Vista Winds LLC

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of seven resident sampled. Findings include: 1. A review of R7's medical record revealed R7 received personal care and medication adminstration services per the service plan dated August 29, 2024. 2. A review of R7's medical record revealed a medication order dated September 17, 2024 to include: carbidopa-levodopa, increase to 25-250 mg to 6x daily, Note: "starting at 7:00 am with 3.5 hrs intervals (7:00, 10:30, 17:30, 21:00, and 12:30), pls give patient remaining 5 tabs in the morning to self-administer throughout the day." 3. A review of R7's medication administration record (MAR) for January 2025 revealed carbidopa-levodopa 25-250 tab was "not given by facility" at 7:00 am from January 1-27, 2025 as ordered. 4. In an interview, E1 acknowledge E1 failed to ensure medication administered to R7 was administered in compliance with a medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of four residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated May 2024. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed medication orders dated February 2024. The medication orders stated the following: -Olanzapine 5 mg tablet take once daily -Amlodipine 2.5 mg tablet take once daily 3. Review of R2's medical record revealed a March 2024 medication administration record (MAR). The MAR stated "Olanzapine 5 mg tablet take once daily". However, there was a circle with initials noted on the log. Upon further review, the log attached to the MAR with columns that document exceptions..reason...notes..stated "Waiting for family to deliver" on March 2-3, 2024. Additionally, The MAR stated "Amlodipine 2.5 take once daily". However, there was a circle with initials noted on the log. Upon further review, the log attached to the MAR with columns that document exceptions..reason...notes..stated "Waiting for family to deliver" on March 10th and March 12, 2024. 4. In an interview, E1 reported the family brings in the medication and does not always bring it to the facility timely. E1 acknowledged R2's medication was not administered in compliance with the available medication order.