 Tablet by mouth every day for heart health,

·Suspected abuse or unexplained injury reporting form dated 03/25/24 indicated  "Resident didn't receive [his/her] Nifedipine medication on Saturday and Sunday [03/23/24-03/24/24]. Med Tech stated they couldn't locate it"

A review of Resident 3's March 2024 MAR and progress notes, and suspected abuse or unexplained injury reporting form dated 03/25/24, indicated the following:

·MAR showed Vitamin D3 1000 IU Tab (Cholecalciferol) to be given 1 tablet by mouth every day,

·Suspected abuse or unexplained injury reporting form dated 03/25/24 indicated Resident 3  "missed Vitamin D dose on Sat and Sun [03/23/24-03/24/24]. Couldn't find it in med room"

In an interview, Staff 1 (ED) stated s/he was made aware of the incidents, and it was reported to APS.

The findings were reviewed with and acknowledged by Staff 1 (ED) on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's April 2024 MAR, progress notes, and suspected abuse or unexplained injury reporting form dated 04/16/24, indicated the following:

·MAR showed Oxycodone/APAP 10-325 MG Tab (Percocet) to be given 1 Tablet by mouth 3 times daily for chronic pain disorder.

·Suspected abuse or unexplained injury reporting form dated 04/16/24 indicated "at 9:04am Med Tech signed MAR that [s/he] gave routine Percocet. When counted on the Narcotic count later that day it was noted that the Percocet had not been given."

In an interview, Staff 1 (ED) stated s/he was made aware of the incident and it was reported to APS.

The findings were reviewed with and acknowledged by Staff 1 (ED) on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 3 of 3 sampled residents (#'s 1, 4 and 5). Findings include, but are not limited to:

A review of Resident 1's March 2024 MAR and progress notes, and event report dated 03/23/24, indicated the following:

·MAR showed Refresh Optive Advanced PF SOL instill 1 drop in both eyes 4 times daily for eye lubricant;

·Event report dated 03/23/24 indicated "medication error: Missed dose; Symbicort and eye drops on 3-16 & 3-17"; and

·Progress note dated 03/23/24 at 3:00 am  "added to alert charting for missed doses of [his/her] inhaler and eye drops on 3-16 & 3-17."

A review of Resident 4's March 2024 MAR and progress notes, and event report dated 03/23/24, indicated the following:

·Med order for Pantoprazole 40 MG Tab (Protonix) to be given 1 tablet by mouth every day for stomach;

·MAR indicated Pantoprazole was not given on 03/16/24 and 03/17/24;

·Event report dated 03/23/24 indicated "Med error: Missed Pantoprazole 40 mg on 3-16 & 3-17."

A review of Resident 5's March 2024 MAR and progress notes, and event report dated 03/22/24, indicated the following:

·MAR showed Torsemide 20 MG Take two tablets by mouth daily; and

·Event report dated 03/22/24 indicated "[Resident] was supposed to have gotten 2 tablets for [his/her] dosage this morning and only received one tab."

In an interview, Staff 1 (ED) stated s/he was made aware of the incidents, and it was reported to APS.

The findings were reviewed with and acknowledged by Staff 1 (ED) on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.