Based on interview and record review, it was determined that the facility failed to ensure that 2 of 4 residents reviewed for insulin were free from potential exposure to bloodborne pathogen transmission when staff administered insulin to two residents using the same insulin pen (Resident Identifiers are #1 and #2). Findings include: Interview on 6/26/24 at 10:45 a.m. with Staff B (Licensed Practical Nurse) revealed that on 6/13/24 at around 9:00 a.m. he/she administered Resident #2's used Aspart insulin pen to Resident #1 by mistake. Resident #2's insulin pen was labeled for Resident #2. Staff B stated that he/she did not discard the insulin pen and used it shortly after on Resident #2 and then placed it back in the medication cart for continued use. Staff B stated that they thought that since the needle had been changed, there was no infection control concerns. Interview on 6/26/24 at approximately 9:15 a.m. with Staff A (Unit Manager) confirmed that Resident #1 had received Resident #2's Aspart insulin in error on 6/13/24 and that the insulin pen was returned to the medication cart for use for Resident #2 after it was used on Resident #1. Review on 6/26/24 of Resident #2's June Medication Administration Record (MAR) revealed the following orders for Aspart insulin: Aspart insulin 12 units two times a day, with a start date of 6/11/12 and an end date of 6/12/24; Aspart Insulin 12 units with meals, with a start date of 6/12/24 and an end date of 6/19/24. Further review of the June MAR revealed that Resident #2 received the following administrations of Aspart insulin from 6/13/24 through 6/17/24: 6/13/24- 3 doses administered; 6/14/24- 3 doses administered; 6/15/24- 3 doses administered; 6/16/24- 3 doses administered; and 6/17/24- 1 dose administered. Interview on 6/26/24 at approximately 1:00 p.m. with Staff C (Previous Director of Nursing) confirmed that Resident #2 had continued to receive Aspart insulin with the same insulin pen that was used on Resident #1 from 6/13/24 until 6/17/24. Staff C notified Public Health because the pen had been used on two different residents potentially exposing both residents to blood borne pathogens. Interview on 6/26/24 at 10:05 a.m. with Staff C revealed that he/she did not realize that there was an infection control concern with the above medication error until Monday 6/17/24. Staff C stated that he/she discarded Resident #2 Aspart insulin pen on 6/17/24 that had been in use. Interview on 6/26/24 at 11:40 a.m. with Staff D (Administrator) confirmed that he/she had been made aware of the medication error on 6/14/24; however, was not made aware of the infection control issue until 6/17/24 when the insulin pen was removed from the medication cart by Staff C. Interview on 6/26/24 at 1:15 p.m. with Staff D revealed that education regarding insulin pens was started for all staff on duty who administer insulin on 6/17/24 and all other staff received education prior to working their next shift. Review on 6/26/24 of the manufacturers' instructions for Insulin Aspart, provided by the facility, revealed: .Do Not share your Insulin Apart FlexPen or needles with anyone else. You may give an infection to them or get an infection from them . Review on 6/26/24 of the facility policy titled Insulin Pens revised on 2/28/21, revealed: .Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed . Review on 6/26/24 of the Centers for Disease Control and Prevention (CDC) handout, retrieved 6/4/24, from https://www.cdc.gov/injection-safety/media/pdfs/Insulin-Pen-Safety-Handout-P.pdf revealed: .Injection equipment (e.g., insulin pens, needles and syringes) should never be used for more than one person . It is critical to remember that insulin pens are meant for only one person .Although invisible to the eye, back flow of blood into the insulin pen can happen during an injection. This creates a risk of bloodborne and bacterial pathogen transmission to patients if the pen is used for more than one person, even when the needle is changed . Review on 6/26/24 of the facility's documentation of education for medication administration and insulin pen safety to staff who administer medications was initiated on 6/17/24. This included the risk of bloodborne pathogens. Review on 6/26/24 of the facility's Quality Assurance and Performance Improvement (QAPI) meeting held on 6/18/24 revealed the facility reviewed the above incident which included a root cause analysis and plan for auditing. Review on 6/26/24 of the facility competencies revealed that they were started on 6/20/24 for staff insulin medication competencies.