**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, facility self report and facility inservice record, the facility failed to ensure a resident was safe in the environment. Review revealed Resident #1 required assistance of one staff for personal hygiene and ambulation. On 7/4/24 at approximately 6:58 a.m., Staff A, Certified Nursing Assistant (CNA) assisted Resident #1 to the bathroom with a walker. Staff A proceeded to leave Resident #1 alone in the bathroom for which Resident #1 lost balance and fell to the bathroom floor and sustained a left hip fracture. Additionally on 8/27/24, Resident #2 was transported to an appointment with no staff assistance, fell while at the appointment, taken to the nearest emergency room and sustained a dental fracture to upper incisors. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 5/23/24 for Resident #1 documented a score of 8 on Brief Interview for Mental Status (BIMS) test which indicated moderately impaired cognitive impairment, was able to be understood and had the ability to understand others. The resident had diagnoses that included hypertension, diabetes mellitus, Non-Alzheimer's Dementia, anxiety and osteoarthrits and required substantial to maximal assistance with toileting, dressing and personal hygiene and supervision or touching assistance with oral hygiene and assistance with ambulation with walker. A Significant Change MDS assessment with a reference date of 7/18/24 for Resident #1 documented has the ability to be understood and ability to understand others. The resident had diagnosis that included hypertension, Non-Alzheimer Dementia and recent hip fracture, with recent fall with bone fracture and surgical wound. A Nursing Care Plan with a created date of 4/11/23, identified a problem of I have an Activity of Daily Living (ADL) self-care performance deficit related to weakness, deconditioning, impaired mobility and I am at risk for injury from falls due to impaired mobility and weakness, dementia and macular degeneration Interventions include: *(7/4/24), Non-skin strips placed on floor in bathroom. *Ambulate with me to the dining room and activities. *I use a front wheeled walker. *Please ensure my call light is in reach and remind me to use it for assistance. *Ambulation: Assist time 1 with front wheeled walker *Oral Cares: Assist times 1 *Toileting: Assist times 1 for toileting and peri cares. A Interdisciplinary Care Conference Worksheet dated 4/24/24, documented resident needs 1 assist with cares with front wheeled walker and has moderate cognitive impairment. A Fall Risk assessment dated [DATE], documented resident with no history of falls and is at moderate risk with shuffling steps and uses an assistive device, walker. The Progress Notes dated 5/23/24 at 9:23 a.m., documented Quarterly Nursing Assessment note: quarterly nursing assessment completed. Resident is disoriented to place and time. Wears glasses to aid in vision. Residents hearing is adequate. Has an upper extremity functional limitation in range of motion on one side of the body. No lower extremity limitations noted with range of motion. Resident transfers with supervision, one person physical assist. Is able to ambulate in corridor with supervision with setup help only. Resident uses a walker. Resident needs physical help with part of the bathing activity. Is able to dress self with limited staff assist. Completes personal hygiene with staff supervision. Resident is occasionally incontinent of urine. The Progress Notes dated 7/4/24 at 7:28 a.m., documented Health Status Note Text: Resident had a fall at 6:55 a.m. in resident's bathroom. Resident was found with head under the sink. Resident was using the walker at the time. Her slipper were off her feet. Resident was on her sides. Resident had loose stool in her brief. Resident states my left hip hurts very much. CNA, states I was in the room getting the husband. Then, I heard the noise from the bathroom and found her on the floor. No bleeding or bruises noted. No open injuries noted. Blood pressure inaudible with manual blood pressure cuff. 911 called at 7:00 a.m. and resident transferred to emergency room at 7:21 a.m. In an Unwitnessed Fall Report dated 7/4/24 at 6:58 a.m., documented CNA notified this nurse of fall of resident in bathroom at 6:56 a.m. At 6:58 a.m., Resident found on the floor of bathroom with head under the sink. Resident in right lateral posture lying on the floor and complaining pain to left hip. Resident then complained of pain to left leg. Resident husband waiting for her outside the room. Resident has small bowel movement in her brief, but due to nature of the fall and pain, no changes in position made to change the brief. Residents left leg was angled at knee and any movement to that limb aggravated pain. Pain level 10/10. No visible injuries or cut noted to head, limb or trunk at this time. Resident states I don't know what happened but my left leg hurts. Mobility status: Ambulatory with assistive device/with out assist at time of fall. An investigation self-report amendment submitted to the Department by the facility on 7/4/24, included the following: Resident is assist time 1 staff, was brought into bathroom with walker to brush her teeth, left unattended and fell. Injury of Fracture of the Left Femoral Neck on the left leg. On Thursday July 4th 2024, at approximately 6:55 a.m., Resident #1 was assisted by Staff A in getting set up with oral cares at the bathroom sink. Staff A then left the bathroom to assist the roommate. While assisting the roommate, Staff A heard a noise from the bathroom. Staff A re-entered the bathroom to find Resident #1 on the floor of the bathroom lying on her left side. Staff B, RN, performed a head-to-toe assessment on Resident #1. Resident #1 stated that my left hip hurts very much. Staff B, RN, made the decision to send Resident #1 to the emergency room per nursing judgement related to head-to-toe assessment and positioning of leg. Corrective Action: Staff A was provided 1-1 education on the need to stay with residents who are coded as needing assistance of 1 or more staff members at all times during personal care tasks. All facility staff members were educated on the need to stay with residents who are coded as needing assistance of 1 or more staff members at all times during personal cares tasks by the Director of Nursing on 7/5/24. The Hospital Consultative Note dated 7/4/24 at 10:53 a.m., documented, Resident #1 is an [AGE] year-old female, whom I was asked to see in consultation for a left displaced femoral neck fracture. She fell in the bathroom this morning. She walks with a walker. She complains of left hip pain. Diagnostic Data: X-rays of left hip reveal a displaced femoral neck fracture without preexisting arthritis. Assessment: Left displaced femoral neck fracture in an ambulator. Observation on 9/17/24 at 8:45 a.m., Staff C, Certified Nursing Assistant (CNA) and Staff D, CNA, transferred Resident #1 with the use of a gait belt and front wheeled walker from the wheelchair to a recliner. Resident had a slow steady gait and complained of left hip pain during the transfer. Interview on 9/16/24 at 2:30 p.m., Staff A, CNA stated that they went into Resident #1 room to assist the resident to the bathroom on 7/4/24 approximately 6:55 a.m. Staff A stated that as Resident #1 was in the bathroom the roommate attempted to open the door to the bathroom so Staff A, left Resident #1 alone in the bathroom as they assisted the roommate back to the recliner. Staff A then heard a noise come from the bathroom. Staff A stated that when they went back into the bathroom, Resident #1 was on the floor. Staff A stated that the expectation of the staff is to stay with a resident that needs assist of 1 for cares, including personal/oral hygiene and that Staff A got education on the need to stay with any resident that required staff assistance. Interview on 9/17/24 at 10:00 a.m., Staff B, Registered Nurse (RN) stated they worked on 7/4/24 when Resident #1 fell in the bathroom. Staff B, confirmed and verified that Resident #1 needed assistance of 1 staff for cares and that it is the expectation of the staff to stay with any resident that requires assistance and that the facility did education about the expectation of staying with a resident that requires assist. Interview on 9/17/24 at 1:50 p.m., The Director of Nursing confirmed and verified that the expectation of staff are to stay with any resident that requires cueing, supervision or assistance with cares. An Inservice Record dated 7/5/24, documented that Residents who are coded as needing assistance of one or more staff members for ADL's should not be left alone while they are completing a personal task (brushing teeth). They [NAME] be supervised throughout the completion of the task. 2. The MDS assessment with a reference date of 6/13/24 for Resident #2 documented a score of 6 on BIMS test which indicated severely impaired cognitive impairment, unclear speech, sometimes is understood and usually understands others. The resident had diagnoses that included hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, depression and Schizophrenia and is independent with ambulation with a walker and had a recent fall with 2 or more injuries. The Plan of Care with an initiated date of 9/10/20, had a focus area of I have impaired cognitive function or impaired thought processes related to cognitive communication disorder. Interventions include: *RESIDENT WILL HAVE STAFF PERSON OR FAMILY MEMBER GO TO APPOINTMENTS WITH HIM *Verbal communication can be difficult to understand at times. Sometimes I will write notes to staff to communicate or make my needs known. The Progress Notes dated 8/27/24 at 9:55 p.m., documented Health Status Note Text: Resident had gone to for a Dental appointment in the morning. In the afternoon after his consultation he had a fall there and was sent to Hospital ER. The Progress Notes dated 8/28/24 at 5:00 a.m., Comprehensive Encounter Date of Service: Chief Complaint: Post ER visit History of Present Illness: Patient is a [AGE] year old male with chronic health conditions. Schizoaffective disorder, insomnia, dyslipidemia, cognitive communication deficit, essential hypertension, regional lumbar radiculopathy, osteoarthritis, spinal stenosis, and Alzheimer's. Today he is seen in his room via telehealth, he is at baseline. He was at a dentist clinic visit yesterday and had a fall with injury to his mouth. He was sent to ER for evaluation. Noted open spot in top front gums from extraction and two small teeth have chips next to open spot, no bruising or bleeding. He is calm, pleasant, disorganized thought process. The Progress Notes dated 8/28/24 at 2:19 a.m., documented Health Status Note Text: Resident returned from ER at 11:15 p.m., accompanied/transported by the facility Administrator. Resident is alert, aware of surroundings. Told this Nurse he lost balance and fell at the dentist office earlier. Only injury is chipped tooth. Resident states only pain is to neck and back, but doesn't need anything for pain at present time. The Medical Center Emergency Department dated 8/27/24, documented, reason for visit is a fall, patient presents via Emergency Medical Services with complaint of being found on the bathroom floor of the dentist office. Patient was apparently dropped off at the dentist for a tooth extraction, but no one from the facility remained with the patient at the appointment. History of Alzheimer's dementia and schizophrenia. C-collar in place upon arrival. Description=fall , initial encounter with broken teeth. Patient presents with fall. History of dementia. Found on floor at dentist office with dental fractures. Dental fracture to upper incisors. Dental cement applied to fractured tooth. Patient brought to the Emergency Department by EMS after being found on the floor of the bathroom at the dentists office. Patient did not have any attendants at his visit. History taking is extremely limited from patient as is not oriented to person, place situation. Speaks in short sentences, difficult to understand. Appears to have multiple dental fractures, one tooth site oozing blood. Dried blood in mouth. Interview on 9/17/24 at 11:25 a.m., the facility administrator confirmed and verified that residents are to have staff accompany them to appointments if families are not able to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interview, the facility failed to ensure that residents did not develop avoidable pressure ulcers for 1 of 1 residents reviewed (Resident #8). The facility reported a census of 64. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #8 identified a Brief Interview for Mental Status (BIMS) score of 11 indicating a moderate cognitive impairment. The MDS revealed the resident required extensive assistance of 1 staff member for bed mobility and personal hygiene, and extensive assistance of 2 staff members for transfers. The MDS further revealed the resident did not walk in her room or in the corridor. The MDS documented diagnoses that included diabetes, prior hip fracture, Parkinson's Disease, prior stroke, depression and traumatic brain injury. The comprehensive care plan revealed a focus area of Activity of Daily Living (ADL) deficit, revision date of 9/8/21. The care plan failed to direct staff to do any bed mobility or repositioning of the resident. The care plan additionally revealed a focused area of Impaired Skin Integrity related to decreased mobility, revision date of 12/6/22. This section of the care plan also failed to direct staff to do any bed mobility or repositioning of the resident. Record review of the current care plan revealed the facility failed to implement interventions related to the presence of a pressure ulcer that was identified on 12/15/22 until it was revised on 1/23/22. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Braden Scale for Predicting Pressure Sore Risk revealed documentation the resident scored a 15 indicating a low risk for the development of pressure ulcers. A score of 9 or less indicates a severe risk. A score of 10-12 indicates a moderate risk. A score of 13-14 indicates a mild risk. A score of 15-18 indicates a low risk. A score of 19 or higher indicates a resident is not considered at risk for pressure ulcer development. The skin sheet, non-ulcer assessment dated [DATE] revealed the resident had blister to her right heel which had burst. The assessment documented the measurements were 7.0 cm x 3.0 cm x 0.1 cm. The skin sheet, non-ulcer assessment dated [DATE] documented the blister to be resolved. The skin sheet, ulcer assessment dated [DATE] documented the resident to have a Stage 2 pressure ulcer to her right heel. The assessment documented the pressure ulcer had measurements of 1.5 cm x 1.5 cm x 0.3 cm and further documented the pressure ulcer as facility acquired. Additional description included scant yellow drainage with no odor and the wound base having granulation tissue (pink or red tissue with a shiny, moist appearance). The skin sheet, ulcer assessment dated [DATE] documented the pressure ulcer measurements had increased to 2.5 cm x 2.5 cm x 0.6 cm. Further description included scant yellow drainage with the wound base having pink or red tissue with a shiny, moist appearance. Further description included scant yellow and brown odorous drainage with the wound base having slough (yellow or white tissue that adheres to the ulcer bed in strings or clumps or is mucinous). The skin sheet, ulcer assessment dated [DATE] documented the pressure ulcer had measurements of 2.2 cm x 2.2 cm x 0.2 cm. The ulcer was now noted to be a Stage 3 pressure ulcer. Further description included scant serosanguineous drainage (thin and watery fluid pink in color due to presence of small amount of red blood cells) with the wound base having pink or red tissue with a shiny, moist appearance. Further description included scant yellow and brown odorous drainage with the wound base having slough (yellow or white tissue that adheres to the ulcer bed in strings or clumps or is mucinous). Weekly weight and skin review notes dated 12/7/22, 12/15/22 and 12/29/22 lacked documentation of Resident #8 being discussed during the any of these weekly meetings. On 1/25/23 at 3:50 pm, the Director of Nursing (DON) stated there were only 3 meetings in December due to the holidays. Review of document titled Dietitian fax to Physician revealed the resident was seen by a Registered Dietitian on 10/28/22. Review of document titled Consultant Dietitian Report revealed the resident was seen by a Registered Dietitian on 1/16/23. The facility was unable to provide documentation of a Registered Dietitian performing any other visits in between those two dates. A progress note dated 1/4/23 at 4:34 pm by Staff A, Licensed Practical Nurse (LPN) documented a noted decline to the wound and physician notification was made. A progress note dated 1/9/23 at 10:48 am by the Assistant Director of Nursing stated a new order for an antibiotic was received for possible cellulitis to the right foot. A progress note dated 1/12/23 at 9:20 am by Staff D, facility Registered Dietitian stated a recommendation of LiquaCel (a liquid collagen liquid protein) to promote skin healing of the stage 2 pressure ulcer. A progress note dated 1/23/23 at 4:03 pm by the ADON stated a referral had been received to send the resident to a wound clinic. A visit note dated 12/19/22 by Staff H, Nurse Practitioner revealed documentation of a Stage II pressure ulcer to the right heel containing 60% slough. A visit note dated 1/23/23 by Staff H, Nurse Practitioner revealed documentation of a Stage III pressure ulcer of the right heel that was black and appeared necrotic (dead skin). Observation on 1/23/23 at 10:55 am revealed the resident to be in her wheelchair wearing heel protectors on both feet. Observation on 1/24/23 at 9:41 revealed the resident to be in her recliner wearing heel protectors on both feet. Observation on 1/25/23 at 10:42 am revealed the resident to be lying in bed with heel protectors on both feet. Observation on 1/26/23 at 9:13 am revealed the resident to be sitting in her wheelchair wearing a sock on her left foot and a slipper on her right foot. No heel protectors were in place. On 1/24/23 at 12:34 PM, Staff I, Licensed Practical Nurse (LPN), MDS Coordinator stated she is new to the role of MDS Coordinator in the facility. She voiced she is currently going through the care plans of all of the residents and updating them as she felt they were not accurate at the time she began the position. On 1/25/23 at 10:08 am, the ADON stated she is the primary person who manages wounds in the facility. She stated she has received no specialty wound training. She further stated the facility used to have a wound Nurse Practitioner for the facility but those visits stopped perhaps last summer. She stated in the beginning of December a blister was found and it slowly declined. She felt it was going back and forth in wound healing. She stated she talking to the Registered Dietitian a couple of weeks earlier about a dietary supplement and that the resident is diabetic. She stated the facility Nurse Practitioner assessed the wound on 12/19/22 and 1/23/23. She voiced the protocol for wounds are that she assesses them once a week unless she is informed of a decline in the wound. She stated her expectation is that a resident who needs assistance to be repositioned should be assisted every 2-3 hours. On 1/25/23 at 1:31 pm, the Director of Nursing (DON) stated that prior to the resident's wound being discovered, interventions for prevention of development of a pressure ulcer would include whatever was on her care plan. She stated she had a pressure reducing cushion on her recliner. She stated the resident does not have a specialty mattress on her bed but all of the mattresses in the facility are considered pressure reducing mattresses. She stated when the resident was in her wheelchair for meals she would be transferred to her bed or recliner after meals. She voiced her expectation is residents should be assisted to reposition every 2-3 hours if they are unable to reposition themselves. On 1/25/23 at 3:47 pm, the Regional Nurse Specialist for the facility stated the facility does not have a policy for Registered Dietitian reviewing residents. She stated it would be considered a standard of care to have the Registered Dietitian involved in residents with wounds. On 1/25/23 at 3:50 pm, the DON stated updating care plans is an interdisciplinary approach. She stated her expectation is that care plans should be updated quarterly and with significant changes. She stated they follow the Resident Assessment Instrument (RAI) process for care plan reviews. She further stated the ADON is the person who typically updates the care plans for any skin issues or any incidents filed in Risk Management (a portion of the Electronic Health Record for incident reports such as falls, skin injuries, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/26/23 beginning at 8:06 am observed Staff C, Certified Medication Aide (CMA), prepare the medications for Resident #34. Staff C poured liquid, levetiracetam 100 mg/ml, into a plastic medication cup as she held it up in the air. The medication cup appeared to hold 10 milliliters (ml) of medication, equaling 1000 mg. Resident #34's January 2023 Medication Administration Record (MAR) listed an order for levetiracetam 750 mg by mouth two times a day. 3. During this continuous observation on 1/26/23 watched Staff C prepare Resident #50 ' s medications, including metoprolol 25 mg, extended release (a blood pressure medication). After Staff C prepared all of Resident #50 ' s medications, she poured his medications into a pouch, including the metoprolol, and crushed the medications using a pill crusher. Then she mixed the crushed medications with pudding. Staff C reported that she crushed all of the medications. The Care Plan Problem dated 11/10/22 indicated that Resident #50 had a risk for adverse side effects (ASE) from high risk medications. The included Intervention dated 11/10/22 instructed the staff that Resident #50 takes anti-hypertensive medications. Please administer them to him as ordered. The document labeled which tablets should never be crushed updated 11/10/21 included a section regarding Controlled release medications. The section directed that these medications are designed to release medicine over an extended period to allow less frequent administration. Crushing may mean a fatal dose is released. Some slow-release tablets are scored and can be divided or halved, but not crushed. Examples include Toprol XL (metoprolol succinate) and Sinemet CR (carbidopa and levodopa). On 1/26/23 at 9:38 am, the Pharmacist Consultant stated the Metoprolol extended release should not be crushed. On 1/26/23 at 12:03 pm, Staff C explained that she knew that metoprolol should not be crushed and that she did it by mistake. She stated her procedure for liquid medications is to look at the lines on the medication cup and measure it. An undated document titled Medication Administration Procedures directed the staff regarding general procedures to follow for all medications: a. Note any allergies or contraindications the resident may have prior to drug administration b. Oral medication administration: - If the medication is liquid, pour the correct amount directly into a graduated medication cup or measuring device provided with the liquid. Based on clinical record reviews, facility policy review, staff, Pharmacist, and Advance Registered Nurse Practitioner (ARNP) interviews, the facility failed to provide 3 of 5 residents (Resident #19, #34, and #50) with medications as ordered. On 4/13/22 Resident #19 received another resident's medications. Resident #19 required an overnight hospitalization due to chest pain experienced after receiving the medication. In addition, the facility gave a medication not as ordered to Resident #34 on 1/26/22 during an observation. This resulted in an excess of an anticonvulsant medication given. The facility also failed to administer Resident #50 hypertensive extended release (ER) medication as directed by crushing the medication, thus changing the release time of the medication. The facility reported a census of 64 residents. Findings include: 1. Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed she is independent with bed mobility, transfers, walking, and eating. The MDS documented a diagnosis of schizophrenia. The MDS indicated that Resident #19 use an antipsychotic medication for seven out of seven days in the lookback period. Resident #19's Clinical Census identified that on 4/13/22 she went to the hospital and returned on 4/14/22 to the facility. The facility document titled, Self-Report, dated 1/24/23 for Resident #19 documented on 4/13/22 that at approximately 7:58 AM, Resident #19 received medications not prescribed for her at approximately 7:15 AM. The form listed that while Staff H, Licensed Practical Nurse (LPN), did her morning medication pass, she mistakenly administered the following medications to Resident #19. a. Fetzima 120 milligrams (mg) (antidepressant medication) b. Jardiance 25 mg (diabetic medication) c. Metformin XR 1,000 mg (diabetic medication) d. Zyprexa 2.5 mg (antipsychotic medication) e. Perphenazine 24 mg (antipsychotic medication) The document instructed the facility notified Resident #19 family, psychiatric nurse, Nurse Practitioner, and Poison Control. Poison Control recommended that Resident #19 went to the emergency room, but she refused. At approximately 10:40 AM, while onsite at the facility, Staff F, Advanced Registered Nurse Practitioner (ARNP), gave an order to send Resident #19 to the Emergency Department (ED) for chest pain. Resident #19 got admitted to the local hospital from the ED for nursing observation. The History and Physical (H&P) from the local hospital dated 4/13/22 documented Resident #19 got evaluated at the local ED and is doing well, but she did have palpitations (feelings of having a fast-beating, fluttering, or pounding heart) and some left-sided chest discomfort with some nausea, but no vomiting. On 1/26/23 at 12:32 PM Staff G, Pharmacist, explained that the medications Resident #19 received in error on 4/13/22, Zyprexa and Perphenazine, may cause some drowsiness. He reported that he could speculate other side effects that could have happened, but he believed that medication error could cause those side effects. On 1/26/23 at 12:36 PM Staff F revealed that the error happened due to Resident #19 having the same first name as another resident. She added that Resident #19 also has a psychiatric doctor that she consulted and decided to keep her at the facility unless symptoms occur. She explained that when she arrived onsite on 4/13/22, Resident #19 was expressing symptoms of chest pain. At that time, they decided to send her to the local ED. Staff F revealed that Resident #19 likely had chest pain due to her anxiety. On 1/26/23 at 12:39 PM Staff H verified that she administered Resident #19 the wrong medications on 4/13/22. She reported Resident #19 as the first person she gave medications to that morning and the medications were right next to another resident in the cart with the same first name. She expressed that she immediately called the ARNP and checked Resident #19's vitals when she realized that she made the error. She expressed that she also called the nurse manager on call and informed Resident #19. After Resident #19 started having a complaint of chest pain, Staff F arrived to the facility and sent Resident #19 to the local hospital. She revealed she received education on the situation and that the facility fired her later that day. The facility's undated policy titled, Medication Administration Procedures, instructed staff to identify the resident before administering medications.