Based on record review and staff and resident interviews the facility failed to give 1 of 3 residents the correct medications and inadvertently gave him another residents medications that included anti-psychotic medication resulting in over sedation and admission to the hospital for observation (Resident #1). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/15/24 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented he did NOT take anti-psychotic medication and had no neurological diagnoses. The MDS also documented his psychiatric/mood disorder was depression. Record review of an emergency room (ER) note dated 9/18/24 for Resident #1 documented he received the following wrong medications at the facility: Zonisamide 100 milligrams (mg) - anti-convulsant Zofran 4 mg - anti-emetic Sucralfate 1 gram (g) - ant-acid Seroquel 200 mg - anti-psychotic Propranolol 20 mg - beta blocker Tylenol 1000 mg - analgesic The ER note also documented he was minimally arousal all afternoon according to family and the facility, and had a blood sugar of 52. He was sedated likely due to the Seroquel he received in error, Poison Control suggest six (6) hours of observation. His low hypoglycemia (blood sugar) was likely due to being sleepy and sedated. Plan is to admit to the Hospital for accidental Seroquel administration and hypoglycemia. The facility will admit him for close monitoring and anticipated metabolism of the inadvertently provided Seroquel. Record review of a document titled, Action Plan for Medication Event on 9/18/24 instructed the following: a. Resident was assessed and physician was notified. b. A full investigation was completed. c. Effective immediately a sign will be placed on the medication cart while medication pass is in progress to deter interruptions. 4. On 9/19/24, re-education of the six (6) rights of medication pass was provided to all nurses and CMA's. 5. Medication Pass audits will be completed two (2) times a week on all shifts for one (1) month. The frequency of audits thereafter will be determined by outcomes. Record review of a Progress Note dated 9/19/24 at 3:02 PM by Resident #1 Doctor documented, he had a minor event on 9/18/24 and given several wrong medications which were intended for another resident. Most notable was an anti-psychotic Seroquel 200 mg. He ultimately settled in for the afternoon and slept, which was expected. He did experience an episode of hypoglycemia that was not directly related to the medication. However, Resident #1 is a gentleman who typically snacks all afternoon, and he did not do that, but rather slept, and that led to hypoglycemic episode that resulted in his transport to the emergency department for evaluation. It was a predictable event, not directly caused by the medication, but caused by his sleeping. During an Interview on 9/20/24 at 6:40 PM with Resident #1 revealed he recently went to the hospital because his blood sugars tanked. He informed everything went fine and he got to come back home to the facility. During an interview with the Administrator on 9/20/24 at 6:47 PM revealed Resident #1 was given the wrong residents medications this week on 9/18/24 and they sent him the hospital for evaluation and he ended up staying the night for observation. During an interview on 9/20/24 at 7:48 PM with the Director of Nursing revealed Staff A, Certified Medication Aide (CMA) received an upsetting personal call prior to the noon medication pass on 9/18/24 and she did all her correct checks but walked to the wrong resident. She informed she immediately put an action plan in place so this would not occur again. During an interview with Staff A, (CMA) on 9/22/24 at 12:58 PM informed she was on break and received a phone call that was upsetting, and got distracted and accidentally gave Resident #1 another resident's medications. She informed as soon as she got back to the cart she identified the error right away and his Doctor and the DON were updated. She informed after this happened she had a conversation with the DON about how it could have been prevented.

Based on observation, policy review, and staff interviews the facility failed to keep bare hands off the drinking surfaces of glasses in order to serve meals under sanitary conditions for 1 of 1 meals observed. The facility reported a census of 39 residents. Findings include: An observation of the noon meal on 4/22/24 from 11:05 AM to 11:42 AM revealed Staff A, Cook, served 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Staff A picked up the glass with one hand, poured juice or milk with the other hand, and set the glass back on the table to serve the resident. Staff A also pushed the beverage cart throughout the dining room with her bare hands. The cart handle was not observed to be sanitized throughout meal service. Staff A was not observed to perform hand hygiene during the meal service. In an interview on 4/24/24 at 12:01 PM Staff B, Dietary Manager explained the facility provided training on appropriate serving techniques upon hire. She explained she expected staff to touch silverware only by the handles, never the tines of silverware. Staff must never touch the drinking rims of any glasses or mugs. Plates must be held by the edge and base; no fingers are allowed on food surface areas. (During the ongoing observation in the kitchen of the noon meal on 4/23/24, multiple staff members were observed grabbing the milk jugs by the handle during meal preparation and service. Hand hygiene prior to touching the jugs was not observed.) The facility lacked a policy regarding dining services and appropriate hand placement during food service.