Based on observation, record review and interview, the facility failed to maintain a medication error rate of less than five percent (%). Two errors were observed in 27 opportunities resulting in a 7.41% medication error rate. This affected one resident (#14) of four residents observed for medication administration. The census was 59. Finding Include: On 10/11/23 at 8:02 A.M. Licensed Practical Nurse (LPN) #238 was observed administering medications to Resident #14. The LPN prepared multiple medications for the resident, including Novolog (short acting) insulin pen and Toujeo Solo Star (long acting) pen. LPN #238 prepared the Novolog pen by removing the cap of the and wiping the top of the pen with alcohol and applying the needle. She dialed the dosage to 14. LPN #238 prepared the Toujeo pen by removing the cap of the pen, wiping the top of the pen with alcohol, applying the needle and then dialed the dosage to 30 units. The LPN did not prime the pens. LPN #238 administered Resident 14's whole pills and injected the Novolog and Toujeo insulin injections into the resident's left arm. Interview on 10/11/23 at 08:11 A.M. with LPN #238 revealed her process for administering insulin via a pen was to remove the cap and wipe the top of the pen with alcohol, then apply the needle and dial the dosage. The LPN verified she did not prime the pen to remove all of the air and to ensure the resident was administered the correct dose of insulin as ordered. Review of the resident's physician orders for October 2023 revealed two insulin orders, Novolog (pen) 14 units with meals and Toujeo Solo Star (pen) 30 units one time a day. Review of the manufacturer's instruction for the Novolog pen revealed to prime the pen prior to each injection. Priming the pen meant removing the air from the needle and cartridge that may collect during normal use and ensure the pen was working properly. Review of the manufacturer's instruction for the Toujeo Solo Star pen revealed to always do a safety check to ensure pen and needle were working properly. Select three units by dialing the dose selector and press the injection button. If insulin comes out of the needle tip the pen was properly working. Review of the facility policy titled Insulin Administration, revised September 2014, revealed the nursing staff would have access to specific instructions (manufacturer if appropriate) on all forms of insulin delivery systems prior to their use.

Based on observation, staff interview and review of the manufacture storage instructions revealed the facility failed to ensure medication storage guidelines were followed. This affected one Resident (Resident #29) of six residents that received insulin on the 300 unit and had the potential to affect 11 newly admitted residents (Resident #8, #11, #16, #55, #59, #117, #212, #213, #214, #215, #216) requiring Tuberculosis skin testing. The census was 59. Findings Include: 1. Observation on 10/10/23 at 4:54 P.M. of the 300-medication cart with Licensed Practical Nurse (LPN) #261 revealed Resident #29's basaglar kwick pen (long acting) insulin had an expiration date of 12/01/24. The pen had an open date of 09/09/23 that indicated the insulin was open for 32 days, exceeding the recommended 28 days. Interview on 10/10/23 at 4:55 P.M. with LPN #261 verified Resident #29's pen had an opened date of 09/09/23 and had been opened over the recommended 28 day use by date. Review of the facility policy titled Storage of Medication, dated November 2020, revealed discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer's instructions for the basaglar kwick pen, dated December 2015, revealed the pen should be thrown away after 28 days, even if it still has insulin left. 2. Observation on 10/10/23 at 5:00 P.M. of the medication room with LPN #261, revealed in the refrigerator was an opened (in use) vial of Tubersol (tuberculin purified protein derivative indicated to aid diagnosis of tuberculosis infection in persons at increased risk of developing active disease) with an expiration date of January 2026. The vial had no open date marked to indicate the recommended 30 day use by date. Review of pharmacy shipping manifest dated 08/03/23 revealed the facility received five Tubersol vials on 08/03/23. Review of the admission list dated 09/03/23 (31 days after the Tubersol was received) through 10/10/23 revealed there were 11 residents (Resident #8, #11, #16, #55, #59, #117, #212, #213, #214, #215, #216) admitted from 09/03/23 through 10/10/23. Interview on 10/10/23 at 5:14 P.M. with LPN #224 verified the finding and stated the vial should have been dated when opened. Review of the manufacturer instructions dated 01/15/23 revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor medication storage refrigerators on a daily bases and maintain the refrigerator temperature at the recommended temperature of 36 to 46 degree Fahrenheit (F). The facility also failed to monitor and expose of 13 expired Insyte Autoguards (used to start intravenous lines) that were located in the Intravenous (IV) cart. This had the potential to affect 13 residents (Resident #1, #2, #5, #20, #25, #32, #42, #45, #47, #50, #207, #258, and #261) of 13 residents reviewed for medication storage, with the potential to affect all 53 residents in the facility. Findings include: 1. Observation on [DATE] at 8:30 A.M. of the medication storage room with the Director of Nursing (DON) revealed one medication storage refrigerator was located in the medication storage room. The forms titled, Temperature log for [DATE], [DATE], [DATE] and [DATE] were located on the door of the refrigerator. Interview with the DON at this time verified the temperature log had documentation of the internal temperature of the refrigerator. The DON revealed the nurses should monitor the internal temperature of the refrigerator daily to assure the medications are stored within the recommended range. Record Review of the Temperature Log for [DATE] revealed the temperature was monitored for only two dates. Record review of the Temperature Log for [DATE], revealed the temperature was monitored for 17 dates. The temperature ranged 35 to 40 degrees F. Record review revealed on [DATE], [DATE], and [DATE] the refrigerator temperature was 35 degrees F. Record review of the Temperature Log for [DATE], revealed the temperature was monitored for 11 dates. The temperature ranged 35 to 40 degrees F. On [DATE] and [DATE], the temperature was 35 degrees F. Record review of the Temperature Log from [DATE] through [DATE] revealed nine temperatures were documented for the internal temperature of the refrigerator which ranged 35 to 40 degrees F. The last temperature documented was [DATE]. On [DATE], the temperature was documented to be 35 degrees F. Observation on [DATE] at 8:15 A.M. with the DON revealed the medication storage refrigerator was 30 to 31 degrees F. Medications stored in the medication storage refrigerator included: 1. One locked narcotic box. 2. 46 insulin vials of insulin (NovoLog, Lantus, Novolin 70/30, Novolin R, and Lispro) belonging to 10 Residents (Resident #1, #2, #5, #20, #32, #42, #47, #50, #207, and #261). 3. One vial of Tuberculin solution titled house stock. 4. One Avanox pen (used in treatment of multiple sclerosis) for Resident #45. 5. Gabapentin solution for Resident #258. 6. Granix injection (a leukocyte growth factor for the reduction in the duration of severe neutropenia), eight boxes, for Resident #25. Observation on [DATE] at 9:05 A.M. with the DON confirmed the internal temperature of the medication storage refrigerator was 30 to 31 degrees F. DON confirmed the lack of temperature monitoring through April, May, June, and [DATE]. Record review of the medication inserts, located under storage for NovoLog, Lantus, Novolin 70/30, Novolin R, Lispro, Tuberculin solution, Avanox pen, Gabapentin solution, and Granix injection revealed medications were to be stored between 36 and 46 degrees F, do not freeze. Interview on [DATE] at 10:35 A.M. with the facility Pharmacy Director #401 revealed he had spoke with the DON in the past and told her the medication refrigerator temperatures must be monitored daily. Interview on [DATE] at 2:15 P.M. with the facility Pharmacy Consultant revealed if the stated medications, NovoLog, Lantus, Novolin 70/30, Novolin R, Lispro, Tuberculin solution, Avanox pen, Gabapentin solution, and Granix injections, are stored below the recommended storage temperature, the potency of the medication may deteriorate or be less effective. Interview on [DATE] at 3:30 P.M. with DON confirmed she received a Pharmacy Recommendation form the Facility Pharmacy on [DATE] stating refrigerator temperatures were to be monitored daily. Record review titled, Medication Storage dated 2007 revealed medications requiring refrigeration or temperatures between 36 F and 46 F are kept in a refrigerator with a thermometer to allow temperature monitoring. 2. Observation on [DATE] at 8:50 A.M. with DON revealed the Intravenous (IV) cart was located in the medication storage room. DON revealed there was only one IV cart for the facility, and all IV supplies were stored in the IV cart. Observation revealed, in the top drawer of the IV cart was 34 Insyte Autoguard BC 22 gauge. Observation revealed, and DON confirmed 13 of the 34 Insyte Autoguard BC 22 gauge expired on [DATE]. Interview ON [DATE] at 9:00 A.M. with DON revealed the pharmacy consultant audits the IV cart monthly and the expired items should have been removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure privacy was maintained for Resident #50 during catheter care/personal care. This affected one of two residents observed for catheter care/personal care. Findings include: Resident #50 was admitted to the facility on [DATE]. Her admitting diagnoses included paraplegia, acute kidney failure, chronic obstructive pulmonary disease, neurogenic bladder and a stage IV pressure ulcer on her right buttocks. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #50 was alert, oriented and cognitively intact. She needed extensive assistance from staff for toileting, personal hygiene and bed mobility. The bladder and bowel sections of this MDS assessment indicated Resident #50 had a urinary catheter inserted to drain the urine from her bladder and she was frequently incontinent of bowel. On 03/27/19 at 9:30 A.M., Licensed Practical Nurse (LPN) #50 was observed providing catheter care and personal care to Resident #50. LPN #50 closed the room door and pulled the privacy curtain closed around Resident #50. However, the curtains on her room window, which was located to the right of the bed, were left open. Outside the window was a walkway and a small building. LPN #50 provided care to clean Resident #50's urinary catheter tubing and around her urethra. Resident #50 was observed to be turned towards the door, exposing her buttocks to the open window. After completion of the catheter care and personal care, LPN #50 applied a clean adult brief and pulled up Resident #50's pants. Interview with LPN #50 on 03/27/19 at 10:00 A.M. verified the curtains to the window remained open during catheter care/personal care and Resident #50 was not provided privacy during this care.