**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident records, and staff interviews, the facility failed to ensure that Resident (R)1 was protected from a significant medication error. Specifically, R1 received multiple medications not prescribed to her: Metoprolol, Amiodarone, Digoxin, Eliquis, Fenofibrate, Furosemide, Loratadine and Potassium. This medication administration error resulted in R1 requiring hospitalization for further evaluation and monitoring. On 07/21/25 at 4:13 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause serious injury, serious harm, serious impairment, or death.On 07/21/25 at 4:20 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 06/28/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services.On 07/21/25 the facility provided an acceptable IJ Removal Plan. On 07/21/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 06/29/25.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care.Review of the facility policy titled Oral Medication Administration Procedure dated January 14, 2020, revealed, that the purpose of the policy is To administer oral medication in an organized and safe manner. Log into clinical software system (or use appropriate paper record) and find the appropriate resident and note the first medication to administer. Read label three times prior to removing medication. Identify resident before administering the medication. a. checks the arm band or photograph, call the resident by name, or check with other staff members if necessary. Administer medication and remain with resident while medication is swallowed.Review of R1's Face Sheet revealed R1 was re-admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperparathyroidism.Review of R1's Orders, revealed that R1 did not have orders for the following: Digoxin 125 (micrograms)mcg, Fenofibrate 160 (milligrams)mg, Amiodarone 200mg, Eliquis 5mg, Vitamin D3 50mcg, Klor-Con (Potassium) 10(milliequivalent)MEQ, Folic Acid 1mg, Loratadine 10mg, Metoprolol 25mg, Pantoprazole 20mg and Vitamin B12 100mcg.Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to: hypokalemia, primary hypertension, chronic atrial fibrillation, and vitamin d deficiency.Record review of R2's Order Summary Report revealed resident had an order for: Digoxin 125mcg, Fenofibrate 160mg, Amiodarone 200mg, Eliquis 5mg, Vitamin D3 50mcg, Klor-Con (Potassium) 10MEQ, Folic Acid 1mg, Loratadine 10mg, Metoprolol 25mg, Pantoprazole 20mg and Vitamin B12 100mcg.Review of a progress note dated, 06/28/25 at 2:58 PM documented by the Assistant Director of Nursing (ADON) revealed, MD [Medical Director] notified related to medication. [vital signs]VS: 112/47, 60 [heart rate]HR, 97.5 oral, O2 99% on [room air] RA. Orders to send to [emergency room] ER. RR [resident representative] notified.Review of an Emergency Department (ED) progress note dated 06/28/25 documented by the Doctor of Osteopathy (DO), revealed: HPI [R1] is a [AGE] year-old white female presents the ED today for evaluation after being inadvertently given another patient's medications. Patient received 25 mg metoprolol, 200 mg of amiodarone, 125 mcg of digoxin, 5 mg of Eliquis, fenofibrate, folic acid, 20 mg of furosemide, 20 mg of loratadine, 10 mill equivalents of potassium, vitamin B12 and D3, 20 mg of Protonix as well as some probiotics. Patient unfortunately has advanced dementia and is unable to provide any history. Apparently prior to receiving the medications patient's heart rate was already in the 50s however upon arrival to the ED heart rate in the upper 40s. Pressure acceptable. Here for evaluation given inadvertent administration of another residents medications.Record review of a, Hospitalist Discharge summary dated [DATE] documented by Hospitalist Medical Doctor (HMD), revealed: Brief HPI. Patient is a [AGE] year-old female that is a long-term care resident at a nursing home facility coming into the emergency department due to her getting medications for different patient. It seems that the patient got 25 mg of metoprolol, 200 mg of amiodarone, 125 mcg of digoxin, Eliquis, 20 mg furosemide, vitamins. Patient has advanced dementia and is unable to provide any history. Patient is admitted for observation Hospital Course Patient is a [AGE] year-old female that came into the emergency department due to wrongful medication being administered at the nursing home facility. She received metoprolol, amiodarone, digoxin, Eliquis and Lasix among other medication. Patient was observed in the hospital on telemetry. It seemed that her heart rate was low, seem to be in the 20s, patient received a dose of atropine 1 time. Cardiology was consulted, after reviewing the telemetry strips, cardiology noted that likely a error in read and the actual heart rate was around 40s to 50s at that time. Patient is being discharged back to her nursing home facility. Intensive care specialist recommended a root cause analysis for the incident. We are also recommending holding Nebivolol at the moment due to her bradycardia until she sees her primary.Review of a document titled, ECF/SNF Provider Progress Note dated 06/30/25, revealed, 98 [year old] yo resident sent to the ER because she was given another person(s) medication. She received metoprolol, amiodarone, digoxin, Eliquis and Lasix among other medications. She was placed in the hospital on telemetry. Heart rate was on the low 20's. Patient received atropine. During an interview on 07/21/25 at 1:32 PM, with Licensed Practical Nurse (LPN1) regarding a medication administration error involving R1. LPN1 explained that her usual process for administering medications includes identifying the correct resident, checking the orders in the electronic health record, and verifying the medication pack. The medication pack includes the name of the medication, route, frequency, resident's full name, room number, and any special instructions such as whether the medication should be crushed. After this verification process, she proceeds with administering the medication. On the morning of the incident, a cook who was familiar with residents' diets called out of work. This led to Certified Nursing Assistants (CNAs) frequently approaching the nurse station to ask questions about residents' dietary needs. While LPN1 was preparing medications for R2, a CNA asked about R1's specific diet. As a result of this interruption, LPN1 had R1 in mind while preparing R2's medications and accidentally administered R2's medications to R1. Immediately after administering the medications, as she walked back to the medication cart, LPN1 realized that R1 had received the wrong medications. She immediately notified the (Registered Nurse) RN Supervisor, who advised her to contact the MD. While LPN1 was on the phone with the supervisor, a CNA collected a set of vital signs for R1. LPN1 reported that the vital signs were within R1's normal range, noting that the resident typically trends with a lower heart rate and blood pressure. LPN1 documented the list of medications incorrectly administered to R1 and reported the incident to the Medical Director. The MD gave an order to send R1 to the emergency room for evaluation and monitoring. LPN1 contacted Emergency Medical Services, gathered all relevant paperwork including the resident's current medication list and the list of medications given in error, and provided a report to the receiving Emergency Department. The resident's representative was then notified of R1's hospital transfer.During an interview on 07/21/25 at 2:02 PM, the ADON outlined the facility's expectations and standard procedure for safe medication administration. The process includes reviewing the resident's Medication Administration Record (MAR) and assessing medication safety parameters prior to administration. The nurse then pulls the corresponding medication packet, which includes the medication name, route, frequency, the resident's full name, and room number. Once the MAR is verified against the medication packet, the next step is to confirm the identity of the resident using their identification band, MAR photograph, and by asking for the resident's name and date of birth when the resident is alert and oriented. The nurse is also expected to lock the computer screen, ensure no sharps are exposed on the cart, secure the medication cart, enter the resident's room, administer the medication, and document whether the medication was taken. During the incident in question, LPN1 contacted the ADON regarding a medication error. Since it occurred on a Saturday morning, the ADON was not on-site but responded promptly upon being notified. LPN1 explained that she had been distracted throughout the morning by multiple staff inquiries related to residents' dietary needs, following the absence of the scheduled cook. While preparing medication for R2, LPN1 was interrupted by a staff member asking about R1's dietary restrictions. As a result, with R1 on her mind, LPN1 mistakenly administered R2's medication to R1. According to the ADON, LPN1 immediately recognized the error after administration and promptly notified the ADON, the RN Supervisor, and the MD. The MD gave the order to send R1 to the emergency department for evaluation and monitoring, which was carried out without delay. The ADON confirmed that LPN1 did not follow the facility's required medication administration protocol, specifically by failing to verify the resident's identity prior to administering the medication. This constituted a failure to meet the facility's expectations for a safe medication pass. During an interview on 07/21/25 at 2:42 PM, the MD reported that he received a call early Saturday morning notifying him that LPN1 had administered R2's medication to R1. Based on the information provided to him at the time, the MD understood that the error occurred due to the nurse being distracted during medication pass, related to staffing issues in the dietary department. The MD was informed of the specific medications that were incorrectly administered to R1, as well as her vital signs at the time. He noted that R1 had a low heart rate, but clarified that this was typical for her, as she had a history of chronically low heart rate. However, given the nature of the medications involved-specifically cardiac medications such as digoxin, amiodarone, and metoprolol-the MD determined that R1 should be sent to the hospital for closer observation and continuous cardiac monitoring The MD stated that R1 was later readmitted to the facility, and, to date, he has had no further concerns regarding her condition. He emphasized that his expectation for safe medication administration includes verifying that the medication order matches the resident for whom it is intended for and ensuring that proper identity checks are performed prior to administration. In his opinion, the nurse involved did not meet those expectations during the incident. He further emphasized that nurses are expected to remain focused during medication passes and to minimize or eliminate distractions to ensure resident safety.During an interview with the Director of Nursing (DON) and Nursing Home Administrator (LNHA) on 07/21/25 at 3:36PM the DON stated, to practice safe medication administration, it is important for nurses to follow the 5 Rights, right patient, right med, right route, right dose and right time and to do 3 verification checks. Verification checks are done through resident arm bands, resident picture on the electronic chart, and name DOB. To prevent this from happening in the future, leadership team came in on 06/28/25 and re-educated and did a med pass observation with all nurses in the facility during that day. The pharmacy team was then consulted to help with completing med pass observation as part of their monthly review. LPN 1 was checked off by ADON, Pharmacist, and the Pharmacy Nursing Consultant and completed med pass in accordance with safe medication practices. The facility also verified that all residents have legible names and DOBs on arm bands and verified that each residents had pictures on their medication record. After conclusion of facility investigation, all safety systems were in check and revealed that the error was one that isolated.On 7/21/25 at approximately 5:30PM, the facility provided an acceptable IJ Removal Plan, which included the following:1. Immediate Corrective Action for Residents Affected: Resident #1 was given medications that were not prescribed to her, but to Resident #2. Upon returning to the med cart and recognizing the error, the nurse immediately notified the physician to inform him of the error and obtained new orders, which included sending the resident to the ER for evaluation Vital signs were checked of Resident #1 and were within normal ranges for this resident The Resident Representative was notified of the error and the orders to send to ER for evaluation The ADON arrived onsite and immediately began an investigation, which included providing education to the nurse and medication administration observation A medication error report was completed on 6/28/2025 A root cause analysis was initiated on 6/28/20252. Identification of Other Residents Affected or Likely to be Affected: An audit was completed to identify if there were any significant medication errors and there were none noted the last 6 months3. Actions to Prevent Occurrence/Recurrence: Facility administration reviewed policies and procedures on medication administration All nurses were given signs to hang on medication carts that say do not disturb unless emergency to help minimize distractions during medication pass All nurses are encouraged to place medication carts outside of the room of the resident they are working with to help avoid distractions and errors Immediate education of all licensed nurses was initiated by ADON on medication administration. This education began on 6/28/2025. All nurses will be educated by July 1 or prior to their next working day Any new hires will receive education on medication administration during their orientation and complete competency prior to completing their orientation period. This will be completed by the SOC or her designee The [NAME] Oak Pharmacy staff will continue to complete medication administration observations monthly There will be at least 3 observations of licensed nurses performing medication pass completed weekly X4 and then monthly X3 on random shifts completed by the DON, ADON, SOC, Unit Managers, or designated staff4. How the Corrective Action Will be Monitored to Ensure It Will not Recur: The DON will review all findings from medication pass observations and report them to the QAA Committee. The committee will review the findings and make recommendations for changes to policies and procedures, forms used, additional education needed, and/or the need for disciplinary action, if necessaryDate Facility Asserts Likelihood for Serious Harm No Longer Exists: 6/29/2025