Based on observation, interview, record review, and review of facility's policies. The facility failed to follow infection control precautions for three of four sampled residents with peripherally inserted central catheters used for intravenous medication administration for Resident (R) 41, R197 and R6. Observation on 04/29/2025 at 09:23 AM revealed R197 had a peripheral inserted central catheter in right upper arm without a protective cap placed on end of catheter hub (the entry port distal of the catheter that connects to tubing or a syringe to deliver medication intravenously) leaving hub exposed. Observation on 04/29/2025 at 09:43 AM revealed R6 had a peripheral inserted central catheter in left upper arm without a protective cap placed on end of catheter hub, leaving hub exposed. Observation on 04/29/2025 at 09:45 AM revealed R41 had a peripheral inserted central catheter in left upper arm without a protective cap placed on end of catheter hub, leaving hub exposed. The findings include: Review of the facility's policy titled, Catheter Insertion and Care revision date, 12/15, stated under general guidelines, step 7. Apply a sterile end cap to the end of primary tubing when it is disconnected from catheter. The facility's policy does not mention placing a protective cap at the end of peripheral inserted central catheter hub. Review of R41's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. Review of R6's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. Review of R197's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. During an interview with Director of Nursing, acting Infection Preventionist, on 04/30/2025 at 04:10 PM, she stated she was unsure and would follow up to why one of four residents had a cap on the hub of her peripheral inserted central catheter and the others did not. She followed up with Clinical Services and she stated that all peripheral inserted catheters had to have caps at the end of their catheter hubs. During an interview with Registered Nurse (RN) 2 on 05/01/2025 at 04:44 PM, he stated after administering an intravenous medication into a peripherally inserted central catheter he would clean the catheter hub again with alcohol and place a cap at the end. During an interview with Assistant Director of Nursing, on 05/01/2025 at 04:55 PM, she stated that nurses should be cleaning the peripheral inserted central catheters with alcohol after disconnection of tubing or a syringe and placing a cap on the end of catheter's hub. She stated that a potential outcome could be introducing infection to the resident if not placing cap to catheter hub. During an interview with RN3 on 05/01/2025 at 05:12 PM, he stated that after he disconnects intravenous tubing or a syringe, he cleans the end of the catheter hub with alcohol, then flushes and then recaps the end of hub. He stated, there is a hole there and that can introduce bacteria if you do not recap. During an interview with the Administrator, on 05/01/2025 at 05:37 PM, she stated that she is not a nurse, but she expects staff to follow facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the facility assessed residents for self-administration of medication for one (1) of three (3) sampled residents (Resident #142). The findings include: A review of facility policy, Guidelines for Self-Administration of Medications, revised 05/22/2018, revealed residents who requested to self-medicate or with self-medication as a part of the plan of care were assessed for the ability. Staff presented the assessment results to the physician for evaluation and an order for self-medication. The order included the type of medication(s) and the facility kept the medication in a locked drawer in the resident's room. The resident and a nurse maintained a key. The facility admitted Resident #142, on 02/24/2022 with diagnosis including Allergic Rhinitis. The admission Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score to be a fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact, and interviewable. A review of the resident's Comprehensive Care Plan, with a created date of 02/28/2022, did not indicate the facility assessed the resident to self-administer medications. Review of the resident's active physician's orders indicated the resident an order for Flonase Allergy Relief, and to administer one (1) spray in each nostril once a day between the hours of 6:00 AM and 10:00 AM, with a start date of 02/24/2022. Observation, on 03/02/2022 at 8:20 AM, of the morning medication pass with Licensed Practical Nurse (LPN) #3 revealed the LPN administered six (6) medications to Resident #142, however, LPN #3 did not administer Flonase Nasal Spray. Interview, on 03/02/2022 at 8:25 AM, with LPN #3, revealed she administered all the ordered morning medications to Resident #142. Review of Resident #142's Medication Administration Record (MAR), along with the physician orders, revealed the resident was not administered Flonase nasal spray by LPN #3. Continued review revealed the resident no physician order for self-administration of the nasal spray. Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed she had not administered Flonase Nasal Spray to the resident because the resident kept the medication in his/her room for self-administration. The LPN continued to state she was unable to locate a Self-Administration Assessment in the resident's Electronic Health Record (EHR). LPN #3 stated she assumed the resident already had the assessment completed by other staff. Observation of Resident #142, on 03/02/2022 at 11:20 AM, revealed the resident removed the Flonase Nasal Spray out of an unlocked drawer at his/her bedside. Interview, on 03/02/2022 at 11:20 AM, with Resident #142 revealed LPN #3 provided him/her with the Flonase Nasal Spray to keep at his/her bedside. The resident continued to state he/she asked the LPN to leave the medication at his/her bedside. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED) revealed staff should complete a self-administration assessment before a medication was left at the bedside. Interview, on 03/03/2022 at 10:05 AM, with the Director of Health Services (DHS) revealed a self-administration assessment should be completed prior to giving the medication to the resident to self-administer.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medication carts were secured when not in use for one (1) of three (3) medication carts. Observation revealed an unlocked, unattended medication cart on the 200 Hall. The findings include: Review of the facility's policy, Medication Administration General Guidelines, revised 11/2018, revealed during administration of medications the medication cart was kept closed and locked when out of sight of the facility medication administration personnel. Additionally, staff stored no medications on top of the cart and the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation, on 03/02/2022 at 7:59 AM, revealed an unlocked, and un-attended medication cart located on the 200 Hall. Staff placed the cart in front of the Nurses Station. Continued observation revealed the top drawer of the medication cart could be opened, and there was a clear, unlabeled, medication cup observed which contained numerous medications. At 8:06 AM, LPN (Licensed Practical Nurse) #2 approached the Medication Cart. Interview with LPN # 2, on 03/02/2022 at 8:06 AM, revealed he/she was responsible for the medication cart, and stated the cart should be locked when not in use. The LPN revealed the medication visible in the medication cup was for Resident #40; however, the LPN was called to assist another staff member and left the medication in the cart. Interview on, 03/02/2022 at 12:50 PM with the Executive Director (ED) revealed staff should lock medication carts when not in use. Interview, on 03/03/2022 at 10:21 AM, with the Director of Health Services (DHS) revealed the medication carts should be locked when not in use.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to ensure a medication error rate of less than 5% for two (2) of three (3) sampled residents (Residents #142 and #143) observed during medication administration. Two (2) errors in medication administration observed during thirty-two (32) medication administration opportunities resulted in a medication error rate of 6.25%. The findings include: A review of the facility policy, Medication Administration General Guidelines, revised 11/2018, revealed if staff could not locate a medication with a current, active order in the medication cart/drawer, then staff searched other areas of the medication cart, medication room, and facility (e.g., other units), if possible. If staff fail to locate the medication after further investigation, staff contacted the pharmacy or removed the medication from the emergency drug supply. Additionally, the policy allowed residents to self-administer medications when specifically authorized by the attending physician, and in accordance with procedures for self-administration of medications. 1. Observations during morning medication pass, on 03/02/2022 at 8:20 AM, with Licensed Practical Nurse (LPN) #3, revealed LPN #3 administered six (6) medications to Resident #142, which did not include Flonase nasal spray. LPN #3 was asked specifically if there were any medications that had already been given prior to the observation, any medications that would have been given at a different time than that observation, or any medications that were omitted during that observation. LPN #3 stated she administered all the medication ordered for the resident at that time frame; none had already been administered, and none were remaining to administer. A review of Resident #142's March 2022 active Physician's Orders revealed an order for Flonase Allergy Relief, administered via one (1) spray in each nostril, once a day, between the hours of 6:00 AM and 10:00 AM, with a start date of 02/24/2022. A medication reconciliation review completed by comparing the resident's Physician's Orders to the Medication Administration Record (MAR) revealed seven (7) medications ordered and documented as administered for the 6:00 AM to 10:00 AM medication pass by LPN #3. The medication that was observed as administered was Flonase nasal spray. Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed she did not administer the Flonase to the resident, although she charted the administration. LPN #3 stated the resident self-administered the medication and stored the medication in his/her room. Additionally, LPN #3 reviewed the resident's Electronic Health Record (EHR) and stated there was no self-administration assessment documented for the resident. Interview with Resident #142, on 03/02/2022 at 11:20 AM, revealed LPN #3 gave the Flonase to Resident #142 to keep at bedside. The resident stated that he/she told LPN #3, Just give me the bottle and I'll do it myself. The resident pulled the Flonase out of an unlocked drawer at the bedside. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED), revealed staff should complete a self-administration assessment before staff left medication at the bedside. Interview, on 03/03/2022 at 10:05 AM, with the Director of Health Services (DHS) revealed staff should complete a self-administration assessment prior to giving the medication to the resident to self-administer. 2. Observation during morning medication pass, on 03/02/2022 at 8:36 AM, revealed LPN #3 administered eleven (11) medications to Resident #143, which did not include metoprolol (used to treat hypertension or heart disease) or Nystatin suspension (used to treat or prevent fungal infection). LPN #3 was asked specifically if there were any medications already administered prior to the observation, any medications to be administered later, or any medications omitted during that medication pass. LPN #3 stated she provided all the medications, except she held the metoprolol, due to the resident's low blood pressure, but everything else was given to the resident. Review of Resident #143's March 2022 active Physician's Orders revealed an order for Nystatin suspension, five (5) milliliters (mL) orally, four (4) times a day, with a start date of 02/23/2022, and a restart date of 03/01/2022. A medication reconciliation review completed by comparing the resident's Physician Orders to the MAR revealed thirteen (13) medications ordered and documented as administered for the 6:00 AM to 10:00 AM medication pass by LPN #3. The medications not observed being administered during that date and time were the metoprolol, held due to Resident Condition and the Nystatin suspension due to Drug/Item Unavailable. Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed the Nystatin suspension was not available from the pharmacy. Continued interview with LPN #3 revealed she was unable to locate the medication in the cart. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED) revealed the nurse should contact the pharmacy or use the emergency medication kit when a medication was not available. The ED stated that if a medication was not given, the doctor should be notified. Interview, on 03/03/2022 at 10:13 AM, with the Director of Health Services (DHS) revealed the nurse should call the doctor to notify them of any missing medication and also call the pharmacy to have something sent over immediately.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of three (3) ice machines were kept clean and sanitary to prevent foodborne illnesses. This failed practice had the potential to affect all residents and staff. The findings include: A review of the facility policy, Kitchen Equipment Preventative Maintenance, revised 02/08/2018, revealed, staff inspected kitchen equipment monthly, unless otherwise directed. Additionally, staff checked the cleanliness of the ice tray and maintained the ice machine per manufacturer's recommendations. Observation, on 02/28/2022 at 2:30 PM, revealed a soda fountain machine with a push-button activated ice dispenser fitted inside a mounted grey plate that was approximately five (5) inches by three (3) inches with approximately a 1/4-inch space between the ice dispenser. Continued observation revealed the gray plate contained caked black, brown, and pink moist substances which had the potential to drip down and into containers. Interview, on 03/02/2022 at 3:25 PM, with the Director of Food Services (DFS) revealed the soda nozzles and juice maker were on a cleaning schedule, but the ice chute on the soda machine was not on a cleaning schedule. The DFS stated they had only used the soda machine for approximately six (6) months. The DFS stated the ice chute on the soda machine was not on a cleaning schedule because he was new to the facility, and he did not think to have the ice chute cleaned. Further interview revealed the equipment should be on a monthly cleaning schedule like the other ice machine. Interview, on 03/02/2022 at 4:11 PM, with the Executive Director (ED) revealed the facility had a cleaning schedule for the ice machines, but not for the soda fountains with an ice dispenser. The ED stated it was her expectation the ice dispenser be cleaned as frequently as the other ice machines, on a quarterly basis. She stated it was the responsibility of the DFS or the Director of Plant Operation's (DPO) to ensure the cleanliness of the ice machine, and both were aware of the equipment. The ED indicated a potential negative outcome of an unclean ice machine was that someone could become sick. Interview, on 03/03/2022 at 10:23 AM, with the Director of Health Services (DHS) revealed her expectation was the ice dispenser be cleaned regularly, and the observation of the black and pink substances was unacceptable. The DHS further stated she did not know the cleaning schedule. She stated the soda fountain with ice dispenser was used by both staff and residents, and a potential negative outcome of an unclean ice dispenser was that it could cause food borne illnesses.