Based on observations, interviews, and record reviews, the facility failed to administer medications as ordered for 2 of 5 sampled residents (#1 and #2) related to a medication used to treat high blood pressure (#1) and a mineral supplement used to treat iron deficiency anemia (#2), and 1 of 4 residents observed during the medication pass who received an incorrect dosage of a vitamin supplement used to support bone formation (#9). The findings are: Review of the facility's Medication Administration Policy and Procedure revised January 2025 revealed: -Medications were administered in a safe and timely manner as prescribed. -Medications were administered in accordance with prescriber orders. -The individual administering the medication checked the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. 1. Review of Resident #1's current FL2 dated 04/19/24 revealed diagnoses included muscle weakness, high blood pressure, gait abnormality, and reflux. Review of Resident #1's Resident Register revealed an admission date of 04/22/24. Review of Resident #1's physician's orders revealed hydrochlorothiazide (HCTZ) 25mg daily (used to treat high blood pressure), hold for systolic blood pressure (SBP) <130, or heart rate (HR) <70. Review of Resident #1's electronic medication administration record (eMAR) for October 2025 revealed: -There was an entry for HCTZ 25mg daily hold for SBP <130 or HR <70. -There was documentation the HCTZ was administered on 10/05/25 with SBP 116, 10/07/25 with SBP 124, 10/08/25 with SBP 113, 10/09/25 with SBP 113, 10/10/25 with SBP 113, 10/18/25 with SBP 111, and 10/19/25 with SBP 120. Review of Resident #1's eMAR for November 2025 revealed: -There was an entry for HCTZ 25mg daily hold for SBP <130 or HR <70. -There was documentation the HCTZ was administered on 11/16/25 with HR 61, 11/17/25 with HR 61, 11/18/25 with HR of 61, 11/19/25 with HR of 61, 11/20/25 with HR of 61, and 11/30/25 with HR of 60. Review of Resident #1's eMAR for 12/01/25 - 12/17/25 revealed: -There was an entry for HCTZ 25mg daily hold for SBP <130 or HR <70. -There was documentation the HCTZ was administered on 12/01/25 with HR 68, 12/02/25 with HR 68, 12/03/25 with HR 68, 12/04/25 with HR 68, 12/11/25 with SBP 127, and 12/17/25 with HR 64. Observation of Resident #1's medications available for administration on 12/17/25 at 1:56pm revealed there was one bubble pack labeled HCTZ 25mg daily hold for SBP <130 or HR <70 and 30 tablets were dispensed on 10/23/25 with 3 tablets remaining. Interview with a medication aide (MA) on 12/17/25 at 11:15am revealed: -It was an error to administer the HCTZ outside of ordered parameters. -He received MA training and knew to look closely at the orders. -He was not paying close attention to the order and should have done so. Interview with a second MA on 12/17/25 at 12:31pm revealed: -She did not remember administering the HCTZ to Resident #1. -She thought it must have been a documentation error when she documented she administered the HCTZ outside of parameters. Interview with the Health Services Manager on 12/17/25 at 11:25am revealed: -The MAs received online training and in person training with a nurse from the pharmacy. -She knew there were pharmacy medication reviews every quarter, and the MARs were reviewed at that time. -The facility did not have any staff responsible for reviewing MARs for accuracy. -The MAs should administer medications as ordered. Interview with the Administrator on 12/17/25 at 12:40pm revealed: -The MAs training consisted of a 15-hour class and exam then a nurse from the contracted pharmacy validated the MAs. -She knew that the pharmacy audited the MARs and medication carts every quarter and there were no other MAR and medication cart audits. Attempted telephone interview with the facility's contracted primary care provider (PCP) on 12/17/25 at 1:52pm was unsuccessful. 2. Review of Resident #2's current FL2 dated 09/02/25 revealed: -Diagnoses included iron deficiency anemia, acute cystitis, osteomyelitis of the left ankle and foot, pressure ulcer of the left heel, chronic kidney disease stage 3, chronic obstructive pulmonary disease, and muscle weakness. -There was an order for ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron) 325mg take 1 tablet every other day. Review of Resident #2's Resident Register revealed an admission date of 09/29/25. Review of Resident #2's September 2025 electronic medication administration record (eMAR) revealed there was no entry for ferrous sulfate 325mg take 1 tablet every other day. Review of Resident #2's October 2025 eMAR revealed there was no entry for ferrous sulfate 325mg take 1 tablet every other day. Review of Resident #2's November 2025 eMAR revealed: -There was an entry for ferrous sulfate 325mg take 1 tablet every other day. -There was documentation ferrous sulfate was administered on 11/23/25, 11/25/25, 11/27/25, and 11/29/25 at 8:00am. -There was no documentation ferrous sulfate was administered prior to 11/23/25. Review of Resident #2's December 2025 eMAR revealed: -There was an entry for ferrous sulfate 325mg take 1 tablet every other day. -There was documentation ferrous sulfate was administered on 12/01/25, 12/03/25, 12/05/25, 12/07/25, 12/09/25, 12/11/25, 12/13/25, 12/15/25, and 12/17/25 at 8:00am. Telephone interview with a pharmacist from the facility's contracted pharmacy on 12/17/25 at 2:20pm revealed: -On 09/27/25, the pharmacy received a faxed copy of Resident #2's FL2 dated 09/02/25 that included an order for ferrous sulfate 325mg take 1 tablet every other day. -The pharmacy dispensed Resident #2's ferrous sulfate 325mg in the quantity of 30 tablets on 09/27/25 and was delivered to the facility on 09/27/25. -The pharmacy dispensed ferrous sulfate 325mg in the quantity of 30 tablets for Resident #2 on 11/06/25 and 12/05/25. Interview with Resident #2 on 12/17/25 at 4:30pm revealed she could not remember when the facility started administering ferrous sulfate to her. Interview with a medication aide (MA) on 12/17/25 at 4:35pm revealed: -She did not remember when Resident #2's ferrous sulfate was ordered, and she began administering it to Resident #2. -She thought Resident #2 was administered ferrous sulfate since she was admitted to the facility. -She could see on the eMAR that the first dose of ferrous sulfate was documented as administered to Resident #2 was on 11/23/25. Interview with the Health Services Manager on 12/17/25 at 4:12pm revealed: -She did not know why Resident #2's eMARs did not show ferrous sulfate 325mg was documented as administered to Resident #2 until 11/23/25. -The facility changed the computer system to an updated version, and she thought the other doses of ferrous sulfate for Resident #2 were documented on the older version of the eMAR system. -She did not have access to the older eMAR system. Interview with the Administrator on 12/18/25 at 8:48am revealed: -She was not aware Resident #2's ferrous sulfate was not documented as administered from 09/29/25-11/22/25 on the eMAR. -She thought Resident #2's ferrous sulfate was administered every other day since admission but was not documented as administered until 11/23/25 because the other doses were documented on the older eMAR system. -She tried to access the older eMAR system but was unsuccessful. -The computer system including the old eMAR system was updated around June 2025. -She expected the MAs to administer Resident #2's ferrous sulfate as ordered. -There was currently no one responsible for completing eMAR audits to make sure medications were administered as ordered. Attempted interview with Resident #2's primary care provider (PCP) on 12/17/25 at 1:52pm and 12/17/25 at 3:48pm was unsuccessful. 3. The medication error rate was 3.4% as evidenced by 1 error out of 29 opportunities during the 8:00am medication pass on 12/18/25. Review of Resident #9's current FL2 dated 12/09/25 revealed diagnoses included a left elbow fracture. Review of Resident #9s Resident Register revealed an admission date of 12/08/25. Review of Resident #9's physician orders dated 12/09/25 revealed there was an order for vitamin D3 (a vitamin supplement to assist the body in absorption of calcium to build healthy bones) 1,000 international units (IU) take 1 capsule daily. Observation of the mediation pass on 12/18/25 at 8:00am revealed: -There was an unopened medication bubble pack with a dispense date on 12/11/25 for Resident #9's vitamin D3 1000 IU in the quantity of 30 capsules with instructions to administer 1 capsule daily and 30 capsules were available for administration. -There was a bottle of vitamin D3 2,000 IU with Resident #9's name handwritten on the bottle. -The medication aide (MA) administered 9 medications to Resident #9 including one tablet of vitamin D3 2,000 IU. -The MA did not administer Resident #9's vitamin D3 1,000 IU to Resident #9. Review of Resident #9's 12/01/25-12/18/25 electronic medication administration record (eMAR) revealed: -There was an entry for vitamin D3 1,000 IU take 1 capsule daily at 8:00am. -There was documentation vitamin D3 1,000 IU 1 capsule was administered daily on 12/12/25-12/18/25 at 8:00am. -There was no entry for vitamin D3 2,000 IU take 1 tablet daily. Telephone with a pharmacist from the facility's contracted pharmacy on 12/18/25 at 1:30pm revealed: -Resident #9's vitamin D3 1,000 IU take 1 capsule daily was dispensed on 12/11/25 in the quantity of 30 capsules. -Resident #9 should have 23 capsules remaining if the vitamin D3 1,000 IU was administered as ordered and the administration began on 12/12/25. Interview with a MA on 12/18/25 at 1:34pm revealed: -The facility's contracted pharmacy dispensed Resident #9's vitamin D3 when Resident #9 was admitted to the facility. -Resident #9 was admitted from home and brought a bottle of vitamin D3 with her when she was admitted to the facility. -Any time a resident brought medications with them when they were admitted to the facility the MAs administered the bottled medications before beginning the bubble packages dispensed by the facility's contracted pharmacy. -She administered the 2,000 IU of vitamin D3 to Resident #9 instead of the ordered 1,000 IU dispensed by the pharmacy because she "missed" the dosage on the bottle was different than the dosage in the bubble package for Resident #9. -The facility's policy for mediation administration included to compare the label on the medication to the eMAR to make sure the dosage was correct. -She did not check the dosage on the bottle or compare it to the eMAR before she administered the vitamin D3 to Resident #9. Interview with the Administrator on 12/18/25 at 8:48am and 1:30pm revealed: -She was not aware Resident #9 had two different dosages of vitamin D3 available for administration on the medication cart. -The only order she found for Resident #9's vitamin D3 was 1,000 IU take 1 capsule daily. -She did not know why the MAs administered Resident #9's vitamin D3 from the bottle brought from home instead of the vitamin D3 dispensed by the pharmacy. -The MAs were responsible for checking the medication dosages on the package and comparing it to the eMAR before administering medications to residents. -There was currently no one responsible for completing eMAR audits to make sure medications were administered as ordered. -She expected the MAs to check medication dosages and compare them to the eMARs before administering the medications to residents. Attempted interview with Resident #2's primary care provider (PCP) on 12/17/25 at 1:52pm and 12/17/25 at 3:48pm was unsuccessful.

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