Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 27 opportunities, affecting three Residents (R4, R5, and R207) of five residents observed for medication administration, resulting in a medication error rate of 11.11 percent. Findings include: On 10/1/24 at 7:36 AM, medication administration was observed with Registered Nurse (RN) A for R4. RN A was observed preparing and dispensing 13 pills for R4. RN A dispensed two cranberry 500 milligram (mg) with vitamin C 200 mg tab into the medication cup with the other 13 pills. RN A took them to R4 and R4 consumed all 13 of their medications prepared by RN A. On 10/1/24 at 7:40 AM, an interview was conducted with RN A, and was asked if she used the correct cranberry supplement for R4. RN A reviewed the order for R4, then looked at her stock cranberry supplement and replied, No, I guess not. RN A was asked if there was another stock cranberry supplement without the added vitamin C and proceeded to the medication supply room. RN A could not locate the correct stock supply medication for cranberry only. Review of R4's physician order, dated 9/26/24, revealed cranberry oral tablet 500 mg (cranberry Vaccinium macrocarpon, give 2 tablets by mouth one time a day for urinary tract health. On 10/1/24 at 8:00 AM, medication administration was observed with RN B for R5. RN B was observed preparing six medications for R5 at the medication cart. RN B popped out a metoprolol 100 mg tab out of a medication card when the medication fell on top of the medication cart. RN B picked up the metoprolol tab with her bare hands and placed it into the medication cup with the other medications she prepared for R5. RN B then walked to R5's room and gave them to R5 who consumed their medication. On 10/1/24 at 8:25 AM, medication administration was observed with RN B for R207. RN B was preparing an insulin glargine pen for R207. RN B failed to prime the insulin glargine pen and failed to clean the tip of the pen with an alcohol swab prior to adding a disposable needle tip. On 10/2/24 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) who was made aware of the medication errors during medication pass. The DON replied, Nurses should be following the medication administration policy. If the policy does not cover specific medication administration types, then nurses are expected to follow the manufactures instructions for preparing and dispensing medications. Review of the manufacture instructions for insulin glargine, read in part, .How to use your insulin glargine pen in 6 steps .Step 2. Wipe the pen tip (rubber seal) with an alcohol swab .Step 3. Dial a test dose of 2 units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times . Review of policy titled, Medication Administration, dated 10/17/23, read in part, .Procedure: 1. Follow infection control practices .a. If medications come into contact with the bare hands of the nurse/QA med tech, or with the cart, the medication should be disposed of per policy and new medications obtained .2. Verify the medication label against the medication administration record for resident mane, time, drug, dose, and route .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00146561 Based on interview and record review the facility failed to ensure scheduled showers were completed for two Residents (#2 & #4) of four residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in lack of personal hygiene assistance, and personal dissatisfaction with ADL care. Findings include: Review of Complaint Intake revealed an allegation that residents were not adequately groomed and scheduled showers were not being completed. Resident #2 (R2) Review of R2's Minimum Data Set (MDS) assessment, dated 8/13/24, revealed R2 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 13, reflective of intact cognition. R2 required Partial/moderate assistance for shower/bathing. During an interview on 9/4/24 at approximately 11:30 a.m., R2 was asked about showers in the facility. R2 stated, I am not really getting the showers I am supposed to get. I have not refused any showers. I am supposed to get two a week. Review of R2's Shower/Bathing Task Schedule, revealed R4 was scheduled for Shower/Bathing - prefers Tuesdays and Thursday . Review of R2's Shower/Bathing task documentation in the Electronic Medical Record (EMR) showed R2 received a shower on 8/8, 8/12, 8/29, and 9/3/24. Shower documentation on 8/20, 8/22, and 8/27 was documented as no, that no shower had been given. R2 had no shower documented between 8/12 and 8/29/24 (17 days). Resident #4 (R4) Review of R4's MDS assessment dated [DATE], revealed R4 was admitted to the facility on [DATE] with a BIMS score of 11 of 15, reflective of moderate cognitive impairment. R4 required Partial/moderate assistance for shower/bathing. Review of R4's Shower/Bathing Task Schedule revealed showers would be given on Wednesday and Sunday on Day Shift. Review of R4's Shower/Bathing task documentation in the EMR showed R4 received a shower on 8/18, 8/28 and 9/1/24. Shower documentation on 8/21 and 8/25/24 was marked as N/A (not applicable). No shower refusals were documented, and no shower/bathing was documented between R4's admission on [DATE] and first shower on 8/18/24 (9 days). During an interview on 9/4/24 at 1:00 p.m., Certified Nurse Aide (CNA) F was asked if the shower room had been unusable by facility residents due to having no hot water, CNA F moved closer to this Surveyor, and whispered, There have been days when we didn't have hot water in here. CNA F said Maintenance Staff had done what they could, but in the last month there were several days when there was not hot water for showers. During an interview on 9/4/24 at 2:10 p.m., the Director of Nursing (DON) agreed any refused shower should have been documented and acknowledged that task documentation for showers/bathing was not present to provide evidence scheduled showers had been completed or refused. During an interview on 9/4/24 at 4:00 p.m., the Nursing Home Administrator (NHA) and DON were both present. Both confirmed showers should be offered and given per the schedules provided on the Resident's Shower/Bathing Task Schedule. Both acknowledged R2's and R4's shower task documentation did not show they had received showers as scheduled.

Based on observation, interview, and record review, the facility failed to prevent unauthorized access to the facility's one medication room. This deficient practice resulted in the potential for unauthorized dispensing and/or diversion of the facility medication supply by unlicensed staff and had the potential to affect all 54 facility residents. Findings include: During an observation and interview on 11/15/23 at 7:29 a.m., Medical Record Clerk (Staff) A was seen opening the facility's medication room door from the inside of the room and exiting the medication room with a clear plastic trash bag. The garbage bag contained what appeared to be multiple (greater than 10) over-the-counter medication bottles at the bottom of the bag and other unrecognizable garbage near the top of the trash bag. When asked if she had been alone in the medication room, Staff A confirmed she had been alone and without supervision. Staff A said she did not have a key to open the medication room door, but nursing staff routinely opened the door and provided Staff A unsupervised access to the room. Staff A stated, I stock all of the medical supplies (including accessible over-the-counter resident medications). I do all the supplies except laundry. During an interview on 11/15/23 at 7:32 a.m., Registered Nurse (RN) B said she had unlocked the medication room door and allowed Staff A unsupervised access to the medication room. RN B said that was the usual procedure and occurred almost daily. When asked if she supervised Staff A while she was in the medication room, RN B stated, No, I open the door for her. RN B said that Staff A went into the medication room alone and was not supervised by nursing staff while in the medication storage room. Observation of the medication storage room on 11/15/23 at 10:48 a.m., showed resident over-the-counter medications were stored accessible and in clear view once entry to the medication storage room was obtained. The multiple and varied over-the-counter medications were lined up on shelves, and openly displayed for easy access in the medication storage room. During an interview on 11/15/23 at 10:51 a.m., the Director of Nursing (DON) was asked if Medical Record Staff A had been authorized by the pharmacist to have unsupervised access to the medication storage room. The DON said she was not sure. A copy of the Pharmacy contract was requested for review along with a copy of any facility policy that addressed unsupervised access to the medication room without nursing or pharmacy supervision. During an interview on 11/15/23 at 11:55 a.m., the DON provided a copy of the facility Medication Management policy, last revised 9/22/2023, but no reference to unsupervised access to the medication room was addressed in the policy. The DON said that was the only policy regarding medication storage that she could find, and no other policy addressed requirements for authorized and/or unsupervised access to the medication room by non-nursing staff. No facility policy was available for review. When asked if the DON would leave the Maintenance Director (as an example of unauthorized access) unsupervised in the medication storage room, the DON said she would not. On 11/15/23 at 12:09 p.m., review of the Pharmacy Products and Services Agreement, dated September 1, 2021, revealed no facility staff had been delegated in the contract as an authorized assistant allowed unsupervised access to the facility medication storage room. During an interview on 11/16/23 at approximately 10:00 a.m., the DON was asked they had reviewed the regulatory requirements for medication storage. The DON said she had not reviewed it thoroughly, but said she understood the concern regarding unsupervised access to the medication storage room by anyone other than licensed nursing personnel, pharmacy staff or pharmacy delegated staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a dignified care environment for one Resident (#25) of 16 residents reviewed. This deficient practice resulted in the potential for feelings of humiliation and low self-worth based on a reasonable person standard. Findings include: Resident #25 was admitted to the facility on [DATE] and had diagnoses including: Parkinson's Disease, and adjustment disorder with mixed anxiety and depressed mood. A review of Resident #25's most recent Minimum Data Set (MDS) assessment, dated 7/21/2022 revealed Resident #25 required extensive assistance with dressing and scored a nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #25 had moderate cognitive impairment. During an observation on 9/14/2022 at 11:45 a.m., Certified Nurse Aide (CNA) H transferred an unidentified Resident in a shower chair from the shower room down the hall to the right of the nurses' station. While in transit, CNA H was observed leaving the resident in the shower chair and rushing into Resident #25's room. CNA H could be heard from the hallway stating in a chastising voice, What are you doing? Upon entering the room, CNA H was observed to be kneeling in front of Resident #25, who was seated in a wheelchair with his left side facing the doorway. Resident #25 had on white athletic socks and his shoes were on the floor in front of the wheelchair. CNA H was then observed to grab Resident #25's right shoe and in a hurried manner, pushed the shoe onto the Resident's right foot. Upon picking up Resident #25's left shoe and looking toward the doorway and this Surveyor, CNA H stated, I am so sick of this [expletive]. CNA H proceeded to pick up Resident #25's left shoe and pushed the shoe onto the Resident's left foot. CNA H then walked to the Resident's closet to obtain the foot pedals for the wheelchair, attached the foot pedals and turned the Resident in the wheelchair toward the door. Resident #25 was observed to have a confused facial expression. CNA H then pushed Resident #25 to the hallway and called out for Registered Nurse (RN) G to ask for assistance transferring Resident #25 to the dining room. CNA H proceeded down the hall pushing the unidentified Resident who was waiting in the hallway. The Director of Nursing (DON) was immediately notified of the observation involving CNA H and Resident #25. The DON stated CNAs are expected to act respectfully and treat Residents in a dignified manner. On 9/14/2022 at 12:02 p.m., the Nursing Home Administrator (NHA) and DON requested an interview with this Surveyor. The NHA reported CNA H was sent home pending an investigation into the incident involving Resident #25. The NHA stated Resident #25 was interviewed and reported no recollection of the incident. The NHA reported CNA H denied saying I am so sick of this [expletive], while in the presence of Resident #25 and this Surveyor. During an interview on 9/14/2022 at approximately 1:30 p.m., Resident #25 stated he already spoke to a group of people in white coats, about the incident involving CNA H. Resident #25 declined to answer questions regarding the incident. On 9/14/2022 at 1:00 p.m., the NHA reported her investigation into the incident revealed CNA H denied her actions as witnessed by this Surveyor, and Resident #25 stated to the NHA he did not hear CNA H say I am so sick of this [expletive]. The NHA stated the incident was fabricated by this Surveyor and did not occur. CNA H was unavailable for interview after the incident and prior to survey exit on 9/14/2022 at 2:25 p.m. A review of the facility policy titled Guest/Resident Dignity & Personal Privacy, revised 4/19/2022 and provided by the DON, revealed the following, in part: The facility provides care for guests/residents in a manner that respects and enhances each guest's/resident's dignity, individuality and right to personal privacy . Dignity means that when interacting with (guests)/residents, staff carries out activities that assist the guest/resident in maintaining and enhancing his or her self-esteem and self-worth . Care for guests/residents in a manner that maintains dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate indwelling, urinary catheter care according to facility policy and professional standards of practice for one Resident (#46) of three residents reviewed for catheter care. This deficient practice resulted in the potential for infection and pain. Findings include: Resident #46 was admitted to the facility on [DATE] and had diagnoses including obstructive uropathy, enlarged prostate and urinary tract infection. An observation on 9/14/2022 at 10:08 a.m., with the Director of Nursing (DON), revealed Resident #46 lying in bed. Urinary catheter tubing was observed to be leading out from under the Resident's blanket on the left side of the bed, leading to a dependent drainage bag attached to the left, lower bed frame. Further observation revealed a white film coating the inside of the distal end of the catheter tubing. A review of Resident #46's electronic medical record (EMR), including progress notes, evaluations, and medication/treatment administration records from 6/01/2022 through 9/14/2022, revealed the Resident's catheter and collection system was last changed during a hospitalization on 6/8/2022. An observation on 9/14/2022 at 11:10 a.m., revealed Certified Nurse Aide (CNA) J providing catheter care to Resident #46 in the shower room. Resident #46 was seated in a shower chair with catheter tubing leading from the insertion site at the Resident's urethral meatus to a dependent drainage bag hanging on a metal handrail attached to the wall to the right of the Resident. Further observation revealed the drainage bag was positioned approximately six inches above the level of Resident #46's bladder. A white film was observed to be adhered to the inside portion of the distal end of the tubing with amber colored urine filling the tubing and leading back toward the resident seated in the shower chair. During an interview at the time of the observation, CNA J was asked what she thought about the positioning of the dependent drainage bag. CNA J stated the bag was positioned too high and above the Resident's bladder. CNA J reported that there was no other option for hanging catheter bags in the shower room. During an interview on 9/14/2022 a1:30 p.m., the DON confirmed Resident #46's catheter and drainage system were last changed during a hospitalization on 6/8/2022. The DON reported dependent drainage bags should always be positioned below the level of a resident's bladder to prevent backflow of urine and infection. A review of the facility policy titled Catheter Associated urinary Tract Infection (CAUTI) Prevention, last revised 8/17/2021 and provided by the DON, revealed the following, in part: To ensure appropriate technique in the care and maintenance of indwelling catheters . Maintain unobstructed urine flow by keeping the collection bag below the level of the bladder .

Based on observation, interview, and record review, the facility failed to label, date, and store oxygen equipment per professional standards of practice for two Residents (#3 and #101) of two residents reviewed for respiratory care. This deficient practice resulted in the potential for contamination and cross-contamination of oxygen equipment and possible transmission of infectious organisms. Findings include: Resident #3 Review of Resident #3's admission Record, revealed a medical diagnosis of chronic obstructive pulmonary disease (COPD) and an admission date of 2/28/22. Review of Resident #3's physician order, read in part, Albuterol Sulfate Nebulizer Solution 1.25 mg/3ml (milligrams/milliliter), 3 ml inhale orally three times a day for 1 unit inhale orally nebulizer every 6 hours for COPD, start date 8/3/22. On 9/12/22 at approximately 3:50 PM, a nebulizer machine was observed sitting on the bedside dresser next to Resident #3's bed. The tubing attached to the nebulizer machine was dated 9/4/22. The administration mask and medication administration container were sitting on top of the bedside dresser without a barrier between the equipment and the top of the bedside dresser. The mask and medication administration container were connected and had visible areas of fluid and condensation noted within them. On 9/13/22 at 9:20 AM, a second observation was made of Resident #3's nebulizer machine and equipment. The tubing attached to the nebulizer machine was dated 9/4/22. The administration mask and medication administration container were sitting on top of the bedside dresser without a barrier between the equipment and the top of the bedside dresser. The mask and medication administration container were connected and had visible areas of fluid and condensation noted within them. Another observation was made on 9/13/22 at 3:25 PM, of Resident #3's nebulizer machine and equipment. No change was noted from prior observation on 9/13/22 at 9:20 AM. Resident #3's nebulizer machine and equipment remained in the same condition. On 9/14/22 at 8:40 AM, an observation was made of Resident #3's nebulizer machine and equipment. Again, there was no change noted to the placement or condition as described in the above observations. An interview was conducted on 9/14/22 at 12:02 PM, with Registered Nurse (RN) F regarding Resident #3's nebulizer equipment. RN F was asked if the equipment should have been left in one piece and if the system should have been newer and responded, The nebulizer equipment should be taken apart after each use, rinsed and dried. All oxygen related equipment is changed weekly and dated on the night shift Saturday. It should have had a date of 9/11/22. Resident #101 Review of Resident #101's admission Record, revealed medical diagnoses of chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with an admission date of 9/8/22. Review of Resident #101's physician orders, read in part, Albuterol Sulfate Nebulizer Solution 2.5 mg/3ml (milligrams/milliliter) 0.083%, 3 ml inhale orally via nebulizer every 2 hours as needed, start date 9/8/22 and oxygen 3 liters per nasal cannula, start date 9/8/22. On 9/13/22 at 9:10 AM, an observation was made of Resident #101 in his room lying in bed. Resident #101 had an oxygen concentrator that was connected to a humidification bottle, delivering 3 liters of oxygen via nasal cannula. Resident #101's oxygen tubing and humidification bottle both were not dated indicating the last time the equipment was changed. On 9/14/22 at 9:30 AM, an observation was made of Resident #101's nebulizer machine and equipment in his room. The nebulizer machine was sitting on his bedside dresser. The equipment was in a graduated cylinder. The medication administration container and the t-piece connector were connected and had visible areas of fluid and condensation noted within them. Resident #101 was also noted to have an oxygen concentrator in his room with a bubbler attached to the concentrator and it was noted that the bubbler was empty, not dated, and not bubbling. It was also noted that Resident #101's oxygen tubing was lying on the floor and there were food crumbs and trash on the floor near the tubing. An interview was conducted on 9/14/22 at 9:35 AM, with RN F regarding Resident #101's oxygen equipment. RN F confirmed that all oxygen equipment should be dated, the nebulizer equipment should be taken apart, rinsed and dried after being used, and the bubbler should not have been left empty. On 9/14/22 at approximately 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked how often the oxygen equipment and supplies were changed and responded, Weekly on Saturday during night shift and are dated when changed. Review of facility policy titled Use of Oxygen, revised 8/17/2021 and provided by the DON, read in part, Policy: To promote guest/resident safety in administering oxygen. The following guidelines will be observed in oxygen. I. The O2 (oxygen) cannula or mask should be changed weekly and dated. II. The tubing should be kept off the floor .VI. The O2 equipment should be cleaned regularly . Review of facility procedure titled Nebulizer Therapy Small Volume, no date and provided by the DON, read in part, .Rinse the nebulizer with sterile or distilled water and allow it to air-dry .

Based on observation, interview and record review, the facility failed to maintain one ice machine and one mechanical dishwashing machine in proper operating condition. This deficient practice had the potential to result in ice being distributed to residents that was not safe and a dish machine which may fail due to improper pressure allowances, affecting all 50 residents. Findings include: On 9/12/22 at 3:27 PM, the bin ice machine, located in the dining room was observed to have a brown colored bio-film on the white plastic cube deflector shield, directly above the holding bin of the machine. On 9/13/22 at approximately 8:10 AM, the ice machine was observed again, with Maintenance Director (MD) B. An interview was conducted with MD B who acknowledged the presence of the bio film on the deflector shield. When asked about the cleaning schedule for the machine, MD B stated it was conducted monthly. When asked what procedure was followed for the cleaning, MD B opened the top panel, pointed to the instructions printed on the inside of the door panel, and stated I follow that. On 9/13/22 documentation of the ice machine cleaning was provided and documented by the Nursing Home Administrator (NHA) the machine was properly cleaned on 8/31/22. When asked who performed the cleaning, MD B stated I did. When asked how he thought that a bio film mass could accumulate in only 12 days, MD B stated I don't know. MD B was requested to provide a list of chemicals used to clean and sanitize the ice machine. At approximately 8:45 AM MD B provided a bottle of chemical used for the cleaning, which was identified as a de-scaling agent, used to remove hardness (lime) scale within the machine. When asked if there was another chemical used for the sanitizing process, MD B stated No. This is the only chemical I use. On 8/13/22 at approximately 2:30 PM, the directions for cleaning were reviewed with both the NHA and MD B. The instructions printed on the inside of the door on the top of the ice machine were again reviewed and demonstrated that steps 10-21 were the sanitizing process, following the cleaning and de-scaling of the machine. The directions were clear that removable components were to be removed and soaked in a specified diluted hypochlorite (bleach) solution by the manufacturer, and the internal components flushed with a specified dilution of the hypochlorite solution to ensure proper disinfection of the components coming in contact with the water and ice. MD B acknowledged that this step was not followed and he was not aware that it was necessary. On 8/12/22 at 3:45 PM, the mechanical dish machine, in the kitchen was observed. The machine was operated for two full cycles. The pressure gauge for the final rinse was observed to be non-functional. A review of the information data plate for the machine revealed the final rinse pressure, during the sanitizing cycle was to be between 10-30 PSI (pounds per square inch). This was also stated in the FDA Food Code 2013 at: 4-204.118 Warewashing Machines, Flow Pressure Device. (A) WAREWASHING machines that provide a fresh hot water SANITIZING rinse shall be equipped with a pressure gauge or similar device such as a transducer that measures and displays the water pressure in the supply line immediately before entering the WAREWASHING machine; and (B) If the flow pressure measuring device is upstream of the fresh hot water SANITIZING rinse control valve, the device shall be mounted in a 6.4 millimeter or one-fourth inch Iron Pipe Size (IPS) valve