Based on interview, review of clinical records including two incidents involving significant medication errors and other documentation as indicated, it was determined that for 29 out of 29 licensed nurses reviewed, the facility failed to have a system/process in place to ensure each licensed nurse had competencies and skills sets necessary to care for current residents' needs. - On 7/6/24, E43 (RN) administered another resident's medications to R322, which resulted in a serious adverse outcome. R322 required emergent admission to the ICU for treatment and monitoring. The facility failed to ensure E43 had a medication administration competency and skill set validated during his orientation. In addition, the facility allowed R322 to continue to administer medications for 14.5 days after the 7/6/24 incident without evidence of a competency and skill set validation for medication administration. An Immediate Jeopardy (IJ) was called on 8/26/24 at 7:07 PM. The IJ was abated on 8/30/24 at 5:00 PM. - On 8/18/24, E55 (LPN) administered another resident's medications to R95. The facility lacked evidence of E55's competency and skill set validation for medication administration during her orientation. - For 24 out of 24 nurses scheduled to work from 3 PM on 8/26/24 through 3 PM on 8/27/24 plus three additional nurses (E56, E57 and E58), the facility lacked evidence of each nurses' competency and skill set validations necessary to care for current residents' needs. Findings include: The facility assessment, dated 7/2024, documented, . 1.1 The facility is licensed to care for 177 residents . 3.5 Staff training/ education and competencies. All staff members have a competency checklist upon hire that is completed during orientation to provide adequate care for our residents . Topics . Date Presented: Orientation & Annually, and as needed . The facility's form entitled Skills Validation Record for a Charge Nurse, last revised 5/2024, included the following sections: -General: job description, employee guide, required education, customer service, survey process, policies & procedures, QAPI, Residents' Rights, Safe smoking practices, Abuse; -Environment: facility tour, emergency eye wash stations, security practices, water shut off process, oxygen storage, call light system, phone/paging system, work orders, missing person process, emergency preparedness/red book review; -Infection Control: hand hygiene/glove usage; cleaning and disinfecting equipment; linen handling/appropriate bagging; transmission based precautions; PPE (donning/doffing); Vaccines; PPD/Screening; -OSHA: Bloodborne standard; Hepatitis B vaccine protocol; Regulated Medical Waste; Respiratory Protection Program (N95 fit test); Exposure Control (post exposure process); -Equipment: Glucometer; Coagucheck; Vital sign machine; CPAP/Bipap; Trach oxygen compressor; Oxygen concentrator/tanks; Nebulizer machine; Device(s) filter care; Suction machine; Mechanical lifts/scales; IV pump; Tube feeding pump; Wound vac; Air mattresses; Fall prevention devices; -Supervising CNAs: Observe hygiene; Shower schedule; Turning/repositioning; Documentation verification; Hydration; Snacks; Feeding assistance; Rounds; -Clinical Processes: Nursing chain of command; Central Supply; Medication room; Medication Pass Observation; Treatment Pass Observation; Refusal process; Behavior management; Restorative nursing; Restraints; Code status (DNR validation, advanced directives, etc.); Code blue; Dietary Processes and communications; Dialysis protocols (communication form, medication scheduled, documentation, etc.); Scheduling (appointments, procedures, transportation, etc.); Nursing documentation best practices (dos & donts sic); ADL documentation review; -Pharmacy Services: admission orders (cut off times, admission alert); Back up pharmacy; Omnicell review (narcotic code, adding new user); Narcotic processes (shift count, discontinued, ordering); OTC medication procedure (Medline); -PCC (PointClickCare) Clinical Documentation: Admissions/Readmissions; Risk Management; Allergies; Batch Orders; Dashboards; Discharges; Elopement; Emergency EMAR backup; Falls; Immunizations; Infection Control Dashboard; Labs and Radiology; Entering IV solution orders; Entering SSI orders; Order entry; Overview Clinical; POC documentation; Progress Notes; Receiving meds from Pharmacy and refills; Reports; Skin Assessments; Tasks; Weights and Vitals; -Clinical Skills Competencies: Intravenous catheters; Venipuncture; Enteral Feeding Tubes; Urinary Catheters (foley/suprapubic/straight/external); Ostomy; Respiratory Care; Tracheostomy; Wound Vac; JP Drain; and Center Specific Skills. 1. Cross refer F760, example 1 6/4/24 - E43 (RN) was hired by the facility. 7/6/24 at 3:40 PM - A nurse's note documented, Patient was given medications that were prescribed for another resident . 7/6/24 at 4:21 PM - The hospital record documented, . presents to the ED (emergency department) with hypoglycemia (low blood sugar) and hypotension (low blood pressure) after receiving the wrong medications at his rehab facility . will need an ICU admission for management . 7/11/24 - The facility submitted to the State Agency a five day follow up investigation and response to the 7/6/24 incident involving R322. In the follow up it stated that All licensed nurses were re-educated on the rights of medication administration and medication competencies were performed. Review of the facility's follow-up documentation provided to the Surveyor for the 7/6/24 incident revealed that re-education/competencies of all licensed facility nurses were incomplete. In addition, the facility lacked evidence that E43's skills/competency was validated after this incident. E43 continued to work in the facility for 14.5 days after the 7/6/24 medication error incident. 8/26/24 at 12:50 PM - During an interview, E48 reviewed the facility's form entitled Skills Validation Record for a Charge Nurse that was being used to validate each nurse's competency and skills set. E48 (Staff Educator) confirmed that she had no evidence of E43's competency and skill set. 8/26/24 at 7:07 PM (revised 9/5/24) - During a meeting with facility management, the Survey Team notified E1 (NHA), E2 (DON 1) and E59 (DON 2) of an Immediate Jeopardy for the failure to have evidence of E43's competency and skill set validation during his new hire orientation, as outlined in the facility assessment. 8/26/24 at 9:07 PM - E1 (NHA) submitted a signed, dated and timed written abatement plan to the State Agency. The facility's abatement included: - Licensed Nurses will be trained on the following competencies: enteral feeding tubes; respiratory care and oxygen equipment (to include CPAP and BiPAP); wounds/skin impairments; bladder scans; hemodialysis; urinary catheters; ostomy care; blood glucose monitoring. - The first staff members to be trained will be the Unit Managers, Shift Supervisors, and Staff Development Coordinator. Training will then be completed by Licensed Nurse Managers (DON, ADON, Unit Managers, Staff Development Coordinator) as well as Licensed Nurse Corporate Level Clinical Directors and will include return demonstration. Training will (sic) conducted on a daily basis until staff threshold met. - Licensed Nurses and Facility Manager will be educated on circumstances relating to Immediate Jeopardy tag. - Pending admissions will be evaluated based on needs to ensure staff working have required competencies completed to provide care. - Because the Center employs a high number of nurses and utilizes agency nurses when needed, education will be ongoing to ensure nurses are educated on the above competencies and the circumstances leading to this education. - 100% of Licensed Nurses will receive education with return demonstration by date of abatement . 8/30/24 at 5:00 PM - The IJ was abated based on interviews with licensed nursing staff and review of facility documentation of individual licensed nurses' competency and skill set education/validations of current residents' needs. 2. Cross refer F760, example 2 6/24/24 - E55 (LPN) was hired by the facility. The facility provided the Surveyor the following information on E55's schedule upon hire: -6/24/24 through 6/28/24, E55 was in classroom training; -7/3/24 through 7/15/24, E55 was trained on the floor; and -Starting 7/16/24, E55 was working on the floor by herself. 8/18/24 at 8:00 PM - The facility's incident report documented that R95 was administered R48's prescribed medications by E55 (LPN). 8/26/24 at 12:50 PM - During an interview, E48 (Staff Educator) stated that she took over the position of Staff Educator at the end of April 2024. E48 stated that nursing orientation includes the first week with classroom review/training, then orientation with another nurse on the floor for 5 to 8 days, based on the nurse's experience. When discussing the facility's Skills Validation Records for nursing staff, E48 stated that the forms were not being returned to her timely. In fact, E48 stated that E55's Skills Validation Record appeared on her desk recently. While reviewing E55's Skills Validation Record with the Surveyor, E48 confirmed that it was not completed correctly. E55's Skills Validation Record was signed off by E52, an agency RN, but never signed by E55 herself. E52 printed and signed her name, and utilized a down arrow for each section, but did not record the date that each skill was reviewed and validated. E52 signed and dated page 6 in the Supervisor's Signature section and dated 7/14/24. In response, the Surveyor requested to see E52's Skills Validation Record since she signed attesting that she validated E55's skills. E48 confirmed that the facility lacked evidence of E52's Skills Validation Record. Review of the facility's Employee Report revealed that E52's hire date was 10/31/23. The facility lacked evidence of E48 and E52's competency and skill set validation. 3. Review of 100 out of 165 current residents in the facility revealed the following nursing care needs, but were not limited to: -accucheck using a glucometer; -dialysis access sites: chest wall or AV fistula, care and assessment of bruit/thrill; -respiratory care (oxygen, nebulizer, CPAP, BiPAP, Aerobika, incentive spirometer, Acapella valve); -bladder scan; -urinary catheters: foley, straight catheter; -wound care; -enteral feeding: pH testing, checking placement, administering meds - G tube; -colostomy; -pacemaker; -urostomy, nephrostomy; and -Life Vest heart monitor. 8/26/24 at 3:50 PM - The Surveyor provided a list of the following scheduled nurses to facility management and requested each nurses' Skills Validation Record (Checklist): E9 (LPN), E16 (LPN), E18 (LPN), E36 (LPN), E38 (RN), E42 (LPN), E50 (LPN), E60 (RN), E61 (LPN), E62 (LPN), E63 (LPN), E64 (LPN), E65 (LPN), E66 (RN), E67 (RN), E68 (LPN), E69 (LPN), E70 (RN), E71 (LPN), E72 (LPN), E73 (LPN), E74 (LPN), E75 (LPN) and E76 (LPN). In response to the request, the facility was not able to provide the Surveyor with each nurse's most recent Skills Validation Record. The facility did provide some documentation on Relias web training completed by some nurses. 4. Review of E56's (LPN) training and competencies records indicated that the employee was hired 7/8/24. No completed nursing skills validation checklist could be located for E56. Review of E57's (Agency RN) training and competencies records indicated that the agency staff's first day in the facility 3/25/24. No completed nursing skills validation checklist could be located for E57. Review of E58's (Agency LPN) training and competencies records indicated that the agency staffs first day in the facility 6/24/24. No completed nursing skills validation checklist could be located for E58. 8/26/24 1:25 PM - During an interview, E48 (Staff Educator) stated that the staff were not retuning the skills checklist after their orientation period on the floor with their preceptors. E48 further confirmed that E56, E57 and E58 did not have the nursing skills validation checklist on their training files. The facility failed to ensure that the required nursing skills validation checklist was completed for 29 out of 29 nursing staff reviewed 8/26/24 2:33 PM - Findings were discussed with E1 (NHA). 8/27/24 2:52 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E10 (VPO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of clinical records and other documentation as indicated, it was determined that for one (R322) out of three residents reviewed for hospitalizations and three (R22, R33 and R95) out of nine residents reviewed for medication administration, the facility failed to ensure that residents were free of significant medication errors. On [DATE], R322 was administered R144's prescribed medications. As a result, R322 was emergently sent to the hospital requiring treatment and monitoring in the Intensive Care Unit (ICU). The facility's multiple failures involved in this incident had the potential to cause a serious adverse outcome or death to R322 with respect to receiving another resident's multiple blood pressure medications and diabetic medications. Due to the failures, an Immediate Jeopardy (IJ) was called on [DATE] at 2:08 PM. The IJ was abated on [DATE] at 11:59 PM. On [DATE], R95 was administered R48's prescribed medications. R95 remained in the facility and was monitored for adverse effects. For R22 and R33, the facility failed to ensure that each resident received their meals within 15 minutes of the administration of short acting insulin. Findings include: The facility's pharmacy policy and procedure entitled, #8.2 General Guidelines for Medication Administration, last revised 08-2020, stated the following: . Medications are administered as prescribed in accordance with good nursing principles and practices . Procedures: . I. Preparation . 4. At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away . II. Administration . 4. When medications are administered by mobile cart taken to the resident's location ., medications are administered at the time they are prepared . 6. Medications are administered without unnecessary interruptions . 8. Residents are identified before medication is administered using one method of identification. Methods of identification may include but not limited to: a. Checking the photograph attached to the medical record. b. Calling the resident by name (except in residents with cognitive impairment). c. Having the resident verify his/her last name. d. If necessary, verifying resident identification with other facility personnel . 12. Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes. Unless otherwise specified by a prescriber, routine medications are administered according to the established medication administration schedule for the facility . IV. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . 1. Cross refer F726, example 2 Review of R144 and R322's clinical records revealed: For R144: [DATE] - R144 was admitted to the facility in room XXXX. [DATE], [DATE] and [DATE] - Review of the [DATE] eMAR, E43 (RN) administered R144's medications scheduled at 8:00 AM. R144 was scheduled to receive the following 13 medications on [DATE] at 8:00 AM: - Losartan Potassium 100 mg, 1 tablet, for hypertension (high blood pressure); - Coreg 12.5 mg, 1 tablet, for hypertension; - Hydralazine 50 mg, 1 tablet, for hypertension; - Spironolactone 25 mg, 1 tablet, for hypertension; - Metformin 1000 mg, 1 tablet, for diabetes mellitis (high blood sugar); - Glipizide 5 mg, 1 tablet, for diabetes mellitis; - Aspirin 81 mg, 1 tablet, for CVA (stroke) and heart health; - Sucralfate 1 gm, 1 tablet before meals scheduled at 7:30 AM, for stomach ulcer; - Omeprazole 40 mg, 1 capsule, for gerd (stomach acid flows back into the esophagus); - Tylenol 325 mg, 3 tablets, for pain; - Miralax powder, 1 scoop mix in water or juice, for constipation; - Senna 8.6 mg, 2 tablets, for constipation; - Symproic 0.2 mg, 1 tablet, for constipation; - FiberCon 625 mg, 2 tablets, for constipation. For R322: [DATE] - R322 was admitted to the facility for short-term rehabilitation with diagnoses, including but not limited to, pneumonia, chronic respiratory failure, pulmonary fibrosis (lung disease when lung tissue becomes damaged and scarred), chronic obstructive pulmonary disease (chronic inflammatory lung disease) and dependent on supplemental oxygen. R322's room was YYYY, which was located on a different hallway from R144. [DATE] - Review of the [DATE] eMAR, E43 (RN) administered R322's medications scheduled at 8:00 AM. [DATE] at 3:40 PM - A nurse's note by E44 (House Supervisor) documented, Patient was given medications that were prescribed for another resident. Patient was assessed; found to have an irregular pulse and low blood pressure. NP (Nurse Practitioner) and responsible party notify. Received order to send patient to ER (emergency room) for evaluation. [DATE] at 4:00 PM - A transfer to hospital summary note by E43 (RN) documented, Patient received medications scheduled for patient [R144] . Patient unremarkable in appearance, denies pain, symptoms, vitals 88/58 BP (blood pressure), HR (heart rate) 94, pulse ox 98% on baseline 4L (liters), skin warm, pink, no signs of distress, patient states 'I feel fine' 'I don't want to go to [name of hospital]'. Supervisor contacted, On-call MD (Medical Doctor) and RN contacted, ADON contacted, patient, [name of F3, family member] . contacted, EMS (Emergency Medical Services) summoned to take patient to [name] ER. [DATE] at 4:21 PM - The hospital record documented the following: . presents to the ED (emergency department) with hypoglycemia (low blood sugar) and hypotension (low blood pressure) after receiving the wrong medications at his rehab facility . EMS was activated. Upon EMS arrival, patient was found to be hypoglycemic in the 50s and oral glucose was given. Upon arrival here in the ED, patient was found to be hypotensive and hypoglycemic . likely secondary to the diabetic medications and antihypertensives he was given. Patient does not have a history of diabetes and is no longer on antihypertensives due to being hypotensive at baseline. Given that the patient was given glipizide (diabetic medication), he will most likely have persistent drops in his glucose. He will likely require repeated boluses (large doses) of D50 (dextrose sugar in water solution) and may still need to be started on a dextrose (sugar) drip. Ultimately, patient will require frequent glucose (sugar) checks and will need an ICU admission for management . [DATE] at 4:45 PM - Two days later, the facility reported the [DATE] incident to the State Agency as Resident [name of R322] . received another resident's medications . Resident became hypotensive and was transferred to hospital for evaluation. Investigation in progress. All licensed nurses to be educated on medication administration. The facility's investigation included the following statements: -E43's (RN) written statement included: . date of incident: [DATE]; time of incident: 14:00 (2:00 PM); I passed medications, realized error, alerted MD and Supervisor . Name(s) of staff member(s) involved: [name of E43 (RN)], E44 (House Supervisor) . Please identify any statements made by resident: 'I feel fine.' Identify all people you spoke with regarding the incident and describe what was said (ie staff, family of resident, etc.): on call Dr (doctor) . [name of E44], EMS, pt (patient), [title of F3, family member], [title of F4, family member]. Identify any documentation you completed related to the incident: Incident . Please provide any additional information: n/a (not applicable). Date the statement completed: (incorrect date). Time statement completed: 1101 (11:01 AM). -E45's (COTA) written statement (undated/untimed) included: . Around 12:30 PM this writer went to attempt to perform OT (occupational therapy) services with resident. [Title of F3] present. Resident stated 'no' and 'I don't want to' multiple times so this writer came back around 2:00 PM to attempt again. Upon returning to room, this writer was informed by resident's [title of F3] that at around 12:00 PM this day, patient was given another resident's dose of medication. The resident stated 'I feel fine.' At this time, nurse was on phone with family member [title of F4] and the charge nurse had come into room. Vitals were taken on resident by nurse and charge nurse made the decision to send the resident to the hospital. Resident continued to say 'I feel fine, I don't want to go to hospital.' This writer and resident's [title of F3] explained the situation in full to resident and he agreed to go. This writer assisted resident in putting on pants, socks, and shoes prior to ambulance getting to facility. This writer assisted resident in sitting up at the edge of the bed and when paramedics arrived, assisted in transfer to stretcher . Resident didn't say anymore, however [title of F3] was upset about incident . [DATE] (date initiated) - The facility's Performance Improvement Plan documented that E43 (RN) had a review of his job performance which indicated a need to improve on Medication Administration. This document was signed and dated . by both E43 (RN) and E3 (ADON). [DATE] - The facility's Employee Corrective Action documented, On [DATE] [name of E43, RN] administered Patient . medications to Patient . resulting in Patient . requiring hospitalization . [name of E43] is being suspended pending investigation. This document was signed and dated [DATE] by E43 (RN), E3 (ADON) and E1 (NHA). [DATE] at 4:38 PM - R322's hospital discharge summary documented, . Patient had blood pressure as low as 69/55 . Patient had point-of-care glucose of 50 requiring ampules (sealed glass vessel holding solution to be injected) of D50. In the emergency department patient was started on norepinephrine infusion (intravenous infusion to raise blood pressure in patients with severe, acute hypotension). The patient was admitted to the ICU for shock (critical medical condition) related to iatrogenic (illness caused by treatment) antihypertensive medication, hypoglycemia (low blood sugar) related to glipizide (diabetic medication) ingestion. He was treated supportively with vasopressors (medications that increase blood pressure in emergency situations), fluids, and stress dose steroids (medication that aids in preventing complications) for his hypotension and shock. For his hypoglycemia, he was given dextrose infusions and ampules as needed. He was also started on octreotride drip (infusion medication to inhibit insulin release from the pancreas) for his sulfonylurea overdose (prolonged low blood sugar). With these interventions, his sugars normalized, and he was weaned off vasopressors by the morning of 7/07. Stress dose steroids have also been discontinued . Patient is now maintaining his blood pressure and blood sugar without supportive medications . [DATE] - The facility submitted the following five day follow-up investigation to the State Agency: -root cause analysis: . Failure to dual identify the resident prior to medication administration resulted in the error. The resident's picture was not available in PointClickCare (PCC/electronic medical record) at the time of the error. -result of investigation: Staff member acknowledges medication error, stating 'I don't remember, in my head I thought I knew who the patient was. We don't bring the laptop in the room. I knew . who was in the room and who he was, but I had them confused, it turned out. On the MAR they were side by side, and I think I just read the first two letters . and got them confused . You stated his family was there, did you check with them on his name? No I didn't. To me, there was no question. I'd done that group of patients before. I just went too fast. I didn't check enough of my fail-safes. What fail-safes should you have checked? I could have verbally asked. To me, it was just a simple mistake on my part. At what point did you realize you had given the medications to the wrong resident? And how? I think it was about an hour from then, when I went to pass the medications to the second gentlemen (sic) and realized I had confused them before because the medications were different. All licensed nurses were reeducated on the rights of medication administration and medication competencies were performed. 100% audit was completed to confirm all residents have a picture in PCC or a bracelet ID (identification). Resident condition is unknown at this time as he did not return to the facility. -system changes: Resident's are to be issued name bracelets until photos are uploaded into PCC. Review of the facility's education after this incident by the Surveyor revealed that all licensed nurses were not educated nor competencies performed on medication administration. [DATE] at 11:58 AM - During an interview, E44 (House Supervisor) stated that she was completing a new admission on the second floor when E43 (RN) came up to ask her how to complete a medication occurrence. E44 stated that she explained the process and the nurse seemed very nonchalant (appearing relaxed and calm). E44 stated that she stopped working on the new admission because she thought she needed to follow-up on exactly what happened. E44 stated that when she arrived on the first floor, E43 was on the phone talking to the NP on-call and family. E44 stated that he [E43] told me at almost 2 PM. E44 stated that she reviewed the medications that were given which included 3 medications for blood pressure. E44 stated that she assessed the resident - blood pressure was low, heart rate irregular, resident has to go out. E44 stated that she called the doctor and received an order to send the resident out to the ER. [DATE] at 12:15 PM - On this date/time, the Surveyor placed a call and left a voicemail for E43 (RN) to return the call. As of [DATE] at 3:30 PM, no return call was received by the Surveyor. [DATE] at 9:44 AM - During an interview, E45 (COTA) stated that she entered the resident's room earlier on [DATE] and R322 declined therapy. E45 stated that when she went back to R322's room, she was present when the nurse, E43, came in and told the resident, with [F3, family member] present, that he gave him someone else's medications. The [title of F3] was upset and immediately called [title of F4] and [title of F4] was asking the nurse what medications were given. E45 stated that she was there when the charge nurse came in and said he was going to the ER. E45 stated that she assisted the resident with putting on his pants. While the facility documented the root cause analysis as R322's picture was not uploaded to PCC as an identifier, the facility failed to identify and address the following additional issues in their investigation: - identify the exact time E43 (RN) administered the wrong medications to R322. It was unclear in the facility's investigation exactly what time R322 was administered the wrong medications that were scheduled for 8:00 AM. Per E45's (COTA) written statement, [title of F3] told her that around 12 PM the resident was given another resident's dose of medications, four hours after the scheduled time. -failed to immediately suspend and/or remove E43 (RN) from administering medications to residents pending the facility's investigation. E43 continued to administer medications on [DATE] entire day shift, and on [DATE] morning day shift then was interviewed and suspended. E43 administered morning medications on [DATE] to R144. -failed to immediately report the significant medication error requiring emergent care to the State Agency within 8 hours, per State requirement. -failed to provide the Surveyor, as requested, with evidence of E43's (RN) education and medication competency before returning to work on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. -failed to perform an audit of the other resident's on E43's assignment on [DATE] for any medication errors, which included timeliness of administration, and document in the facility's investigation. [DATE] at approximately 11:30 AM - During a combined interview with E1 (NHA), E2 (DON), E3 (ADON) and E10 (VPO) to discuss R322's incident, the Surveyor asked about the education and competency of E43 (RN) as it was not included in the documentation provided. E3 (ADON) stated that it was included and immediately reviewed the red folder with the documentation that provided to the Surveyor. E3 (ADON) confirmed it was not there. No further documentation was provided to the Surveyor. The Surveyor also asked about E43's current status in the facility. E1 (NHA) stated that E43 resigned about two weeks ago. No reason provided. [DATE] at 9:40 AM - During a follow-up interview, E44 (House Supervisor) confirmed that she notified E36 (UM/on call nurse) and E3 (ADON) on [DATE] between 2 PM - 4 PM of the medication error and transfer to hospital. [DATE] at 12:12 PM - During an interview, F4 (R322's family member) stated that F3 (R322's family member) called me and told me that R322 received the wrong medications. F4 stated that [F3] left the facility to go get ice cream and came back and all hell broke loose. F4 stated that the nurse (E43, RN) reviewed all of the medications and what they were for over the phone and he said Oh we are going to monitor his vitals. He seemed calm and said - all well this happens. He was really rude. F4 said, He could have died. And he was a DNR (do not resuscitate) and if he died we would never have known. [DATE] at 2:18 PM - During an interview, F3 (R322's family member) stated that she kept notes and reviewed them with the Surveyor. F3 stated she arrived at the facility at 10:40 AM and R322 was very alert. F3 stated that F3 stated that he had not been eating a lot. F3 stated that around 12:05 PM, the nurse [E43] brought him his meds and I asked the nurse what medications are being given. [E43] replied just the normal daily and Tylenol. F3 stated that the nurse confirmed that he didn't have narcotics and that he knew that [F4] did not want the resident to have any narcotics. At 12:15 PM, lunch was served and [R322] started to ignore me and did not want to eat. E45 (COTA) came in and [R322] was out of it as he didn't want to eat or do anything. At 12:20 PM, [R322] put his bed back. At 12:30 PM, I texted [another family member] that I think they gave him something because he was out of it. At 12:48 PM and 12:50 PM, [R322] kept taking off his nasal cannula off his nose. [R322] slept for little while and woke up at 1:45 PM and asked for ice cream. F3 said that I thought I would give him anything he would eat. F3 said she went to the grocery store at 1:45 PM and returned at 2:15 PM. The supervising nurse told me that they had given [R322] the wrong medications. I called [F4]. E45 (COTA) came back and I told her what happened. F3 stated that the supervising nurse checked vital signs, notified the doctor and called 911. The other nurse [E43] was on the phone with [F4] because [F4] wanted to know what medications were given. F3 stated that R322 ate some ice cream and said he was fine. F3 stated that the EMTs asked if the resident was a DNR and I knew he was a DNR. F3 stated that the nurse [E43] seemed very calm and it didn't seem like a big deal as he kept asking the resident, How are you buddy? [DATE] at 2:08 PM - During a meeting with facility management, the Survey Team notified E1 (NHA), E2 (DON) and E59 (incoming DON) of an Immediate Jeopardy for R322's significant medication error that occurred on [DATE]. [DATE] at 7:12 PM - E1 (NHA) submitted a signed, dated and timed written abatement plan to the State Agency. The facility's abatement included: -Licensed nurses will be assigned education Avoiding Common Medication Errors on Relias platform to complete in a proctored group setting at the Center or individually independently if not on schedule . Those completing it individually and independently will be educated once they are scheduled by a nurse manager on the specifics of the reasons/need for the education. Licensed nurses will complete this education and pass the final exam associated with it. Licensed nurses will complete a return demonstration of the education with a Nurse Manager utilizing a real-life medication administration for one resident. The nurse will be required to demonstrate review of the Rights of Medication Administration prior to administering the medication and passing the return-demonstration. -Administration team was notified of incident on [DATE] @ (at) 5:00 p.m. to be aware of the situation as leaders of the Facility. -Each resident's picture is uploaded into PCC unless refused, and those that refuse have all agreed to wear a wrist identification band. As of [DATE] all photos are up to date and complete for all residents admitted within the last 24 hours. -At time of education, Nurses will be educated on timely reporting of errors to supervisors and physicians . Date of abatement [DATE] @ 11:59 p.m. [DATE] at 10:35 AM - During an interview, E36 (UM/on call nurse) stated that she was on the phone with E44 (House Supervisor) regarding another issue when she was told about R322's medication error. E36 stated that E44 was still upstairs and did not know the details about the med error yet. E36 stated that she found out later that day that R322 was sent to the hospital. E36 confirmed that she called E3 (ADON) on [DATE] regarding the medication error. [DATE] at 2:08 PM - During an interview, E2 (DON) stated that E34 (HR) was the Manager on Duty (MOD) on [DATE]. E2 confirmed that MOD's do not report any incidents to the State Agency, only the DON and ADON. E2 confirmed E3 (ADON) was back up as she was off that weekend. Based on record review of the facility's abatement plan which included nursing staff education, testing, signed attestation and observation of medication administration, follow-up interviews with nursing staff, review of new admissions records for pictures or identification bracelets and no further medication error incidents, the facility's IJ was abated on [DATE] at 11:59 PM. 2. Cross refer to F726, example 3 Review of R48 and R95's clinical records revealed: For R48: [DATE] - R48's census record documented her room and bed as XXX, B bed. [DATE] - R48's [DATE] eMAR revealed the following scheduled medications: - Ambien 5 MG, one tablet, for insomnia at 8 PM; - Tramadol 25 MG, one tablet, for pain at 8 PM; and - Xanax 0.5 MG, one tablet, for anxiety disorder at 9 PM. E55 (LPN) signed off the above medications as administered on the eMAR. In addition, E55 documented in the medication cart's controlled substance tracking book that the above three medications were signed out by E55 between 7:05 PM through 7:10 PM. For R95: [DATE] - R95's census record documented her room and bed as XXX, A bed. [DATE] - The quarterly MDS assessment documented that R95 had a BIMS of 7 (cognitive impairment). [DATE] at 8:00 PM - The facility's incident report documented, [Name of R95] received medications that were for her roommate: Tramadol 25 mg, Alprazolam 0.5 mg and Ambien 5 mg. Patient unable to give description. [DATE] at 9:37 PM - The facility reported the medication error to the State Agency and stated that New orders to monitor vitals and neuro checks. Nurse has been suspended pending investigation. [DATE] (untimed) - A documented telephone interview between E2 (DON) and E55 (LPN) revealed: Tell me about when you were giving medications in room XXX at about 7:00 pm. I confirmed correct name and dosage to computer for the medications for [name of R48]. I took out the 3 meds, Tramadol, Ambien and Alprazolam. Why did you take only the 3 out and not her other scheduled medications? I was going to get the others, but I got sidetracked by the conversation at the nurse's station. Why didn't you also pull out the other scheduled 8:00 pm medications? I like to get the narcotics out and sign them out of the book. I usually get the narcotics then the other meds, but I walked away and when I came back I did not get the other meds out. My relief was there, and they were talking at the nurse's station, and I wanted to confirm with her (nurse relieving) that she was ready to report over, so I could start my documentation. I was up there for a while because I did not want to interrupt anyone's conversation. After I talked to her, I got the medications off the cart and I went into the room to the wrong patient, I got completely sidetracked. Was the nurse relieving you at the nurse's station? Yes, I was pretty sure it was, I wanted to confirm with her. There were other staff up there, I am not sure who everyone is (sic). I had a lot going on, the patient next door had some redness on her foot up to her thigh, her foot and ankle were swollen, I had a lot of stuff going on in my head. I went back to nursing cart, I already had the medication out in a cup, (Tramadol, Ambien, and Alprazolam) it was already prepared and I went to room XXX: (sic) I mistakenly went to the wrong bed, I realized when I went to chart, I gave the meds to A bed. [name of R95] How did you identify the patient when you went into the room? I looked at her and said I had her medications; I did not ask her name. Did you look at her picture in PCC? I looked at the picture and I was in the right room. When I went back from the nurse's station to get the medication off the cart I went to the wrong bed. Were you in the room prior to this time, did either of these residents get medication on the first med pass? Yes, I believe they got the medications that were due around 4:00 p.m. (review of the MAR determined that each resident did receive 4:00 pm medications that were signed out appropriately). 7:30 came and I started on the 8:00 o'clock meds. Did you identify those patients in the room? There was no distraction going on so I as (sic) able to focus. Do you remember how you identified the patients the first time you were in the (sic) there to give medications at 4:00 pm? Yes, I asked their names and I identified them by their picture. How did you ask them their name? I said, 'Hey [name of R95], or [name of R48]', before giving each of them their medications, they said yes that's me or they said yes. What time did you give the medications? It was about 7:30 when I gave the medication. It took about 20 minutes to give report then I went to do my documentation, then I realized I made a mistake, I told the nurse who took over, I got a hold of E60 (RN Supervisor) then E36 (UM/on call nurse) and then [name of E36] called [E2] (Director of Nursing). I came out of the room to give nurse, [name of E44], report at the cart, report and narcotic count were completed. Sat down at the computer to chart medication, I looked and saw the room number I realized it was XXXB bed's meds that I gave to XXXA. I immediately contacted nursing supervisor DON- nurse on call - and the NP. NP gave orders for vitals and neuro checks, and alert charting. [Title and name of R95's resident representative] was contacted 3x to no avail. A voicemail left with call back for contacting. Undated/untimed - A documented telephone interview between E2 (DON) and E44 (on-coming Nurse) revealed: I relieved the nurse for the patient. She realized her mistake and told me; the supervisor was told. We checked the patient, and she was fine. Everyone was notified. The patient was monitored when I was there, she was fine. [DATE] - The facility submitted a five day follow up to the State Agency, which included: - Root cause analysis: The nurse did not follow proper procedure for medication administration causing the medication error. - Result of Investigation: . the resident remained at the facility, vitals and neuro checks remained stable and there were no adverse outcomes in the patient's condition. The nurse had received the 10 rights of medication administration education during the new hire orientation which took place between [DATE] and [DATE]. The nurse remained suspended pending investigation. She will be returned to the facility after education, coaching/counseling and a medication pass observation has been completed . The other resident's medication administration records on the nurse's assignment were reviewed with no discrepancies noted, alert and oriented residents on the nurses' assignment were interviewed and asked if they had any issues with their medications given on 3-11 (PM) shift on [DATE] and there were no issues. [DATE] at 9:40 AM - During an interview, E44 (on-coming nurse) confirmed that she worked 7 PM to 11 PM on [DATE]. E44 stated that she relieved E55 (LPN) and was made aware of the medication error as E55 immediately self-reported and was upset about it. E44 stated that she was familiar with the resident and monitored R95 closely. E44 stated that the resident did not have a negative outcome. [DATE] at 12:35 PM - Observation of R95 in her room revealed that she was alert and was able to tell this Surveyor her name when asked. The facility failed to ensure R95 remained free of significant medication error. 3. Review of R22's clinical records revealed: [DATE] - R22 was admitted to the facility with diagnoses including diabetes and heart disease. [DATE] - R22's care plans documented, The resident is at risk for complications and blood glucose due to diagnosis of diabetes .and insulin use. [DATE] - R22's quarterly MDS assessment documented a BIMS score of 15 (indicating sufficient judgement to manage every day events.) [DATE] - R22's Medication Administration Record (MAR) documented, Humalog Kwik Pen-injector 100 Unit/ML (fast acting insulin), inject per sliding scale before meals - if 0 - 100 = No insulin; 101 - 150 = 2 units insulin; 151 - 200 = 4 units insulin; 201 - 250 = 6 units insulin; 251 - 300 = 8 units insulin. Humalog Kwik Pen manufacturer ([NAME] Lilly and Company, [DATE]) instructions, Take (insulin) within 15 minutes before or right after a meal. [DATE] 7:30 AM - R22's MAR documented a blood glucose of 124 and received two (2) units of fast acting insulin. R22 was observed receiving a meal tray at 9:45 AM (2 hours and 30 minutes later.) [DATE] 11:30 AM - R22's MAR documented a blood glucose of 224 and received six (6) units of fast acting insulin. R22 was observed receiving a meal tray at 1:45 PM (2 hours and 45 minutes later.) [DATE] 7:30 AM - R22's MAR documented a blood glucose of 295 and received 8 (eight) units of fast acting insulin. R22 was observed receiving a meal tray at 9:45 AM (2 hours and 30 minutes later.) During an interview, R22 stated, I usually get my insulin when they (nurses) check my blood sugar. [DATE] 10:00 AM - During an interview E42 (LPN) stated, I gave the residents their insulin when I checked their blood sugars. 4. Review of R33's clinical records revealed: [DATE] - R33 was admitted to the facility with diagnoses including diabetes and long -term use of insulin. [DATE] - R33's MAR documented, Humalog Kwik Pen 100 Unit/ML (fast acting insulin) inject as per sliding scale before meals: 101 - 150 = 2units; 151 - 200 = 4units; 201 - 250 = 6units; 251 - 300 = 8units; 301 - 350 = 10units; 351 - 400 = 12units [DATE] - R33's care plan documented, .At risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with insulin use .administer insulin as ordered. [DATE] - R33's annual MDS assessment documented a BIMS score of 15 (indicating sufficient judgement to manage every day e[TRUNCATED]

2. The laundry room tour on 8/21/23 at 10:00 AM revealed the following: 8/21/23 at 10:00 AM - The laundry room back door of the soiled linen room was propped open and not kept closed. Finding was reviewed and confirmed by E24 (Director of Housekeeping) on 8/17/23 at approximately 11:15 AM. 9/8/23 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (Interim DON). Based on interview and review of facility documentation as indicated, it was determined that the facility failed to implement their infection control program for COVID-19 after a resident on 8/4/23 tested positive and subsequent positives were identified on 8/15/23 and 8/19/23, putting residents at risk for a severe adverse outcome. On 8/22/23 at 4:40 PM, an Immediate Jeopardy (IJ) was called. Based on review of the facility's corrective actions, the IJ was abated on 8/23/23 at 3:00 PM. Additionally, the facility failed to maintain laundry services in a sanitary manner. Findings include: The facility's policy and procedure entitled COVID-19, dated 5/10/23, stated, . 5. Containment/Management: a. Identification of a new case in a patient: . -Initiate contact tracing and identify close contacts/exposures. -Serial testing of close contacts/exposures: -test immediately, if negative, test again 48 hr later, if negative, test again 48 hr later . -If any new cases are identified, perform contact tracing for new case and initiate serial testing . 7. Case Reporting . b. Notify local and state health authorities of any diagnosed COVID-19 case . 1. Review of the facility's infection control line listing revealed the residents and the dates when each tested COVID-19 positive in the facility: 8/4/23 - R75; 8/15/23 - R359; and 8/19/23 - R130 and R358. 8/22/23 at 1:23 PM - During a combined interview, E3 (Interim DON/IP) and E4 (UM/RN) were asked if the facility conducted contact tracing and testing. E3 and E4 both stated that they did not conduct contact tracing and testing. 8/22/23 at 3:49 PM - During an interview, the Surveyor requested the facility's infection control line listing from E1 (NHA) as soon as possible. 8/22/23 at 4:40 PM - The facility management was notified that an Immediate Jeopardy was being called for the failure to implement their infection control program for COVID-19. The facility failed to do the following: -initiate contact tracing and identify close contacts/exposures; -conduct serial outbreak testing; -notify the Department of Public Health (DPH) of the COVID-19 outbreak as required; and -educate staff working in the building about the outbreak and the use of source control. 8/22/23 at 8:45 PM - The facility's abatement plan outlined the following corrective actions to be initiated immediately: -Infection Preventionist/designee initiated broad-based testing of COVID-19 for residents and staff. -Administrator notified the Department of Public Health of the COVID-19 outbreak. -Administrator/DON and Infection Preventionist educated by the Regional Clinical Director on the COVID-19 infection control program, to include: initiation of contact tracing and identification of close contact/exposures, conducting serial testing, notifying DPH of the COVID-19 outbreak, and educating staff working in the building about the outbreak and the use of source control. -Education of staff on COVID-19 outbreak and the use and availability of source control initiated. All staff will be educated and tested before their next scheduled shift. 8/23/23 at 4:43 PM - E1 (NHA) provided the Surveyor with evidence that DPH was notified of the COVID-19 outbreak, line listings were sent, and communication with DPH would continue on status of outbreak going forward. Review of the facility's staff education and testing documentation and follow-up interviews, the facility abated the immediate jeopardy as of 8/23/23 at 3 PM. 9/8/23 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (Interim DON).