Based on interview and record review, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Onsite facility review, on 09/11/24, of the facilities Medication Incident Form dated 04/02/24 revealed that Resident 1 was administered medication without a current order.

Documentation revealed the facility immediately notified the facility LPN. APS referral was dated 04/05/24 and stated Resident 1 had no negative effects from the medication error.

In an interview on 09/11/24 with Staff 1 (Administrator) s/he stated an internal investigation was conducted and the incident was reported to APS. Staff 1 confirmed the med aide involved in the error was pulled from the med cart and was provided additional training.

The above information was shared on 09/11/24 and acknowledged by Staff 1.

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

Facility Plan of Correction: The Med Aide that administered the wrong medications to the wrong resident was removed from the med cart and was provided additional training.