Based on interview and record review, conducted during a site visit on 12/30/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 3 of 3 sampled residents (#s 3, 4 and 5). Findings include, but are not limited to:

A review of Resident 3's physician orders dated 02/13/23 indicated:

Multiple Vitamins-Minerals tabs for supplement; Take 1 tablet by mouth Daily.

Cholecalciferol (Vitamin D-3) 50 mcg for Vitamin D deficiency; Take 1 tablet by mouth Daily.

A review of Resident 3's 02/01/23 - 02/28/23 MAR indicated the following:

·6:00 am Multivitamin-Minerals TABS not indicated as administered;

·6:00 am Vitamin D3 2000IU not indicated as administered.

A review of Resident 3's progress notes indicated on 02/28/23 "Noc med aide on 02/27/23 to 02/28/23 locked the med keys in the med cart at some point during shift." S/he did not pass any 6:00 am medications to any residents.

A review of Resident 4's physician orders dated 01/05/23 indicated:

·Levothyroxine (for thyroid) to be given every morning on an empty stomach at least 1 hour before product containing calcium, iron vitamins - 6AM.

A review of Resident 4's 02/01/23 - 02/28/23 MAR indicated the following:

·6:00 am Levothyroxine not indicated as administered.

A review of Resident 4's progress notes indicated on 02/28/23  "Noc med aide on 02/27/23 to 02/28/23 locked the med keys in the med cart at some point during shift." S/he did not pass any 6:00 am medications to any residents.

A review of Resident 5's physician orders dated 09/23/22 indicated:

·Levothyroxine (for thyroid) to be given every morning on an empty stomach - 6AM.

A review of Resident 5's 02/01/23 - 02/28/23 MAR indicated the following:

·6:00 am Levothyroxine not indicated as administered.

A review of Resident 5's progress notes indicated on 02/28/23 "Noc med aide on 02/27/23 to 02/28/23 locked the med keys in the med cart at some point during shift." S/he did not pass any 6:00 am medications to any residents.

In an interview Staff 3 (RCC) stated that the blank spaces on resident MAR's indicated medications had not been given and the progress notes confirmed an incident on 02/28/23 where 6:00 am medications were not given.

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with Staff 2 (Assistant Administrator) on 01/03/25 via email.

Verbal Plan of Correction:

The facility had set up a lockbox with spare keys to prevent this from occurring in the future.