Norwood Towers Post-acute

actions:-On 02/17/26 staff assessed Resident #44 and notified the on-call provider of the medication

-On 02/17/26 the DON, two Assistant Directors of Nursing (ADONs), and Regional Clinical Consultant

was staff was distracted.

The facility developed a plan of action by 02/18/26. -On 02/17/26 the DON re-educated MT #272 and reviewed expectations related to resident identification and verification prior to medication delivery.-On 02/18/26 staff sent Resident #44 to the emergency room for evaluation related to the medication error on 02/17/26.

The resident returned with no new orders. -On 02/18/26 the DON began re-education of all nurses and MTs on the five rights of medication administration with specific emphasis on maintaining focus during medication passes, avoiding distractions and completing resident identification verification prior to each administration.

Education of all nurses and MTs was completed on 02/18/26. -Starting on 02/18/26 the DON or Designee began completion of medication administration competencies for all nurses and MTs.

Competencies included direct observation of resident identification practices, demonstration of the five rights of medication administration, proper use of medication administration records and safe response to interruptions during medication passes.

Any staff unable to successfully demonstrate the competencies would receive one-on-one re-education and re-evaluation prior to resuming independent medication administration duties.

Five competencies had been completed by 02/23/26 with competencies to continue until after nurse and MT had successfully completed the competency. -Starting 02/18/26 the DON or designee began conducting random medication administration audits on a minimum of five residents for four weeks and as needed thereafter with findings reviews at Quality Assurance Performance Improvement (QAPI) meetings.This deficiency represents noncompliance investigated under Complaint Number 2747068.