Lazona House

Based on record review, documentation review and interview, the administrator failed to ensure that a medication administered to a resident was administered in compliance with an order. Findings include: 1 . A review of facility documents revealed an incident report for a medication error involving R1, on October 9, 2025. The nurse administered the incorrect medication (Phenobarbital) and dose -36 mg (milligram) to R1, that was to be administered to a different resident. 2 . A review of R1's medication orders revealed an order for phenobarbital 20 mg/ 5 ml (milliliter) via G-tube every 12 hours. 3 . The Compliance Officer reviewed the incident report which revealed the Primary Care Physician and responsible person were notified of the medication error. The Primary Care Physician ordered R1 to be taken to the emergency room for evaluation and observation. 4 . In an interview, E1 acknowledged that there was a medication error to a resident.