Continuing Care At Lantern Hill

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

required assistance from staff in the completion of their activities of daily living (ADLs). The resident's MDS further revealed in Section N-Medications, under N0415. High-Risk Drug Classes: Use and Indication, that

the resident was taking .F. Antibiotic and an Indication was noted. A review of Resident #2's individual HCP under 10. Medications which included a Goal and Care Plan Approaches which included but not limited to:

The nurse and/or caregiver will administer my medications as prescribed and monitor for side effects daily.A review of Resident #2's Medication Administration Record (MAR) titled December 2025 Medications indicated an entry order of piperacillin-tazobactam (Zosyn) 4.5 gram intravenous solution (4.5 gm/100ml) VIAL Intravenous; Every Eight Hours for Thirty-Two Days Starting 11/13/2025 Order ID: 4005870 with Order Date:11/13/2025; Discontinued (12/03/2025); Notes: Indication: 1st distal phalanx osteomyelitis. The MAR revealed under Schedule of 6:00 am and column 03 [stands for date 12/03] showed LPN #1 initial of [redacted] indicating the nurse administered the medication. On 12/18/25 at 2:52 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated LPN #1 did not follow the facility's medication administration procedure. The DON further stated the LPN was hired around four months ago and passed her medication administration pass competencies with both the ADON and the pharmacist consultant (PC), attended the education in-services as required. DON said that when they knew of the incident on medication error on 12/3/25 with the two residents, the LPN was educated on medication administration competency.The LNHA stated LPN #1 was suspended pending investigation and was eventually terminated on 12/9/25. The DON stated LPN #1 did not follow the medication pass protocol and procedure despite education in-services that were done with her by the facility. A Removal Plan (RP) was submitted by the facility on 12/19/25 at 6:21 PM indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: On 12/3/25, LPN #1 was found to administer the incorrect IV antibiotic medications to Resident #1 and Resident #2; MD was notified immediately and both residents were closely monitored; 12/3/25 at lunchtime, Resident #1 vomited one time, face flushed and felt cold with chills, MD at bedside and the resident was transferred to the ER; Resident #2 had no adverse reactions to the medication error; on 12/3/25, nurse medication administration

observation checklist was completed and LPN #1 demonstrated competency immediately after medication error was found; LPN #1 was suspended on 12/3/25 and terminated on 12/9/25; on 12/3/25, a 100% audit of all current residents that have physician order of IV antibiotics were reviewed by the assistant director of nursing (ADON) to validate the correct IV antibiotics orders and that IV medications were in the medication room; medication administration education began on 12/3/25 and IV competencies began for all nurses - all nursing staff must complete education and competencies before their next scheduled shift; all newly hired nurses will be educated on proper medication administration including return demonstration during orientation; on 12/4/25 a new process was created requiring two nurses to verify the correct IV medication

before administering to residents, and random audits were being conducted monitoring nurses who were administering IVs started on 12/4/25. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 12/23/25. NJAC 8:39-29.2(d)

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