**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the safe and accurate administration of prescribed medications to residents, resulting in Immediate Jeopardy. Systemic Failures were identified across multiple areas, including transcription errors, incorrect dosing, and medication omissions. The facility did not consistently follow the five rights of medication administration, nor did it implement effective systems to identify, prevent, investigate, or track medication errors. These failures directly impacted two residents. Resident R1 did not receive two prescribed diuretic (manage fluid overload) medications, resulting in ongoing congestive heart failure. Resident R4 received 50 mg of prednisone instead of the prescribed 5 mg of a potent anti-inflammatory medication, leading to new cardiac symptoms, hospitalization, and admission to the intensive care unit (ICU), where he remains. The facility's lack of oversight and failure to implement corrective actions placed all residents at risk for serious harm, injury, or death, and necessitated immediate intervention to protect resident health and safety.The immediate jeopardy (IJ) began on 7/21/25 when the interdisciplinary team identified R1's medication errors but failed to conduct a comprehensive analysis of their pharmacy protocols or medication errors to uncover systemic failures in medication management. This led to R4 receiving 10 times the prescribed dose of Prednisone that resulted in ICU admission. The interim administrator, director of nursing were notified of the IJ on 8/14/25 at 12:58 p.m. The IJ was removed on 8/22/25 at 2:51 p.m., but non-compliance remained at a lower scope and severity of D meaning no actual harm with potential for more than minimal harm that is not widespread. Findings include A facility reported incident dated 7/18/25, identified R1's Metolazone (diuretic medication given to treat fluid retention) was not given in accordance with physician orders. R1's annual minimum data set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of biventricular heart failure (a severe form of heart failure where both the left and right sides of the heart are unable to pump blood effectively, leading to symptoms of both left-sided (shortness of breath, fatigue) and right-sided (swelling in the legs, abdomen) heart failure), hypertensive heart and chronic kidney disease (where high blood pressure damages the heart and kidneys, while damaged kidneys exacerbate high blood pressure) and hypertension. Further identified R1 received diuretics. R1's order summary dated 1/8/25 through 7/21/25, directed to give Metolazone give one 2.5 mg tablet daily 30 minutes before AM Torsemide (diuretic medication given to treat fluid retention) when weight is 165 pounds or greater, related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease.R1's medication administration record (MAR) dated July 2025, identified R1 was given doses of metolazone when R1's weight was below 165 lbs., not in accordance with physician orders. Administrations included: -7/7/25 weight was 161 pounds, and medication was signed as given.-7/10/25 weight was 163.6 pounds, and medication was signed as given. -7/12/25 weight was 163.6 pounds, and medication was signed as given.-7/18/25 weight was 158 pounds, and medication was signed as given. R1's progress note dated 7/18/25, at 1:03 p.m., identified an aide initially shared to this writer that R1 was complaining of not feeling well while in her wheelchair and leaned forward in her tray table but still conversant. She assisted her to the bathroom, as requested. Vital Signs (VS) checked as resident is still complaining of not feeling well. VS checked and noted initial BP (blood pressure) to be 56/34 (Normal blood120/80 mmHg). and immediately informed this writer of the low BP. Immediately attended to and saw R1 seated on the toilet. R1 was initially conversant but gradually passed out and observed to have inward stiffening of upper extremities and stopped responding, lasting for about a minute. R1 gradually regained consciousness and was transported back to bed. The note also indicated R1 said, I wasn't feeling well and 'I have a little hard time breathing earlier but it's better.' Will inform NP and continue to monitor. At 2:08 p.m., Writer informed and updated NP about R1's condition and ordered to send her to the ED for further investigation. Informed R1 and agreed. At 2:15 p.m., ambulance came and left the facility at 2:25 p.m.R1's emergency department (ED) note dated 7/18/25, at 5:48 p.m., identified R1 was diagnosed with vasovagal syncope (triggered by an overstimulation of the vagus nerve that leads to a sudden drop-in heart rate and/or blood pressure, resulting in temporary loss of consciousness due to reduced blood flow to the brain). Nursing home reported R1 was hypotensive to the 50's and had lost consciousness when they found her. R1 was still seated on the toilet with her head leaning on the wall to her right. R1 reported similar episodes in the past where she was hypotensive and had similar symptoms. R1 also reported that she checks her weight each day and when she is above a certain weight, she takes her diuretic. R1 stated she took her pill yesterday and went down 10lbs overnight. (Weight loss was not consistent with R1's record).R1's MAR dated July 2025, identified the following weights:-7/16/25: 166.2 pounds-7/17/25: 161.2 pounds; reflecting a 5 lb. weight loss in one day7/18/25: 158 pounds; reflecting an 8.2 lb. weight loss in two days. R1's NP visit dated 7/21/25, reviewed the 7/18/25 syncopal event and added recurrent hypotensive episodes linked to diuretic use, particularly Metolazone, the note identified a plan to adjust Torsemide 40 mg in the am and 20 mg in the pm for more consistent diuresis, trying to eliminate the need for PRN (as needed) metolazone and identified metolazone 2.5 mg discontinued.R1's Medication Error Report dated 7/21/25, at 11:00 a.m., identified on 7/18/25 R1 was given Metolazone dose when her weight was 158 pounds, had a syncopal episode and transferred to the ED. Report further identified the same error had occurred on 7/7/25, 7/10/25, and 7/12/25 Metolazone order has been discontinued. Weight parameters have been adjusted. R1‘s IDT team initial post investigation review form dated 7/21/25 at 11:00 a.m., identified the root cause of the medication error was medications are currently kept with routine medications which could lead to this medication being pulled out of the cart with other morning medications. NP noted that Metolazone was given when the weight parameters for giving it had not been met on 7/18. The investigation had identified errors had occurred several times before 7/18 with the Metolazone. IDT discussed options to possibly move medications that are PRN to different location in the cart so they are not inadvertently given with routine meds. Further indicated discussion of changing where and how the order was transcribed into EHR (i.e. put in with the daily weight order so that when wt. is > 165 initiate PRN Metolazone order, or possibly changing the FONT of the order to make it more pronounced with caps or bold face to bring it to nurse's attention more.) In this particular case the NP decided to eliminate the metolazone altogether which eliminated the need to move med or change where order is written or how it is written.R1's IDT progress note was reviewed in conjunction with the IDT Final Post Review Follow Up form both dated 7/28/25, identified IDT reviewed the Medication Error incident. The intervention(s) put in place was a new process (was implemented) whereby the order for daily weights will be edited and further instructions for when the NP/MD orders a medication to be given in response to the weight. We feel this will provide the nurses with increased cues as they enter the weight to know if the resident needs it or not. IDT determined the effectiveness of the interventions put into place are effective at this time. There were two parts to this error- 1. nothing was cuing the nurse to check PRN meds post entering of weights. 2. Nurses had kept the medication with the routine meds and this was moved also. Lastly the doctor did decide to discontinue this medication altogether for this resident. Review of R1's medication error documentation reviewed between 7/18/25 through 8/7/25 did not identify if audits had been completed to determine extent of medication errors that resulted from staff not following rights of medication administration and/or medication cart organization and/or transcription of orders with parameters. Further there was no indication staff were provided with education pertaining to systems or re-educated on the rights of medication administration. R1's Nurse practitioner (NP) visit dated 8/1/25, identified R1 was being seen for congestive heart failure and weight gain. R1 reported to nursing her legs are feeling more swollen and weight was above parameter at 166.2 pounds. New order to give torsemide 40 mg twice a day for edema. (Order dated 7/21/25 included continue daily standing weights notify provider of weight less than 155 lb. or greater than 165 lb.) R1's MAR included multiple orders for physician orders for Torsemide and identified R1 was administered Torsemide not in accordance with physician orders. On 8/1/25 R1 was administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total of 100 mg which was 20 mg over what was prescribed. -On 8/2/25 R1 was administered 40 mg at 6:00 a.m., administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total 140 mg which was 60 mg over the prescribed dose. -On 8/3/25 R1 was administered 40 mg at 6:00 a.m., administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total 140 mg which was 60 mg over the prescribed dose. -On 8/4/25 R1's 6:00 a.m. and block (7:00 a.m.-11:00 a.m.) dose of 40 mg was blank indicating doses were not administered. The MAR indicated this dose and dosing time were discontinued on 8/4/25 at 8:56 a.m. R1's NP visit dated 8/4/25, identified R1 presented with increased fluid retention and shortness of breath related to heart failure. R1 had increased shortness of breath especially during conversation, notable episode of dyspnea at a social event, symptoms have lessened over the last two days with reduced talking, abdominal distention which decreased when lying down, increased lower extremity swelling. Torsemide ordered on 8/1/25, to give 40 mg twice a day however medication error occurred, nurse confirmed R1 received a total of 120 mg per day for 3 days. New order for torsemide give 80 mg twice a day x 3 days, then reduce back to 40 mg twice a day. R1's MAR on 8/4/25 through 8/7/25 R1 continued to not receive the correct dose of Torsemide per physician order. The MAR identified the aforementioned physician order for 80 mg twice day x 3 days, however the start date was for the morning of 8/5/25 at 8:00 a.m. The MAR identified the following: -On 8/4/25, R1 was administered 40 mg of Torsemide at 3:00 p.m. and 80 mg at 4:22 p.m. for a total of 120 mg, equating to 40 mg under the prescribed dose. -On 8/6/25, R1 did not receive any doses of Torsemide. -On 8/7/25, R1 was administered 40 mg at 8:00 a.m. and the 2:00 p.m. dosing time was blank. R1's progress note dated 8/7/25 at 12:56 p.m., identified writer noted R1's increasing weight despite her diuretic revision recently. During conversation, a while ago, R1 claimed that she had to pause for some time after wheeling herself and noted her legs to be more swollen. Observed to be speaking in phrases but no obvious labored breathing nor complains of chest pain. Auscultation to lungs revealed minimal crackles, bibasilar (lower portion of both lungs) with no wheezing appreciated. Situation, Background, Assessment, and Recommendation (SBAR) sent and called NP. She agreed to increase back the Torsemide for a couple of days. Will be waiting for orders later this afternoon. R1 informed of this, and she acknowledged.R1's new physician order dated 8/7/25, at 3:01 p.m., directed Torsemide 40 mg give two tablets twice until 8/12/25 at 10:00 a.m., take 1-2 tablets (40-80 mg total) by mouth 2 times a day. 80 mg by mouth two times a day x 5 days starting 8/7/2025; then reduce back to 40 mg by mouth twice a day. R1's MAR on 8/7/25 identified R1 received a total of 120 mg of Torsemide which was 40 mg under the prescribed dose. R1's Medication Error Report dated 8/7/25 did not identify all the medication errors, the report identified that Torsemide 40 mg dose was omitted on 8/4/25 at 7:00 a.m., and on 8/7/25 at 2:00 p.m. Immediate intervention identified- only included management was alerted to medication error on 8/11/25 at 6:00 p.m. while doing a whole house audit. The error report did not identify or include medication errors that occurred on 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/6/25, and 8/7/25. During an interview on 8/11/25 at 2:28 p.m., registered nurse manager (NM)-A verified R1 had med errors where she received metolazone 2.5 mg in error on 7/7/25, 7/10/25, 7/12/25 and 7/18/25; R1's NP found those errors in which the three nurses who made the four errors were not following the rights of medication administration by looking at the actual physician order. NM-A was not aware of any subsequent errors involving R1. NM-A was provided and reviewed R1's record, NM-A confirmed R1 had not received her torsemide as ordered; on 8/4/25 lacked 40 mg dose, 8/6/25 was completely omitted, and 8/7/25 lacked a 40 mg dose. NM-A stated on 8/7/25, R1 was displaying signs and symptoms of CHF so she called the NP to keep torsemide at 80 mg twice a day for an additional 5 days. NM-A stated she was not aware of the torsemide medication errors until just this moment, the errors should have been identified earlier. NM-A was unsure of the process for medication errors and stated she would just report it to the director of nursing (DON). During an observation and interview on 8/11/25, at 12:38 p.m., R1 was seated in her wheelchair in her room, R1's legs were swollen and had wraps on them. R1 explained she was a former nurse. R1 reported she was getting Metolazone when her weight was above 165 pounds, it helped get rid of the swelling in her legs. R1 stated a few weeks ago she blacked out in the bathroom and had to be sent to the ED because her blood pressure dropped in the 50's. R1 was wondering if the nurses were reading the orders right for her diuretics because she had been exhibiting signs and symptoms of congestive heart failure for the last two weeks such as shortness of breath, feeling weak, bad swelling in her legs, just in the last week she had noted shortness of breath with just talking. R1 stated as far as she knew there had been no medication errors with her diuretics but wondered if the nurses had been giving them to her correctly with the increase in symptoms, leg swelling and weight gain.During an interview on 8/11/25 at 1:11 p.m., registered nurse (RN)-G stated R1 currently received torsemide 40 mg twice a day until 8/12/25. No one had reported to her that R1 was having any shortness of breath. RN-G wrapped R1's legs earlier in the morning and noted them to be more swollen, R1's last reported weight was 168.8 pounds and would have to notify the provider if her weight goes above 165. (Nurses progress note dated 8/11/25 at 3:06 p.m. included physician notification identifying R1's weight was outside the parameters).During an observation and interview on 8/13/25 at 10:58 a.m., registered nurse (RN)-B was standing at the medication cart. RN-B removed five cards of R1's Torsemide with the original pharmacy labels which included: -Torsemide 10 mg tablets-give 2 to 4 tablets two times per day (give 40 mg in the a.m. and 20 mg in the p.m.) Prescription date of 7/21/25 with 29 tablets remaining-Torsemide 20 mg tablets-give 2 tablets twice daily. Prescription date 8/1/25 with 14 tablets remaining on one card and second card with 30 tablets. -Torsemide 20 mg tablets-give 2 to 4 tablets (40-80mg) two times per day; 80 mg twice daily for 3 days starting 8/4/25 then reduce back to 40 mg twice daily. Prescription date 8/6/25 with 12 pills remaining.-Metolazone 2.5 mg tablets-give 1 tablet 30 minutes prior to a.m. Torsemide when weight is greater than 165 pounds. Prescription dated 5/6/25, with 10 pills remaining. When RN-B pulled R1's Torsemide cards out of the medication cart and compared it with R1's physician order in the MAR, RN-B could not articulate what R1's current Torsemide medication order was when reading it in the MAR. RN-B stated it would be 80 mg twice per day which would mean she would give 40 mg in the morning and 40 mg in the evening totaling 80 mg (instead of 80 mg twice for total of 160 mg). RN-B was unsure of what she administered to R1 for the morning dose of Torsemide. RN-B explained R1 would receive a dose of metolazone if her weight was greater than 165 pounds; her weight was 169.2 pounds this morning, so R1 would get a dose. RN-B was unaware that R1's Metolazone had been discontinued on 7/21/25, and the Metolazone bubble pack was in the medication cart and stated she would have given it. During an interview on 8/13/25 at 2:18 p.m., licensed practical nurse (LPN)-A stated R1's current Torsemide order was very confusing and hard to understand what the exact dose was to administer which could increase the risk of an error reoccurring. LPN-A indicated she had not received any training on how to transcribe physician orders in the EHR. LPN-A was not able to articulate the process on how to complete a medication error report and how to contact the pharmacy if a medication was not available to administer. During an interview on 8/13/25 at 4:19 p.m., Health unit Coordinator/licensed practical nurse (HUC/LPN) stated there were no processes in place to ensure discontinued/changed medications were removed from the medication carts. HUC/LPN further stated when she transcribed a new prescription order in the electronic health record (EHR) she sometimes would place a sticky note on the medication cart to inform the nurses the medication needs to be removed. HUC/LPN indicated she does not ensure the medication bubble packs are always removed from the cart with new medication orders. During an interview on 8/13/25 at 2:36 p.m., RN-C stated she had noticed a problem with medications that had been discontinued/changed related to the bubble packs being left in the medication carts. This could be a recipe for a disaster and could lead to medication errors if the nurse does not verify the prescription cards to the MAR. RN-C had not received any education on rights of medication administration, preventing medication errors, or entering/verifying new orders. RN-C stated all new orders should be entered by the HUC/LPN, the DON, or the nurse managers and at times they (nurses) were not even told what orders were new or have changed.R1's NP visit dated 8/13/25, identified despite recent increases in torsemide, R1 continued to exhibit signs and symptoms of CHF such as bilateral lower extremity edema, increased weights, and shortness of breath. Current weights twice a week, unable to successfully titrate the torsemide back down. Unable to use Metolazone due to syncope and hypotension in the past. New orders identified to continue Torsemide 80 mg twice a day. Will implement daily weights. R1's August 2025 MAR, dated 8/18/25, at 1:24 p.m., identified physician order for Torsemide to give 100 mg twice a day for 3 days. 2:00 p.m. dose of 100 mg of torsemide was left blank. During an observation and interview on 8/20/25 at approximately 10:30 a.m., DON indicated she had transcribed the order into the EHR on 8/18/25 and directed the nurse to give the medication. DON indicated she was informed via an offsite auditor just this morning (two days later) the medication record did not identify the medication was administered. DON confirmed she had not reviewed R1's MAR on 8/18/25 nor on 8/19/25 to assure the dose was given. DON was unaware and unable to articulate how to reconcile medications in order to determine if the dose had been administered. During an interview on 8/11/25 at 4:06 p.m., director of nursing (DON) stated R1's medication error with Metolazone in July 2025, resulted in R1 being sent to the ED with a syncopal event. DON stated they did not review any other resident charts to ensure there were no other medication errors. DON stated the facility did not really have a system in place for nurses who were identified that made the error; there was not we are not tracking it or doing any education. DON indicated typically with a medication error we would be expected to fill out a risk management report, notify the provider, resident/representative and follow provider orders. DON indicated since R1's July med error they were not doing any audits to identify similar medication errors. DON indicated she was not aware of R1's missed torsemide doses on 8/4/25, 8/6/25 and 8/7/25. R4 R4's face sheet dated 8/12/25, identified diagnoses of end-stage renal disease (a condition in which the kidneys lose the ability to remove waste), hypertensive heart disease (heart damage cause by long-term high blood pressure), post kidney transplant (a surgical procedure that replaces a damaged kidney with a healthy one from a donor), atrial fibrillation (an irregular, often rapid heartbeat that commonly causes poor blood flow), and diabetes (a condition where the body uses glucose as fuel). R4's care plan focus identified end stage renal disease with a kidney transplant and immunocompromised. Interventions included: medications for anti-rejection (medications taken to prevent organ rejection) as ordered and monitor for side effects of medications such as increased blood pressure.R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4's cognition was intact. R4's diagnoses included, end stage renal disease, dependence on renal dialysis, and kidney transplant status. R4's physician orders included the following orders:-Prednisone (steroid used to reduce inflammation and suppresses the immune system) 5 mg tablets one tablet daily for renal (kidney) transplant (start date 7/24/25) R4's medication administration record (MAR) from 7/24/25 through 8/12/25, identified the physician order for 5 mg of prednisone and indicated R4 was administered 17 doses of the 5 mg prednisone tab. However, R4's Medication Error form dated 8/11/25, identified R4 had been receiving 50 mg prednisone instead of 5 mg of prednisone for the last 17 days due to pharmacy sending the wrong dosage. Immediate action taken was that medication was pulled from the cart and the physician was made aware. R4's Post Incident Medication Error Report form dated 8/11/25, identified the prednisone error as mentioned as well as the root cause of pharmacy error, in addition to nursing staff were not following the rights of medication administration. Neither form included a comprehensive analysis/investigation nor strategies to prevent or mitigate the risk of recurrent like errors. Review of R4's record identified between 7/29/25 and 8/12/25, R4 had increased blood pressures without identification of an overdose of prednisone had been administered at any point as a result of not reconciling medication against physician order upon delivery and then six licensed staff were not performing the rights of medication administration prior to administration to ensure the dose was accurate. R4's records identified the following course of events that ultimately lead to hospitalization as a result of the prednisone medication errors. R4's NP progress note dated 8/1/25, identified R1's blood pressure was elevated today however had been stable otherwise. Blood pressure reading was 161/80 (normal BP is 120/80). R4's NP note dated 8/6/25, identified R4 had elevated blood pressure readings. The note also included new orders for blood pressure medication in addition to a diuretic. 8/1/25 at 8:06 a.m., 161/60 at 3:50 p.m., 178/798/4/25 at 7:27 a.m., 192/59 at 3:26 p.m., 184/76, at 5:48 p.m., 188/778/5/25 at 12:21 p.m., 139/708/6/25 at 10:14 a.m., 166/73Review of R4's occupational therapy (OT) notes from 7/29/25 through 8/12/25, identified R4 did not feel well on 7/29/25; R4 had elevated blood pressures on 8/6/25 of 160/78 and 8/7/25 of 160/78 millimeters of mercury (mmHg) and 169/78 mmHg. Review of R4's physical therapy (PT) notes from 7/29/25 through 8/11/25, identified R4 had elevated blood pressures on 7/31/25, 8/6/25, 8/8/25, and 8/11/25. R4 also had shortness of breath on 8/6/25, 8/8/25, and 8/11/25. R4's NP progress note dated 8/11/25, identified an addendum that nursing reported a medication error where R4 had been receiving 50 milligrams (mg) of prednisone daily since 7/24/25, rather than receiving 5 mg daily. Blood glucose has been stable however R4 has been hypertensive. Further identified R4 received prednisone for immunosuppressive therapy. Last week losartan (high blood pressure medication) was increased to 50 mg daily on non-dialysis days and remains hypertensive. Today's blood pressure was 184/88, rechecked and was 168/75. Will collaborate with NP in nephrology who manages R4's dialysis. Consideration of increasing losartan daily since R4 was hypertensive on dialysis and non-dialysis days but would like a better understanding of what R4's blood pressures are during dialysis.R4's OT treatment encounter notes dated 8/12/25, identified vital signs were monitored during therapy session. R4 then got a call from the hospital regarding monitor which was reporting R4 was in atrial fibrillation yesterday with variable heart rates. Checked pulse manually and beat was steady at 68. Did have nursing clinical manager come in therapy room per R4's request and R4 had nursing talk to the hospital. Hospital reported they will put notes in for NP. Relayed R4's vital signs to nursing.R4's progress note dated 8/13/25, identified during a therapy session R4 began having chest pain and shortness of breath and was sent to the emergency department (ED) for evaluation. R4's ED note dated 8/13/25, identified R4 was seen due to chest discomfort and shortness of breath. R4 needed oxygen at 4 liters/min (L/min), had pitting edema in bilateral (both) feet and was in atrial fibrillation. R4's Pro BNP (a blood test used to help diagnose heart failure) was greater than 70,000 -which roughly three months ago was 13,000 and was showing some concerns for new heart failure and needing intravenous (IV) diuresis and was admitted to cardiology. R4's hospital Discharge summary dated [DATE], identified R4 had received and incidental increase dose of prednisone for several weeks. R4's heart failure exacerbation (the process of making a problem worse) and atrial arrhythmia were felt to be related to the prednisone error. R4 received dialysis twice and underwent ultrafiltration (a treatment that focuses only on fluid removal, using pressure to push water through a membrane without significant solute (dissolved substance) exchange. R4's discharge diagnoses were as follows:1.Acute dyspnea in the setting of acute on chronic heart failure, likely related to #2 and #3.2.New onset atrial arrhythmias, intermittent, likely related to #1 and #3.3.Accidental/unintentional overdose on prednisone, reported 13 days of Prednisone 50 mg (normally takes 5 mg day). During an interview on 8/13/25, at 2:18 p.m., LPN-A indicated she worked on 8/9/25, and was responsible for administering R4's medications. LPN-A explained when she looked at R4's prescription card did not match the physician order on the displayed MAR on 8/9/25; R4's MAR order directed to give Prednisone 5 mg tablet give one tablet daily, however, the label on the prescription card was Prednisone 50 mg tablets-give one tablet daily. Because there was a discrepancy, she referenced the pharmacy prescription order summary and found on 7/24/25 prednisone 50 mg had been filled and assumed that was the correct order. She did not know how to find the original physician order in the electronic health record (EHR) to compare and verify the dose, she denied contacting the pharmacy, or calling the physician to verify the dosage was correct and administered R4 his morning dose (on 8/9/25). LPN-A further stated she was not aware the dose she administered to R4 was given in error and did not receive any communication and/or education from the director of nursing (DON) that she had made prednisone error for R4. During an interview on 8/13/25 at 5:23 p.m., LPN-B stated he had not been made aware he made a medication error for R4's prednisone dose on 7/29/25 and 8/6/25. LPN-B had not received any education on medication error prevention or the rights of medication administration. During an interview on 8/13/25 at 4:19 p.m., HUC/LPN stated on 8/11/25, she received a phone call from the pharmacy informing her that R4's prednisone order that had been dispensed 7/24/25, had accidently been dispensed as prednisone 50 mg tablets instead of 5mg. HUC/LPN immediately went to the medication cart and removed the R4's prednisone prescription (Rx) card and identified the pharmacy was correct in that prednisone 50 mg tablets had been dispensed to the facility on 7/24/25, and the card was almost empty. She then had RN-E try to identify if there was a discrepancy between the pharmacy order and the physician order, however RN-E was not able to identify an issue with the prescription. HUC/LPN then brought R4's prednisone prescription card immediately to the DON to inform her of the error. HUC/LPN stated no new process had been put in place to ensure all new prescriptions that are entered into the physician orders and are the correct prescription received form the pharmacy. During an interview on 8/13/25 at 5:29 p.m., DON stated R4's medication error was due to pharmacy error, however, the nurses had not performed the rights of medication administration to identify the incorrect dose even though the label on the prednisone card identified it as 50 mg and not 5 mg as ordered. Had nurses performed the rights of medication administration, the error may have been identified sooner or not occurred. DON also stated she had not made any process changes to ensure prescriptions being delivered from the pharmacy are correct to prevent a similar error. During an interview on 8/13/25 at 12:18 p.m., NP stated R4 began having symptoms of increased blood pressure and weight gain over the past week. R4 was currently in the ED due to shortness of breath, chest pain, and was currently in atrial fibrillation with ventricular rate. R4 received multiple increased doses of prednisone likely caused his symptoms and even if the pharmacy had dispensed the incorrect dose when R4 was re-admitted to the facility on [DATE]. NP stated R4 receiving so many higher doses of prednisone put R4 at risk for serious harm or even death. NP stated R1's Metolazone being administered when it should not have been given could have led to her syncopal episode on 7/18/25. NP stated R1's Metolazone had been discontinued on 7/21/25, and the med card should have been removed from the medication cart at the time of it being discontinued. R1 having multiple cards of torsemide in the cart with different doses/directions put her at risk for an incorrect dose being given and could be the contributing factor to R1 not having improvement in her CHF symptoms. NP stated the type of errors for R1 had the potential to cause serious harm or even death. During a phone interview on 8/12/25 at 12:55 p.m., consultant pharmacist (CP) was not aware of several recent medication errors that were found regarding transcription, not available and omission of medications with several different residents and several different nurses. CP stated she meets with the quality assurance committee quarterly and attended lasts months meeting, stating they discuss significant medication errors but could not remember if it was discussed what prevention measures were in place. CP further stated for prevention with each medication error there should be a root cause analysis performed, the nurse making the error should be notified and educated. The facility could be performing education with staf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review, the facility failed to follow physician orders, complete assessments, monitor or input appropriate interventions and recognize changes in condition, for 6 of 6 residents (R31, R201, R21, R194, R6, R18) reviewed for quality of care. As a result of the facility's failures, an immediate jeopardy (IJ) situation was identified for R31 who had displayed respiratory distress with labored breathing, increased anxiety and required additional medication, R201 who had displayed signs of a UTI and was transferred to the ER for treatment, R21 who had displayed signs of a urinary tract infection (UTI) and was transferred to the hospital ER for treatment. The immediate jeopardy began on 4/12/25, when R31's daily weight were not completed as ordered and facility was not monitoring, which led to R31's respiratory distress, and failed to identify, monitor and assess R201 and R21 for change of condition related to blood in the catheters led to kidney/bladder infections. The administrator, assistant administrator, director of nursing (DON), regional vice president was notified of the immediate jeopardy at 5:47 p.m. on 4/18/25. The immediate jeopardy was removed on 4/21/25 at 1:07 p.m., but noncompliance remained at the lower scope and severity level of G - isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R31 was admitted on [DATE] and admission Minimum Data Set (MDS) assessment dated [DATE], identified the MDS was In progress with no information completed. R31's electronic medical record (EMR), included diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypercapnia (increased levels of carbon dioxide in the blood) and hypoxia (insufficient oxygen at the tissue level), Cor pulmonale (enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs), essential hypertension, anxiety disorder, shortness of breath, and was dependent on supplemental oxygen. R31's physician orders, dated 4/11/25, included the following: Oxygen via nasal cannula 2 L/min (liters per minute) at rest while awake, 4 L via nasal cannula with exercise or activity and 2 L via BiPAP when BiPAP is on; and daily fasting weight for edema and to notify the provider of a two (2) pound weight gain in two days or five (5) pound gain in seven days. Lasix 20 mg (milligrams) daily for edema. R31's post hospital follow up visit note dated 4/11/25, nurse practitioner (NP), indicated R31 had presented to the ER on [DATE] for shortness of breath and was found to be in hypoxic respiratory failure, and tachypneic (abnormally rapid and shallow breathing). R31's was admitted to the intensive care on 3/28/25 to 4/3/25 and was treated for volume overload, pneumonia, and COPD exacerbation. While in the Intensive Care Unit (ICU), R31 was aggressively diuressed (the excretion of a large amount of fluid). R31 required supplemental oxygen via nasal cannula 2 L at rest while awake, 4 L via nasal cannula with exercise or activity and 2 L via BiPAP while sleeping and medications. NP continued the current order of Lasix 20 milligrams (mg) daily and asked nursing to complete daily standing fasting weights and to notify provider of weight gain of two (2) pounds in two (2) days or five pounds in seven days and will follow up the following week to determine dry weight goal. R31's care plan dated 4/11/25, included R31 respiratory diagnosis with abnormal lung sound and shortness of breath. Interventions were identified to administer medications as prescribed by physician, give nebulizer treatment and oxygen therapy as ordered, and to notify physician if increased coughing occurs. The care plan also indicated R31 was at nutritional risk related to diagnoses of COPD, respiratory failure, oxygen dependence, altered skin integrity and recent weight loss with low body weight. Interventions were identified to observe changes in weight and to notify physician. R31's daily weight record from 4/11/25 to 4/18/25 revealed R31 had not been weighed 6 of the 7 days: -4/11/25, wt. (weight) 142.56 lbs. -4/12/25, wt. not taken -4/13/25, wt. not taken -4/14/25, wt. not taken -4/15/25, wt. not taken -4/16/25, wt. not taken -4/17/25, wt. not taken -4/18/25, wt. not taken During observation on 4/16/25 at 10:42 a.m., R31 was sitting in his room with oxygen on. R31 was observed to have labored breathing. During observation on 4/18/25 at 11:32 a.m., R31 was laying in bed with oxygen on. R31 was observed to have labored breathing. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A stated residents who have an order for daily weights should have their weight obtained in the morning before breakfast. RN-A stated any staff can obtain a weight and document the weight in the electronic medical record (EMR). RN-A said whoever obtains the weight are responsible for charting it. During interview on 4/18/25 at 12:09 a.m., NP stated R31 was extremely complicated and fragile. NP stated R31 was experiencing labored breathing, had diminished lung sounds and was on the incorrect oxygen setting while lying in bed during the visit. NP stated R31's oxygen orders were for two liters at rest although was found to be set at four liters while lying in bed. NP stated she had wanted R31 to go to the ER for evaluation although R31 refused. NP stated she had also offered R31 Dilaudid (medication that reduces respiratory rate and reduces breathing difficulties) to help with his breathing and hydroxyzine for anxiety, NP indicated R31 refused. NP stated she was not sure if the Lasix (newly added medication from hospital) was effective or if R31 was having fluid buildup because she did not know what R31's weights were due to facility not following orders to obtain daily weights. NP stated she expected facility to obtain daily weight and to record them and follow any parameters in order to initiate interventions/treatments to help prevent resident from fluid buildup which can make breathing difficult. R31's weight obtained per NP on 4/18/25, was 156.6 lbs, a 14.1 pound increase. During a follow up interview on 4/18/25 at 3:11 p.m., NP stated R31 had slightly improved from the first visit and an action plan was made with R31 and R31's son. NP stated she obtained R31's weight today of ~157 pounds. NP stated R31's dismissal weight from the hospital was 142 pounds. R31 had a 14.4-pound weight gain in the past week. NP stated she was going to increase R31's Lasix. NP stated she felt like R31 could have been in respiratory failure this morning upon her initial assessment. NP stated oxygen orders were not initiated or started over the weekend from 4/11/25 (date of admission) to 4/14/25 and staff were administering the oxygen at whatever liter per minute R31 told them to put it on or whatever they felt was appropriate. NP stated son was very concerned as he noted a change in R31's breathing over the weekend. NP stated she notified the facility of this and that is when the facility initiated and entered the oxygen orders in R31's EMR. NP stated she expected staff to obtain a full set of vitals on residents every day to monitor for any changes in condition. During interview on 4/18/25 at 3:22 p.m., occupational therapist (OT) stated R31 had slowed down while in therapy over the past couple of days and did not have therapy today due to the NP holding therapy services until further notice. During interview on 4/17/25 at 12:03 p.m., licensed practical nurse (LPN)-G stated if there was a change in condition with a resident, she would notify the charge nurse, or the provider and document change in a progress note in the resident's chart. LPN-G stated if a resident had an order for daily weights, it would be reflected on the medication/treatment administration record. LPN-G stated the nursing assistants (NA)'s obtain the weight and would notify a nurse with weight results, who would then document weight in the EMR. LPN-G stated there is not a good system in place regarding weights as weights are missed. LPN-G reviewed R31's chart and confirmed R31 had an order for fasting daily weights and the last recorded weight was on 4/11/25. LPN-G stated it was important to get the daily weights on R31 due to his fragile health concerns and that the provider needed to be notified of any weight change to allow for immediate intervention to be done. During interview on 4/17/25 at 3:02 p.m., RN-C stated when a resident has an order for daily weights, she obtains the daily weight as it is needed and important due to condition and respiratory failure. During interview on 4/18/25 at 2:44 p.m., LPN-A stated the NA's obtain the daily weights but if the nurse noticed it was not completed the nurse should obtain the weight. LPN-A stated daily weights should be done by 10:00-10:30 a.m. but could be delayed due to other factors that may arise. NA's know what weights to be obtained by looking in the EMR under their tasks. LPN-A stated if a daily weight does not get done then she would expect that resident to be the first one obtained the following day. During interview on 4/18/25 at 2:47 a.m., NA-B stated the nurse lets her know and she would write down which residents need weights. Once she got the weight, she would then give it to the nurse who would document. During interview on 4/18/25 at 3:11 p.m., NA-C stated the nurse gives her a paper log at the beginning of the shift, which is where she would write the weights on it and would return it to the nurse to document at the end of the shift. During interview on 4/17/25 at 2:00 p.m., director of nursing (DON) stated the admissions nurse, health unit coordinator (HUC), nurse manager and herself are responsible for processing and entering orders. DON stated the floor nurses are allowed to process orders if order was received after hours. DON stated all orders are verified by another nurse to ensure it was correct. During a follow-up interview on 4/18/25 at 4:25 p.m., DON stated daily weights are to be completed in the morning and if there are parameters in place for a resident and the weight is outside the parameter, she would expect staff to notify the provider of any change. DON confirmed R31 had an order, with parameters for fasting daily weights and the order was not followed. DON stated daily weights are important to be done for a person with any cardiac issues in order to identify immediately. DON confirmed the oxygen order was received on 4/11/25 although was not entered until 4/14/25. R201 R201's was admitted on [DATE] and admission MDS assessment dated [DATE], identified the MDS was In progress with no information completed. R201's EMR, included diagnoses of acute pyelonephritis (kidney infection), urinary tract infections, and chronic kidney disease (stage 4). R201's physician orders, dated 4/11/25, included the following: right nephrostomy (tube inserted into the kidney to drain urine directly into a collection bag outside the body) site care - cleanse with normal saline daily, pat dry and cover with split gauze and paper tape daily every evening shift. R201's care plan dated 4/7/25, indicated R201 had altered elimination and would need treatment/monitoring/cares due to weakness and immobility. Interventions identified R201 had a nephrostomy. Care plan also indicated R201 had an alteration in skin integrity related to surgical incision. Intervention identified staff to observe site daily for signs of infection or poor healing: drainage, odor, redness, warmth of incision line and to notify physician of any signs of infection. The care plan lacked location of surgical incision. During observation and interview on 4/14/25 at 6:28 p.m., R201's nephrostomy bag contained dark red urine. R201 stated she was informed by staff she had an episode this morning where R201 became unresponsive and lethargic. During observation on 4/15/25 at 11:27 a.m., R201 just returned from therapy and nephrostomy bag contained dark red urine. During observation on 4/16/25 at 8:49 a.m., R201 was lying in bed with nephrostomy bag with dark red urine present. R201's EMR lacked documentation of monitoring of urine output (change in urine color), nor notification to provider of any changes in condition. During interview on 4/14/25 at 6:44 p.m., R201's family member (FM-B) stated they were not notified of an event related to unresponsiveness and when she went to the nursing station to inquire about the event, FM-B was told that R201 went unresponsive for a few seconds, was ashen (pale gray color) in color and was lethargic following event. During interview on 4/14/25 at 6:47 p.m., RN-C stated she was told in report R201 was hard to wake up that morning and became lethargic. RN-C confirmed there was no documentation in R201's EMR regarding event. R201's progress note, dated 4/16/25 at 4:16 p.m., indicated R201 was sent to ER by provider for further evaluation. During interview on 4/17/25 at 9:26 a.m., FM-B stated when the NP came to R201's room for a regular visit, during her assessment she noticed the urine in R201's nephrostomy bag was red. NP recommended R201 be sent to the ER for further evaluation. FM-B stated R201 had been hospitalized for a kidney and bladder infection and was having a stent exchanged in the morning. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A stated standard catheter, nephrostomy care consisted of ensuring urine is flowing appropriately and monitoring the amount and color of the urine. RN-A stated if there was something abnormal, she would document in the EMR and notify the provider. RN-A stated she did not receive a lot of training on nephrostomies and had only one observation of a nephrostomy. During interview on 4/17/25 at 12:03 p.m., licensed practical nurse (LPN)-G stated NA's empty nephrostomy bag and would notify her of any changes or concerns such as flowing of urine, dark colored urine. LPN-G stated she would notify the charge nurse and would encourage resident to drink more fluids. LPN-G stated she would assess urine for odor, assess resident for change in cognition and would monitor. LPN-G stated she would document abnormal findings in a progress note. LPN-G stated nephrostomy bag is emptied once to twice per shift. LPN-G stated she had not received any training regarding nephrostomies. During interview on 4/17/25 at 2:00 p.m., DON stated if there was a skill, task, or diagnosis not cared for in the facility, we would complete in person training for staff. DON stated the admission nurse would inform the DON prior to admission with what cares may need training on. This will allow the facility to initiate education ahead of time. During interview on 4/17/25 at 2:26 p.m., RN-D stated there were no specific training related to nephrostomies. During interview on 4/17/25 at 3:02 p.m., RN-C stated NA's empty R201's nephrostomy bag and write down the urine output which she would then document in the EMR. RN-C stated NAs notify her of any changes. RN-C stated she would go and assess the abnormality (such as blood in the bag) and would call the provider to obtain an order. RN-C stated she was not notified of the dark red urine in R201's nephrostomy bag by any NA's. During a follow up interview on 4/18/25 at 11:40 a.m., DON stated if a resident is suspected to have a UTI or is displaying symptoms of a UTI, she would expect staff to monitor vital signs and symptoms, update the provider, increase fluids, enter progress note with information and initiate a nursing order on the MAR (medication administration record) for monitoring. During interview on 4/18/25 at 12:03 p.m., NP confirmed she was not notified R201's urine output was red. NP stated when she went to check in on R201 on 4/16/25, she had noticed red urine and had staff send R201 to the ER for further evaluation. NP confirmed when the resident previously had blood in her urine, it was an indication of a kidney, bladder infection. NP confirmed if she had been notified, she may have been able to prevent the visit to the emergency room by ordering a urine test to test for infection. During interview on 4/18/25 at 2:47 p.m., NA-B stated she emptied nephrostomy/catheter bags in the beginning of her shift and again at the end of her shift, document the amount drained. NA-B stated if she noticed a change in the urine, such as blood, she would let the nurse know immediately. During interview on 4/18/25 at 4:25 p.m., DON stated she expected there to be an order to obtain and monitor output for a resident with a nephrostomy/catheter. DON stated monitoring should consist of checking for redness around the insertion site, urine output and characteristics of the output, and any signs of drainage. DON stated she would expect staff to notify the provider immediately of any changes. DON stated staff should have notified the provider immediately when blood was noticed for direction from the doctor on what to do. DON confirmed there was no documentation of notification to the provider regarding dark red urine. R6 R6's quarterly Minimum Data Set (MDS) assessment, dated 3/10/25 indicated R6 had severe cognitive impairment with no behaviors, is dependent on staff for all activities of daily living (ADLs) and has an indwelling catheter and ostomy. MDS also included R6 had diagnoses of multiple sclerosis (a progressive disease of the nervous system), neurogenic bladder (disease where the bladder does not function properly), and history of recurrent urinary tract infections. A catheter/urostomy/nephrostomy care plan indicated R6 would remain free of signs and symptoms (s/sx) of urinary tract infections. Interventions included: catheter bag cover at all times in bed and wheelchair, change catheter as ordered by physician, empty catheter every shift and record output, keep catheter tubing free of kinks, keep drainage bag below bladder level, secure catheter to leg to avoid tension on urinary meatus (opening). Monitor/record/request/report to medical doctor (MD) change in amount, color, consistency, or odor, UTI s/sx, chills, fever, nausea/vomiting, and pain. R6's medication administration record included: -cefdinir (antibiotic) twice a day for infection x 7 days ordered 3/19/25 and discontinued 3/24/25. Medication was given 3/19/25-3/24/25. -Amoxicillin-potassium clavulanate (antibiotic) twice a day for bacterial infection x 7 days ordered 3/22/25 and given 3/22/25-3/29/25. -suprapubic catheter (a tube inserted into the bladder through the abdomen) 18f change the 28th of every month -suprapubic catheter change drainage bag weekly -routine catheter care every day and evening shift -suprapubic catheter check tubing for proper positioning and cath care every shift -suprapubic catheter monitor intake and output every shift A provider telephone encounter form dated 3/18/25 at 3:55 p.m., indicated staff called from facility stating her the end of her tube feeding broke and will be sending R6 to the emergency department (ED) to get it replaced. Please send order to send to ED A provider telephone order dated 3/18/25 at 4:08 p.m., indicated ok to send to the ER. R6's hospital emergency room progress note dated 3/19/25 indicated R6 was sent to the emergency room due to her PEG tube (tube in stomach to for liquid feeding) was broken and needed replacing. R6 was also found to have a urinary tract infection and acute cystitis (inflammation of the bladder) and would return to the facility with orders for antibiotics. R6's hospital after visit summary (AVS) report dated 3/18/25, R6 was sent to the emergency room due to complication mechanical gastrostomy [feeding tube]. It included results from a urinalysis indicating bacteria present. Cefdinir was ordered. R6's hospital orders dated 3/21/25, indicated prescription for amoxicillin-pot clavulanate 875-125 twice a day for 7 days starting 3/21/25 and ending 3/28/25. It also included orders to discontinue previously ordered cefdinir. R6's clinical assessment screen indicated two separate entries for nursing skilled services data collection from 3/18/25-3/29/25. Both entries occurred on 3/24/25 at 6:51 a.m. and 11:14 a.m. On both entries, urinary tract infection monitoring was left blank. R6's progress notes lacked documentation R6 returned from the emergency room, monitoring of urinary symptoms related to the UTI, or side effects of antibiotic as indicated by: -3/18/25 8:30 p.m., hosp -3/21/25 10:02 a.m.,cefdinir capsule 300 mg Give 1 capsule by mouth two times a day for infection for 7 days-Awaiting delivery -3/21/25 10:07 a.m. had vitals documented due to R6 having an emesis the previous evening. -3/23/25 6:59 a.m., indicated cefdinir was held due to antibiotic change -3/23/25 4:50 p.m., indicated cefdinir was unavailable R18 Quarterly MDS assessment dated [DATE], indicated R18 was severely cognitively impaired with no behaviors and was incontinent of bladder and bowel. An incontinence/altered elimination care plan indicated R18 had ongoing incontinence and cannot communicate the need to void. Interventions included: assist perineal hygiene after toileting, encourage fluid intake, observe for signs/symptoms of UTI (dysuria, frequency, urgency, nocturia, suprapubic pain and discomfort, back pain, hematuria and report to MD/NP, offer toileting upon rising, before and after meals and bedtime and PRN. R18's medication administration record included: cefdinir 300 mg take 1 capsule by mouth two times a day for UTI for 5 days. Take before morning and evening meals dated 4/11/25 and in/out catheter to get UA sample dated 4/9/25. It lacked symptom monitoring or antibiotic side effect monitoring. R18's provider progress notes indicated the following on date: -4/8/25 family is noting increased confusion since 4/7/25 and is concerned of UTI. Family is requesting UA. -4/9/2025 indicated order for urine specimen to be sent to lab. -4/11/25 indicated positive urinalysis (test to check for infection) and order for cefdinir 300 mg take 1 capsule by mouth twice a day before morning and evening meal x 5 days. -4/13/25 indicated sensitivities confirming continued use of cefdinir. R18's clinical assessment screen lacked monitoring for urinary tract infection, vital signs lacked vitals taken during time frame antibiotics administered, progress notes lacked indication of urinary symptoms, why UA was obtained, symptom monitoring, or antibiotic side effect monitoring. During interview on 4/16/25 at 2:09 p.m., licensed practical nurse (LPN)-F stated if a resident is exhibiting signs or symptoms of a urinary tract infection, communication is faxed to the nurse line. If after hours or on weekends, a phone call is placed to an on-call provider. Documentation is made in progress notes. LPN-F reviewed R18's progress notes and confirmed there is no documentation of urinary symptoms. LPN-F also confirmed R18 started on antibiotics 4/11/25 and the record lacked documentation of vital monitoring, symptom monitor, or antibiotic monitoring. During interview on 4/17/25 at 12:04 p.m., registered nurse (RN)-B stated residents diagnosed with a urinary tract infection should be monitored for symptoms on the treatment administration record (TAR). If it is not documented on the TAR, a progress note is made. During interview on 4/17/2025 at 1:06 p.m., the medical director (MD)-B stated daily nursing assessments for urinary tract infection should follow whatever the protocol is. During interview on 4/17/25 at 3:05 p.m., LPN-B stated R18 is normally not very verbal but had recently been singing a lot, prompting staff to obtain a urine sample. The urine sample tested positive for bacteria and resident was started on antibiotic. R18 has not had any aggressive behaviors and typically is not able to express symptoms. LPN-B stated R18 has not had any fevers. LPN-B stated, I don't know what we ended up doing with her [R18] to be honest. Staff monitor residents diagnosed with urinary tract infection by obtaining temperature, monitoring for signs of infection, and side effects of antibiotics. Results are documented on the electronic medical record. Any abnormal findings are documented in a separate progress note. During interview on 4/18/25 at 11:40 a.m., the director of nursing (DON) confirmed facility progress notes lacked documentation R6 was sent to the emergency room, returned to the facility, and monitored related to the urinary tract infection and antibiotic use. The DON confirmed the hospital AVS is the only record R6 was sent to the emergency room. The director of nursing stated she is automatically notified of newly ordered antibiotics by the facility charting system and does not recall receiving notification of antibiotic ordered. Regarding R18, the DON stated R18's family member reported R18 had been singing lately which is abnormal behavior. The family member questioned if R18 had an infection due to talking more. R18 did not exhibit any other symptoms. The DON stated she would expect some sort of documentation when a urine sample is obtained. If a resident is suspected of having a urinary tract infection, the expectation is to have monitoring put in place for vitals and symptoms. The provider should be updated, fluids increased, and cognition monitored. Monitoring should be entered as a progress note or a nursing order on the medication administration record. A resident on antibiotic should be monitor for signs and symptoms of the infection being treated, side effects of the antibiotics, and temperature. This monitoring may also be placed on the medication administration record R21 R21's MDS assessment dated [DATE], indicated intact cognition. R21 had a functional impairment of both lower extremities. R21 required substantial assistance with toileting and hygiene. R21 had an indwelling catheter requiring substantial assistance for care. R21's medical diagnosis included benign prostatic hyperplasia (overgrowth of cells causing organ enlargement) with lower urinary tract symptoms causing urinary retention. This diagnosis is further complicated by obstructive and reflux uropathy (blockage preventing urine from flowing normally). R21's care plan for Foley Catheter dated 9/13/23 included R21 will be free of signs and symptoms of urinary tract infections, will receive catheter cares per order, have catheter emptied every shift, monitor and record output every shift, and monitor/record/request/report to provider change in amount, color, consistency, or odor. R21's physician orders include catheter change every month on the 11th, routine catheter care twice daily, change urinary drainage bag once a week on Mondays, and flush catheter with 30 ml (milliliters) of normal saline every shift as needed. During observation on 4/14/25 at 1:49 p.m., R21 had a leg bag for catheter drainage of urine. The drainage in the leg bag was red in color and filled approximately three quarters of the leg bag. R21 stated he was not in pain, did not recall if the drainage was new, and was unsure when staff had changed the catheter or the drainage bag. During observation on 4/14/25 at 6:09 p.m., R21 continued to have dark red urine in the catheter leg bag. R21's progress note dated on 4/15/2025 at 7:20 a.m., indicated R21 had approximately 600 ml's of blood in his urinary leg bag. The progress note lacked indication if staff notified a provider about the amount or color of the drainage in the urinary leg bag. R21's TAR indicated R21 had routine catheter care performed twice a day for the last seven days. R21's progress note dated on 4/15/2025 at 4:15 p.m., indicated R21 was sent to the emergency department and his son was notified. R21 returned to the facility after emergent evaluation; was diagnosed with a urinary tract infection and started on an oral antibiotic. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A could not state what routine catheter care entailed. RN-A stated she just looked to make sure the catheter was still flowing, what the output looked like, and if the catheter might need to be flushed. RN-A stated she charts the amount of urine output, not the characteristics. RN-A stated if the urine looked abnormal, such as redness, she would enter a progress note and notify the provider via a situation/background/assessment/recommendation (SBAR) note. RN-A confirmed a progress note and SBAR notification was not charted for R21. During an interview on 4/16/25 at 10:33 a.m., the nurse practitioner (NP)-A indicated an unawareness of R21's output included blood. NP-A confirmed when the resident previously had blood in his urine, it was an indication of a urinary tract infection. NP-A confirmed if she had been notified, she would have been able to help prevent the visit to the emergency room by ordering a urine test to test for infection and would start oral antibiotics. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) identified the facility charting does not have a location to document urine characteristics such as color, clarity, and odor. The DON indicated if a provider was notified about a change the staff are expected to input a progress note. The DON confirmed staff communicate these components of urine output via word of mouth or a progress note. DON identified a progress note of R21's urine characteristics dated 4/15/2025 at 7:20 a.m., although DON would have expected a progress note of R21's urine characteristics and notification to the provider when the blood was identified on 4/14/25. The Immediate Jeopardy was removed on 4/21/25, at 1:07 p.m. when it was determined the facility provided re-education and competency testing to licensed nursing staff on the facility's policies/procedures pertaining to change of condition, notification of changes, physician's orders, congestive heart failure, nephrostomy, COPD and catheters to include standards of documentation. In addition, the facility developed and implemented an auditing system for monitoring. R194 R194's admission Minimum Data Set (MDS) assessment was not completed in full at time of survey. R194's cognitive function was noted to be intact. R194 admitted on [DATE], following surgical repair of spinal stenosis (condition that narrows the space in the spine, putting pressure on the spinal cord or nerves). R194 diagnosis included atrial fibrillation (irregular heart rhythm), early ventricular depolarization (electrical signal in the heart come from lower chambers instead of upper chambers), atherosclerosis of the aorta (plaque buildup in the heart), bilateral carotid artery stenosis (partial or full blockage of the carotid artery located on each side of the neck), and hypertensive heart disease (develops due to prolonged high blood pressure, causing heart failure and abnormal heart muscle thickening). R194's care plan dated 3/28/25, identified a cardiac diagnosis and a pacemaker requiring monitoring, medications, and treatments. R194 care plan did not include person-centered interventions. R194's admission medication orders on 3/28/25 included amiodarone 200 mg each morning (used for irregular heart rate), metoprolol tartrate 75 mg twice per day (used for irregular heart rate and high blood pressure), apixaban 5 mg twice per day (used as a blood thinner), nitroglycerin 0.4 mg sublingual tablet every 5 minutes for 4 doses as needed (used for acute chest pain), and torsemide 10 mg every morning (used to treat fluid retention). During an interview on 4/14/25 at 1:47 p.m., R194 stated he fell earlier this morning due to low blood pressure (a condition called hypotension). R194 stated he started to feel dizzy in physical therapy (PT) and the physical therapist was assisting hi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to administer the right prescribed medications to right residents for 2 of 3 residents (R1, R2). R1 had a sudden change in cardiac status and required hospitalized . This resulted in an immediate jeopardy (IJ) for R1, the facility immediately implemented correction and is being issued at past non compliance. The immediate jeopardy (IJ) began on [DATE], when registered nurse (RN)-A failed to verify identity of R1 prior to the administration of prescribed medications on the morning of [DATE]. The administrator and director of nursing were notified of the IJ on [DATE], at 3:30 p.m. The IJ was removed on [DATE], and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: The facility Incident Report #2070 dated [DATE], at 10:07 a.m. identified on [DATE], at 8:00 a.m. registered nurse (RN)-A mistakenly administered R2's medication to R1 which included Amlodipine Besylate 7.5 mg (blood pressure medication (med)), Aspirin 325 mg, Carvedilol 3.125 mg (blood pressure med), Finasteride 5 mg (prostate med), Isosorbide Mononitrate 60 mg (blood pressure med), Losartan Potassium 25 mg (blood pressure med), Miralax 1 packet (med used for constipation), Ocular Vitamin, Senna Plus (med used for constipation), and Tamsulosin HCL capsule 0.4 mg (prostate med). Incident Report #2070 further identified RN-B called PA-A and new orders were received for checking (R1's) blood pressure and pulse every hour. PA-A was contacted when the blood pressure of 94/52 was obtained, and directed R1 be transported to the hospital for further monitoring. The identified root cause indicated RN-A was not familiar with the residents; when she said a name the resident responded to that name. R1's Face Sheet indicated R1 was admitted to the facility on [DATE], and discharged [DATE], to hospital. R1's admitting diagnosis included hypertensive heart (heart disease) and chronic kidney disease with heart failure, nonrheumatic aortic valve stenosis (narrowing of heart valve), atrial flutter (irregular heart rhythm), congestive heart failure, and occlusion and stenosis of right carotid artery (narrowing of the blood vessels in the neck). R1's Minimum Date Set (MDS) dated [DATE], indicted R1 had moderate cognitive impairment. R1's Care Plan with target date [DATE], indicated R1 was a new admit to the short term stay unit and desired to be discharged from the facility to his assisted living apartment; demonstrated cognitive loss and directed staff to allow adequate time for R1 to respond and not rush supply words; had a diagnosis of cardiac disease and to administer medications per physician orders; and required assistance with meal set-up due to blindness in his right eye. R1's physician orders on [DATE] included: -Aceon tablet 2 mg (blood pressure medication (med)). Give 2 tablets by mouth one time a day for stage IV chronic kidney disease. -Daily-Vite multiple vitamin tablet. Give 1 tablet by mouth one time a day for supplement. -Miralax (med to relieve constipation). Give 1 packet by mouth one time a day for constipation. -Protonix 40 mg (acid reflux med). Give 1 tablet by mouth one time a day for gastric bleed; give before breakfast. -Glimepiride1 mg (med to lower blood sugars). Give 1 tablet by mouth one time a day for diabetes. Give with breakfast. -Do not take a laxative within 2 hours before or after taking other medications. Senna Plus Tablet Give 2 tablets by mouth two times a day for constipation. -Metoprolol Succinate tablet extended release 24 Hour 25 mg. Give 0.5 tablet by mouth one time a day for hypertension (HTN). Do not crush or chew. R1's progress note dated [DATE], at 10:07 a.m. included (R1) had an incident of medication error this shift. The incident occurred at [DATE] 8:00 a.m. (R1) was evaluated for injuries, physician, family, and appropriate staff notified. R1's progress note dated [DATE], at 10:18 a.m. included Resident received another resident's medication which included Amlodipine Besylate 7.5 mg, Aspirin 325 mg, Carvedilol 3-1.25 mg, Finasteride 5 mg, Isosorbide Mononitrate 60 mg, Larsartan Potassium 25 mg, Miralax 1 packet, Ocular vitamin, Senna Plus, and Tamsulosin. Called the provider and new orders were received of checking blood pressure and pulse every hour. Provider contacted with blood pressure of 94/52 and got order to send him to the hospital for further monitoring. R1's progress note dated [DATE], at 11:48 a.m. included Resident sent to emergency room for follow up monitoring after medication error. Systolic blood pressures ranged anywhere from 88-94 (normal range is between 90 and 120). Resident denied any symptoms but received several blood pressure medications. Resident left facility via ambulance at 11:00 a.m. R1's hospital care summary dated [DATE], indicated R1 was admitted to the ED with hypotension (low blood pressure) and drug overdose. Poison Control was contacted and advised to admit R1 to the hospital given R1's severe aortic stenosis and being administered five anti-hypertension agents. R1 was admitted to inpatient care and promptly went into cardiac arrest upon arriving to the medical unit. R1 subsequently died. R2's face sheet indicated R2 was admitted to the facility on [DATE] and remains a resident at the facility. R2's admitting diagnosis dated [DATE], included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, aphasia (difficulty speaking) following cerebral infarction, atherosclerotic heart disease of native coronary artery (narrowing of heart arteries), cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery (stroke), dysphasia (difficulty swallowing), congestive heart failure, hypertension, altered mental status, history of transient ischemic attack and cerebral infarction (small strokes). R2's Care Plan with target date [DATE], indicated R2 demonstrated cognitive loss and allow adequate time to respond, and do not rush or supply words. R2 had cardiac diagnoses that rquired medications. R2 sat at the supervision table for meals. Had hearing loss, had vision problem, and had difficulty with speech. R2's MDS dated [DATE], indicated R2 had severe cognitive deficit; had hearing aides; sometimes unable to express his ideas or wants and for staff to understand his needs; and impaired vision. R2's prescribed medication list on [DATE] included: -Hydralazine Hydrochloride tablet 25 mg. Give 1 tablet by mouth every 8 hours as needed for blood pressure give if systolic blood pressure is >160. -Miralax for constipation as needed for bowel movement production. -Carvedilol 3 -125 mg. Give 1 tablet by mouth two times a day related to heart disease. -Isosorbide Mononitrate extended release 24 Hour 60 mg. Give 1 tablet by mouth 1 time a day for HTN. -Amlodipine Besylate tablet 2.5 mg. Give 2 tablets by mouth 1 time per day for HTN. -Aspirin Tablet 325 mg. Give 1 tablet per day for prevention. -Atorvastatin Calcium tablet 40 mg (cholesterol med). Give 1 tablet by mouth at bedtime for hyperlipidemia. -Finasteride Tablet 5 mg. Give 1 tablet per day for benign prostate hypertension. -Losartan Potassium tablet 25 mg. Give 1 tablet per day for HTN. -Miralax Powder. Give 1 packet by mouth one time a day for constipation. -Protonix Tablet Delayed Release 40 mg. Give 1 tablet by mouth in the morning before breakfast for gastroesophageal reflux disease. -Tamsulosin capsule 0.4 mg. Give 2 capsules by mouth one time a day for benign prostatic hypertension. Open and put 1 capsule at a time into applesauce. -Ocular Vitamins. Give 1 tablet 2 times per day for supplement. -Senna Plus Tablet 8.6-50 mg. Give 1 tablet by mouth two times a day for constipation; hold for loose stools. -Acetaminophen tablet 500 mg. Give 2 tablets every 6 hours for pain -Hyoscyamine Sulfate tablets 0.125 mg. Give 1 tablet sublingually every 4 hours for increased secretions. R2's progress note dated [DATE], at 10:44 a.m. documented R2 received R1's medication which included Senna Plus, Aceon, Miralax, glimepiride, and daily vitamin tablet. Provider was notified and new orders were given to give R2 his morning meditations and check his blood sugar now and a half hour after lunch and supper. Will continue to monitor. Review of progress notes from [DATE] to [DATE] identified R2 did not have adverse effects from the medication error. Facility's investigation included hand written statement by RN-A dated [DATE]. The statement identified RN-A confirmed she switched R1 and R2's morning pass medications. Statement included it made it hard to tell which resident was who when they were in dining room to eat breakfast and R1 is not usually in the dining room. I said their name, and each responded to the name. I noticed the mistake after giving R2, R1's medication that was actually R1 and notified someone right away what I did. During interview on [DATE], at 10:14 a.m. RN-A indicated that morning R2's medications had been prepared for administration. She had thought it was R2 who had been sitting at the dining room table alone. So, she approached who she thought was R2 and said good morning R2, who responded good morning. Since R2 responded the medications that had been prepared were administered. Shortly after who she thought was R1 arrived to the dining room table. RN-A greeted R1 good morning, and R1 replied good morning and administered R1 his pills. RN-A stated in this encounter she did not state R1's name but surmised it was R1 because R2 had already received his medications. RN-A indicated something did not feel right. RN-A returned to the medication cart and accessed R1's electronic medical record and reviewed R1's picture and realized she had made medication errors. RN-A stated she gave R1's medications to R2 and R2's medications to R1. RN-A indicated she should have looked at the pictures of the residents before administering their medications and she did not confirm it was the right resident. RN-A also verbalized that maybe the residents did not hear what she was saying, because she was wearing a mask. During interview on [DATE], 8:25 a.m. ADM stated he took the lead on the investigation and root cause analysis with RN-A's medication errors. ADM convened the Quality Assurance and Process Improvement (QAPI) committee to review the facility policies on medication administration. It was determined by QAPI that the facility had appropriate policies and procedures and RN-A did not follow the facility policies and procedures, nor standard nursing practice for medication administration. RN-A is a supplemental contracted nurse and was terminated from returning to the facility. During an interview on [DATE], at 12:47 p.m. physician assistant (PA)-A stated she received a telephone call from the facility regarding the medication errors for R1 and R2. PA-A stated she was most concerned with R1's blood pressure and directed staff to closely monitor R1's blood pressures. PA-A directed if R1's blood pressure is at 90/60 or less, to contact her and she will place an order to transport R1 to the emergency department (ED). PA-A stated R1 was not a fragile patient and was doing well on his own, living in assisted living. Review of the facility 7 Rights of Medication Administration procedure Pathway Health, not dated, directed staff to check if it is the right resident, right medication, right dose, right route, right time, right reason, and right documentation. Review of the facility General Dose Preparation and Medication Administration with revision date [DATE], directed staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Review of Oral Drug Administration, [NAME] Medical Books revised [DATE], directed staff to confirm the patient's identity using at least two patient identifiers; and verify that you're administering the right medication at the proper time, in the prescribed dose to reduce the risk of medication errors. The immediate jeopardy that began on [DATE], was removed on [DATE] when it was verified and confirmed by observation, interview, and document review the facility immediately implemented the following actions: -On [DATE] facility immediately suspended, followed by terminating RN-A's employment; further reported to the MN Board of Nursing -On [DATE] all licensed staff and trained medication assistants were educated on medication administration policy with focus on 7 rights of medication administration. Followed by developing and implementing a hands-on competency evaluation. Additionally developed an ongoing plan to continue education/competency until all staff have completed prior to their next shift. -On [DATE] Facility completed record review audits to ensure all residents potentially effected to ensure no further medication errors were identified. -On [DATE] facility reviewed the medication error with QAPI. -By [DATE] Reviewed all their policies and procedures relating to medication administration and found to be appropriate. -By [DATE] reviewed medication errors to ensure no identifiable trends related to rights of medication administration that could have warranted further analysis and intervention; no trend was identified.