**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews for one (1) of three (3) sampled residents, facility staff failed to accurately transcribe a physician's order for Lorazepam (a benzodiazepine approved to treat anxiety, insomnia) medication. Subsequently, Resident #1 was administered the medication incorrectly five (5) times on 03/29/24. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction due to embolism of left middle cerebral artery, Hemiplegia and Hemiparesis following cerebral infarction and Aphasia. According to an American Nurses Association Issue Brief dated 4/2021 documented in part, The administration of medications involves complex thinking and application of scientific knowledge. What began with five rights has now been extended to the eight rights of medication administration, the: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation, Right Reason, and Right Response. https://www.nursingworld.org. An admission Order dated 03/28/24 documented in part, Admit to [Name of Hospice] . Lorazepam concentrate 2mg/ml (milligram/milliliter) give 0.5mg (0.25ml) Q (every) 4 hrs (hours) PRN (as needed) PO (by mouth)- Dx: (diagnoses) anxiety/restlessness. It should be noted that the previous orders were reviewed by Employee #10 (Registered Nurse/RN) and Employee #4 (RN) on 03/28/24 for accuracy of transcription. A review of a Physician's Order Report dated 03/09/24 - 04/09/24 documented in part, Lorazepam 2mg/ml give 0.5mg (0.25ml) Q (every) 4 hrs (hours) PRN (as needed) PO (by mouth) for anxiety/restlessness with a start date of 03/28/24. A review of Resident #1's March 2024 electronic Medication Administration History [Record] documented in part the following order: Lorazepam 2mg/ml; Amount to administer 0.5mg (0.25ml); oral; Frequency- Every 4 hours; Special Instructions: .Give 0.5mg (0.25ml); . by mouth every 4 hours PRN for agitation/restlessness; start date of 03/28/24 . On 03/29/24 at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM Lorazepam 2mg/ml was administered to Resident #1 lacking documented evidence that the resident exhibited signs of agitation or restlessness prior to the administration of Lorazepam. A Facility Reported Incident (FRI) received by the State Agency on 04/05/24 documented, On 3/28/24, an order was obtained for Ativan (Lorazepam) 0.25 ml po q 4 hrs PRN. Nurse who entered the order did not check the PRN (as needed) box, and order appear[ed] as routine. Resident received 6 doses on 3/29/24 before an error was noticed and medication re-entered as PRN. Resident remains on Hospice services for comfort care. During a face-to-face interview conducted on 04/10/24 at 9:05AM, Employee #2 (Director or Nursing/DON) stated that, Employee #10 (RN) did not transcribe the Lorazepam order correctly in the resident's electronic Medication Administration Record. Employee #2 then said that Employee #10 should have indicated that the medication was prescribed as a PRN order. Instead, he indicated that the medication was to be administered routinely and that's why staff administered Lorazepam five (5) times on 03/29/24. During a telephone interview conducted on 04/10/24 at 4:30 PM, Employee #10 stated, In the special instructions I wrote it exactly as it is, q4h but I just didn't check the PRN box. I totally accept responsibility for this mistake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, for one (1) of 22 sampled residents, facility staff failed to ensure that Resident #21 was treated with respect and dignity as evidenced by failure to provide a privacy cover for the resident's urine collection bag, which was visible from a commonly accessed hallway in the facility. The findings included: Resident #21 was admitted to the facility on [DATE] with multiple diagnoses' which included: Urinary Tract Infection, Chronic Kidney Disease Stage 3 Moderate and Unspecified Dementia. Review of the resident's physician orders revealed the following: -01/13/20 Catheter Care: routine catheter care every shift . -01/13/20 Flush Foley catheter with 30 ml (milliliters) of normal saline solution every shift . -07/01/21 Catheter Foley keep free of kinks and below bladder . -02/13/23 Catheter Foley 18 FR (French) 5 CC (cubic centimeters) balloon, change as needed . A review of Resident #21's medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE], where facility staff coded the resident as having severe cognitive impairment and the presence of an indwelling urinary catheter. During an observation on 04/25/23 at approximately 10:20 AM, while walking past Resident #21's room, the surveyor observed Resident #21's indwelling catheter urine collection bag laying on the floor, uncovered and with the catheter tubing also laying on the floor and under the urine collection bag. During a face-to-face interview conducted on 04/25/23 at 11:45 AM, Employee #9 (Registered Nurse/Charge Nurse) acknowledged the finding and stated, I'm not sure if we have the covers. Cross Reference 22B DCMR sec 3269.1 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility staff failed to follow its policy to investigate a fall with an injury that Resident #196 sustained while in the facility. Resident #196 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Parkinson's Disease, Pneumonia, Disorientation, Dementia, Dizziness and Giddiness, and Other Abnormalities of Gait and Mobility. A review of the medical record revealed the following: A Minimum Data Set admission assessment dated [DATE] showed that the facility staff coded the resident as having severely impaired cognition, requiring extensive assistance for bed mobility transfers, eating, toilet use, and personal hygiene. [Physician's Order] 11/09/21: Falls precautions every shift. Call lights and personal needs within reach, frequent rounds, bed in low position while in bed, every shift . DL - Transfer, as needed PRN. [Physician's Order] 11/09/21: Floor mats to both sides of bed while in bed. Dx (diagnosis): Minimize injury every shift A Care Plan initiated on 11/10/21, documented: Falls: Resident has potential for fall-related to delusion/delirium, decreased orientation, unsteady gait/balance related to Parkinson .new to the rehab environment .Resident with actual fall on 11/18 . Approach: Call light within reach, personal items within reach, make frequent rounds . [Progress Note] 11/18/21 at 4:23 AM: On 11/18/2021 at around 03:15 am .heard voice calling for help. Resident .in a sitting position with head facing down [on] the floor . Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter) .conversive at this time and said [pronoun] was trying to reach eyepad (sp.) [iPad] and fell. Voiced no pain at this time. Moving all extremities, able to stand with 2 (two) staff assists. [Physician's Name] notified via telephone conversation with orders to monitor and [if] any behavior changes, to transfer to ER [Emergency Room] for [e]valuation [POA ] updated . Questioned if we restraint resident. Made aware that this is not acceptable and only half side rails when in bed. Also mentioned what [Physician's Name] order[ed] and said [pronoun] agreed not to transfer to ER [Emergency Room] but monitor and if any behavior changes then transfer. Neuro checks initiated . A Care Plan dated 11/22/21 that documented: Problem: Forehead laceration s/p (status post) fall .Approach: Apply treatment as ordered .Evaluation Notes: 11/22/2021: . Resident fell on 11/18, around 3:15 am alarm .Resident sustained a forehead laceration 1.5 cm (centimeters) x (times) 2 cm, saying he tried to reach for his iPad and consequently lost his balance and fell . A review of a Facility Reported Incident (FRI) (DC00010404) dated 11/22/21 submitted by the facility to the State Agency documented the following: On 11/18/2021 at around 03:15 am alarm sounded heard voice calling for help. Resident observed somewhat in a sitting position with head facing down[on] the floor near the bathroom door in his room with small amount of blood in the floor. Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter). Resident .said .was trying to reach his eyepad (sp.) [iPad] and fell .[POA ] updated .agreed not to transfer to ER [Emergency Room] . A review of Resident #196's medical record and the facility's administrative records lacked documented evidence that the facility followed its policy and procedures for investigating Resident #196's fall with an injury. During a face-to-face interview on 04/24/23 at 3:49 PM, when asked about Resident #196's fall Employee #8 (Registered Nurse/Charge Nurse) assigned to Resident #196 on 11/18/21) stated, I cannot remember the incident. If I wrote a statement on the incident then that would include what I know about the incident. During a face-to-face interview on 04/25/23 at 10:15 AM, Employee #2 (Director of Nursing) stated that there was no investigation for Resident# 196's fall. Based on record review and staff interview, for two (2) of 22 sampled residents, facility staff failed to implement its policies and procedures for conducting investigations. (Residents' #17 and #196.) The findings included: Review of the policy Abuse Neglect and Exploitation with a revision date of 09/20/22, documented, It is [Facility Name]'s policy that reports of abuse ( .including injuries of unknown origin) are promptly and thoroughly investigated .The investigation will include .involved staff and witness statements of events . Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be submitted within five working days of the initial report .The Administrator or Designee will be notified immediately. The Department of Health shall be notified as soon as possible but not to exceed 2 hours after forming a suspicion of abuse. 1. Facility staff failed to report Resident #17's allegation of abuse to the State Agency within two-hours; and have documented evidence that a thorough investigation was conducted. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Neurocognitive Disorder with Lewy Bodies, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant side, Insomnia, and Acquired Absence of Left Leg Above Knee. A review of the medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE], showing that the facility staff coded the resident as having minimal difficulty with hearing and as using a hearing aid, having clear speech, able to make self-understood and understanding others. The assessment also showed a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated intact cognition; extensive assistance and 2-person physical assistance for bed mobility, transfer and toilet use; impairment on one side in the upper extremities and having impairment on both sides in the lower extremities; and used a wheelchair for mobility. A nurse progress note dated 12/22/22 at 1:11 AM documented, .Around 10PM resident was put into bed by 2 staff. MED (sp) Medication nurse stated that he was called by resident that one staff hit him in the head. When the nurse about to see if there is a bruise or any changes seen. Resident got upset and asked the nurse what she was looking for. Resident had behavior issue yesterday evening. A Nurse Progress Note dated 12/22/22 at 3:34 PM documented, .Sister went on to say that resident told her that [ .] hit him on his head with fist on right side yesterday and tried to crash his W/C (wheelchair) into his bed 3 times. Reviewed notes from yesterday and sister informed that resident had a similar complaint .Based on info (sp) (Information) gathered resident stated that around 8 PM he was put to bed by a nurse [ .] and later said her last name was [ .] He proceeded to say that a nurse name [ .] tapped him on nose when he was in bed and said don't ring the bell again. Resident said he said if I do then what? Resident went on to say that prior to being in bed (on evening shift), He was in his W/C and he says same nurse pushed his W/C in the bed 3 times and hit him in the head (pointing to the right lateral side) Resident commented he had a headache afterward but denies current pain with exception he said his eyes were feeling discomfort . A Facility Reported Incident (FRI), DC00011401, submitted by the facility to the State Agency on 12/22/22 at 7:17 PM documented, Resident reported to his sister that [Employee #12] hit him on his head with fist on the right side of huis (his) (sp) head 12/21/22 and tried to crash his wheelchair into his bed. Resident told the 7am -3pm charge nurse that it was around 8pm . The facility staff failed to show any documented evidence of following their policy to notify the State Agency within 2 hours of Resident #17's allegation of abuse and there is no evidence that the results of their investigation was submitted to the State Agency. During a face-to-face interview conducted on 04/25/23 at approximately 12:00 PM, Employee #2 (Director of Nursing) stated that there was no follow-up investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 22 sampled residents, facility staff failed to conduct a thorough investigation of a resident's allegation of abuse by staff and report the findings to the administrator, and to the State Survey Agency within 2 hours of the allegation. Resident #17. The findings included: Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be submitted within five working days of the initial report .The Administrator or Designee will be notified immediately. The Department of Health shall be notified as soon as possible but not to exceed 2 hours after forming a suspicion of abuse. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant side, Neurocognitive Disorder with Lewy Bodies, Insomnia, and Acquired Absence of Left Leg Above Knee. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the following for Resident #17: having minimal difficulty with hearing and as using a hearing aid, having clear speech, able to make self-understood and understanding others. The facility staff coded the resident as having a Brief Interview for Mental Status (BIMS) summary score of 15 which indicates intact cognition. The facility staff coded the resident as requiring extensive assistance and 2-person physical assistance for bed mobility, transfer and toilet use. The facility staff coded the resident as having an impairment on one side in the upper extremities and having impairment on both sides in the lower extremities. The facility staff coded the resident using a wheelchair for mobility. A review of a Facility Reported Incident (FRI) (DC00011401) submitted by the facility to the State Agency on 12/22/22 at 7:17 PM revealed the following: Resident reported to his sister that [Employee #12] hit him on his head with fist on the right side of huis (his) (sp) head 12/21/22 and tried to crash his wheelchair into his bed. Resident told the 7am -3pm charge nurse that it was around 8pm. He said that the nurse name was [Nurse Aide Name] but [Another Nurse Aide Name] worked that morning. When asked where he was hit he pointed to the right lateral side of his head. An assessment of his head was completed, no redness was noted to the site where he pointed, no sign of injury, skin pink and resident denied pain and discomfort on palpation. When asked how the staff pushed his chair in the bed, he just started to get upset and saying that I took something out of the hallway with me. I explained that it was PPE (personal protective equipment). Resident was not willing to continue the conversation . A review of the incident report submitted to the State Agency documents that the allegation occurred on 12/21/22 at 8:00 PM and was submitted to the State Agency on 12/22/22 at 7:17 PM, 23 hours after the allegation was made by the resident. A review of the medical record revealed on the face sheet that the resident had a responsible party. The Nurse Progress Note dated 12/22/22 at 1:11 AM documented, .Around 10PM resident was put into bed by 2 staff. MED (sp) Medication nurse stated that he was called by resident that one staff hit him in the head. When the nurse about to see if there is a bruise or any changes seen. Resident got upset and asked the nurse what she was looking for. Resident had behavior issue yesterday evening. A subsequent nursing progress note dated 12/22/22 at 3:34 PM revealed, .Sister went on to say that resident told her that [ .] hit him on his head with fist on right side yesterday and tried to crash his W/C (wheelchair) into his bed 3 times. Reviewed notes from yesterday and sister informed that resident had a similar complaint .Based on info (sp) (Information) gathered resident stated that around 8 PM he was put to bed by a nurse [ .] and later said her last name was [ .] He proceeded to say that a nurse name [ .] tapped him on nose when he was in bed and said don't ring the bell again. Resident said he said if I do then what? Resident went on to say that prior to being in bed (on evening shift), He was in his W/C (wheelchair)and he says same nurse pushed his W/C (wheelchair) in the bed 3 times and hit him in the head (pointing to the right lateral side) Resident commented he had a headache afterward but denies current pain with exception he said his eyes were feeling discomfort . The facility staff failed to show any documented evidence that the State Agency was notified within 2 hours of Resident #17's allegation of abuse and there is no evidence that the results of their investigation was submitted to the State Agency. During a face-to-face interview conducted on 04/24/23 at 5:10 PM, Employee #9 (Registered Nurse Charge Nurse) acknowledged the findings and stated, I am not sure why that was not done and sometimes he reports things that don't happen. During a face-to-face interview conducted on 04/25/23 at approximately 12:00 PM, Employee #2 (Director of Nursing) stated that there was no follow up investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility staff failed to conduct a thorough investigation of a fall that Resident #196 sustained while in the facility. Resident #196 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Parkinson's Disease, Pneumonia, Disorientation, Dementia, Dizziness and Giddiness, and Other Abnormalities of Gait and Mobility. A review of Resident #196's medical record revealed the following: An admission Minimum Data Set (MDS) dated [DATE] showed that the facility staff coded the resident as having severely impaired cognition, requiring extensive assistance for bed mobility transfers, eating, toilet use, and personal hygiene. [Physician's Order] 11/09/21: Falls precautions every shift. Call lights and personal needs within reach, frequent rounds, bed in low position while in bed, every shift . DL - Transfer, as needed PRN. [Physician's Order] 11/09/21: Floor mats to both sides of bed while in bed. Dx (diagnosis): Minimize injury every shift A review care plan initiated 11/10/21 documented: Falls: Resident has potential for fall-related to delusion/delirium, decreased orientation, unsteady gait/balance related to Parkinson .new to the rehab environment .Resident with actual fall on 11/18 . Approach: Call light within reach, personal items within reach, make frequent rounds . [Progress Note] 11/18/21 at 4:23 AM: On 11/18/2021 at around 03:15 am .heard voice calling for help. Resident .in a sitting position with head facing down [on] the floor . Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter) .conversive at this time and said [pronoun] was trying to reach eye pad (sp.) [iPad] and fell. Voiced no pain at this time. Moving all extremities, able to stand with 2 (two) staff assist. [Physician's Name] notified via telephone conversation with orders to monitor and [if] any behavior changes, to transfer to ER [Emergency Room] for [e]valuation [POA ] updated . Questioned if we restraint resident. Made aware that this is not acceptable and only half side rails when in bed. Also mentioned what [Physician's Name] order[ed] and said [pronoun] agreed not to transfer to ER [Emergency Room] but monitor and if any behavior changes then transfer. Neuro checks initiated A care plan dated 11/22/21 documented the following:Problem: Forehead laceration s/p (status post) fall .Approach: Apply treatment as ordered .Evaluation Notes: 11/22/2021: Resident fell on 11/18, around 3:15 am alarm .Resident sustained a forehead laceration 1.5 cm x 2 cm, saying he tried to reach for his iPad and consequently lost his balance and fell. A Facility Reported Incident ( FRI )(DC #00010404) dated 11/22/21, was submitted to the State Agency by the facility and it documented the following: On 11/18/2021 at around 03:15 am alarm sounded heard voice calling for help. Resident observed somewhat in a sitting position with head facing down[on] the floor near the bathroom door in his room with small amount of blood in the floor. Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter). Resident .said .was trying to reach his eyepad (sp.) [iPad] and fell .[POA ] updated .agreed not to transfer to ER [Emergency Room] . Resident #196's medical record and the facility's administrative records lacked documented evidence that the facility followed its policy and procedures to investigate Resident #196's fall with an injury. During a face-to-face interview on 04/24/23 at 3:49 PM, when asked about Resident #196's fall Employee #8 (Registered Nurse/Charge Nurse assigned to Resident #196 on 11/18/21) stated, I cannot remember the incident. If I wrote a statement on the incident then that would include what I know about the incident. During a face-to-face interview on 04/25/23 at 10:15 AM, Employee #2 (Director of Nursing) stated that there was no investigation into Resident# 196's fall. Cross Reference 22B DCMR sec 3232.2 Based on record reviews and staff interviews, for two (2) of 22 sampled residents, facility staff failed to conduct a thorough investigations for one resident's allegation of abuse and one resident's unwitnessed fall. Residents' #17 and #196. The findings included: Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be submitted within five working days of the initial report .The Administrator or Designee will be notified immediately. The Department of Health shall be notified as soon as possible but not to exceed 2 hours after forming a suspicion of abuse. 1. Facility staff failed to show documented evidence that a thorough investigation was conducted into Resident #17's allegation of abuse by staff. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant side, Neurocognitive Disorder with Lewy Bodies, Insomnia, and Acquired Absence of Left Leg Above Knee. A review of a Facility Reported Incident (FRI) (DC00011401) submitted by the facility to the State Agency on 12/22/22 at 7:17 PM revealed the following: Resident reported to his sister that [Employee #12] hit him on his head with fist on the right side of huis (his) (sp) head 12/21/22 and tried to crash his wheelchair into his bed. Resident told the 7am -3pm charge nurse that it was around 8pm. He said that the nurse name was [Nurse Aide Name] but [Another Nurse Aide Name] worked that morning. When asked where he was hit he pointed to the right lateral side of his head. An assessment of his head was completed, no redness was noted to the site where he pointed, no sign of injury, skin pink and resident denied pain and discomfort on palpation. When asked how the staff pushed his chair in the bed, he just started to get upset and saying that I took something out of the hallway with me. I explained that it was PPE (personal protective equipment). Resident was not willing to continue the conversation . A review of the incident report submitted to the State Agency documents that the allegation occurred on 12/21/22 at 8:00 PM and was submitted to the State Agency on 12/22/22 at 7:17 Pm 23 hours after the allegation was made by the resident. A review of the medical record revealed the following: A review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the following for Resident #17: having minimal difficulty with hearing and as using a hearing aid, having clear speech, able to make self-understood and understanding others. The facility staff coded the resident as having a Brief Interview for Mental Status (BIMS) summary score of 15 which indicates intact cognition. The facility staff coded the resident as requiring extensive assistance and 2-person physical assistance for bed mobility, transfer and toilet use. The facility staff coded the resident as having an impairment on one side in the upper extremities and having impairment on both sides in the lower extremities. The facility staff coded the resident using a wheelchair for mobility. [Nurse Progress Note] 12/22/22 at 3:34 Pm .Sister went on to say that resident told her that [ .] hit him on his head with fist on right side yesterday and tried to crash his W/C (wheelchair) into his bed 3 times. Reviewed notes from yesterday and sister informed that resident had a similar complaint .Based on info (sp) (Information) gathered resident stated that around 8 PM he was put to bed by a nurse [ .] and later said her last name was [ .] He proceeded to say that a nurse name [ .] tapped him on nose when he was in bed and said don't ring the bell again. Resident said he said if I do then what? Resident went on to say that prior to being in bed (on evening shift), He was in his W/C (wheelchair)and he says same nurse pushed his W/C (wheelchair) in the bed 3 times and hit him in the head (pointing to the right lateral side) Resident commented he had a headache afterward but denies current pain with exception he said his eyes were feeling discomfort . [Nurse Progress Note] 12/22/22 at 1:11 AM .Around 10PM resident was put into bed by 2 staff. MED (sp) Medication nurse stated that he was called by resident that one staff hit him in the head. When the nurse about to see if there is a bruise or any changes seen. Resident got upset and asked the nurse what she was looking for. Resident had behavior issue yesterday evening. The facility staff failed to show any documented evidence that the State Agency was notified within 2 hours of Resident #17's allegation of abuse and there is no evidence that the results of their investigation was submitted to the State Agency. During a face-to-face interview conducted on 04/24/23 at 5:10 PM, Employee #9 (Registered Nurse Charge Nurse) acknowledged the findings and stated I am not sure why that was not done and sometimes he reports things that don't happen. During a face-to-face interview conducted on 04/25/23 at approximately 12:00 PM, Employee #2 (Director of Nursing) stated that there was no follow-up investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, for one (1) of 22 sampled residents, facility staff failed to accurately code the resident's Minimum Data Set (MDS) assessment. Resident #17. The findings included: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side and Acquired Absence of Left Leg Above Knee. Review of the medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded that the resident required supervision with one-person physical assistance to walk in the room. During an observation on 04/19/23 at approximately 12:30 PM in the dining area, Resident #17 was seen sitting in a wheelchair and had a left above-the-knee amputation. During a face-to-face interview conducted on 04/24/23 at 3:17 PM, Employee #9 (Registered Nurse/Charge Nurse) stated that the resident has an above-the-knee amputation of the left leg and the resident does not use any artificial limb but does use a wheelchair to ambulate. During a face-to-face interview conducted on 04/25/23 at 1:15 PM, Employee #7 (MDS Coordinator) stated, That is a mistake, I accept that. Cross Reference 22B DCMR sec 3231.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, for one (1) of 22 sampled residents, facility staff failed to implement Resident #196's fall care plan approaches/interventions and subsequently the resident had a fall with injury on 11/18/21. The findings included: Resident #196 was admitted to the facility on [DATE] with multiple diagnoses that included: Parkinson's Disease, Other Abnormalities of Gait and Mobility, Dizziness and Giddiness, Pneumonia, Disorientation and Dementia. Review of Resident #196's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded: severely impaired cognition; required extensive assistance for bed mobility transfers, eating, toilet use, and personal hygiene. [Physician's Order] 11/09/21: Falls precautions every shift. Call lights and personal needs within reach, frequent rounds, bed in low position while in bed, every shift . [Physician's Order] 11/09/21: Floor mats to both sides of bed while in bed. Dx (diagnosis): Minimize injury every shift . A Falls Risk Assessment completed on 11/09/21 documented: .Mental Status- Intermittent Confusion; .Elimination Status - Regularly Incontinent .Gait/Balance/Ambulation- .Unable to Perform Function; Gait/Balance Normal - No; Balance Problem while Standing - Yes; Balance Problem while Walking - Yes .Fall Risk Score: 16.0 Level: High Risk. A review of a Care Plan initiated on 11/10/21 documented the following: Falls: Resident has potential for fall related to delusion/delirium, decreased orientation, unsteady gait/balance related to Parkinson .new to the rehab environment .Resident with actual fall on 11/18 . Approach: Call light within reach, personal items within reach, make frequent rounds . [Progress Note] dated 11/18/21 at 4:23 AM: On 11/18/2021 at around 03:15 am .heard voice calling for help. Resident .in a sitting position with head facing down [on] the floor . Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter) .conversive at this time and said [pronoun] was trying to reach [iPad]. [iPad] and fell. Voiced no pain at this time. Moving all extremities, able to stand with 2 (two) staff assist. [Physician's Name] notified via telephone conversation with orders to monitor and [if] any behavior changes, to transfer to ER [Emergency Room] for [e]valuation [POA ] updated . Questioned if we restraint resident. Made aware that this is not acceptable and only half side rails when in bed. Also mentioned what [Physician's Name] order[ed] and said [pronoun] agreed not to transfer to ER [Emergency Room] but monitor and if any behavior changes then transfer. Neuro checks initiated . Care Plan dated 11/22/21: Problem: Forehead laceration s/p (status post) fall .Approach: Apply treatment as ordered .Evaluation Notes: 11/22/2021: Resident fell on 11/18, around 3:15 am alarm .Resident sustained a forehead laceration 1.5 cm x 2 cm, saying he tried to reach for his iPad and consequently lost his balance and fell. A Facility Reported Incident (FRI), (DC00010404), dated 11/22/21 documented the following: On 11/18/2021 at around 03:15 am alarm sounded heard voice calling for help. Resident observed somewhat in a sitting position with head facing down [on] the floor near the bathroom door in his room with small amount of blood in the floor. Sustained laceration in [on] his forehead measuring 1.5 x 0.2 cm (centimeter). Resident .said .was trying to reach his [iPad] and fell .[POA ] updated .agreed not to transfer to ER [Emergency Room] . Review of Resident #196's medical record and the facility's administrative records lacked documented evidence that the facility implemented the Care Plan approach to, [place] call light within reach, personal items within reach, and make frequent rounds . The evidence showed that Resident #196's Ipad was not within reach subsequently when reaching for the Ipad the reseident fell. During a face-to-face interview on 04/24/23 at 3:49 PM, when asked what frequent monitoring meant, Employee #8 (Registered Nurse/Charge Nurse) stated that frequent monitoring for Resident #196 meant, One hour, I would go and check on the resident and the next hour the CNA would check on the resident to see if anything was needed. I wouldn't write anything down, but we (Nurse and CNA) would give each other a verbal report. During a face-to-face interview on 04/25/23 at 12:01 PM, Employee #2 (Director of Nursing) stated that there were no hourly monitoring sheets for Resident #196 in the Resident's medical record. Cross-reference 22B DCMR Sec. 3210.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, for one (1) of 22 sampled residents, facility staff failed to ensure that respiratory treatment was provided to Resident #4 in accordance with the physician's order. The findings included: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Congestive Heart Failure, and Morbid Obesity. Care plan dated 09/05/22 documented: Respiratory . requires use of oxygen therapy continuously due to chronic respiratory failure. Approach . staff will check vital signs, administer oxygen and breathing treatment as ordered and report to physician. [Physician's Order] 12/01/22: Oxygen at 5 L (liters)/min (minutes) via nasal cannula continuously every shift. Diagnosis: SOB (shortness of breath) every shift . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having intact cognition and requiring oxygen therapy. During a unit tour on 04/20/23 at 11:34 AM, Resident #4 was observed asleep in bed, receiving supplemental oxygen via nasal cannula, with the oxygen concentrator set at 6 liters per minute. During a second observation and face-to-face interview on 04/20/23 at 4:05 PM, Resident #4 was observed sitting in a wheelchair next to the bed. The resident was receiving oxygen via nasal cannula that was connected to a portable oxygen tank, hanging on the back of the resident's wheelchair. The oxygen level set at 4 liters per minute. The resident stated that they had just returned to the room and was waiting to be assisted back in bed. At that time, Employee #9 (Registered Nurse/RN) entered the room. The surveyor asked Employee #9 how many liters of oxygen Resident #4 is ordered to be on, the employee stated, The physician's order for the resident's oxygen is 5 liters per minute. Employee #9 was shown that the resident was currently on 4 liters and the concentrator at the bedside, was still observed to be at 6 liters. Employee #9 acknowledged the findings and adjusted the oxygen concentrator and oxygen tank levels to 5 liters of oxygen per minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, for one (1) of 22 sampled residents, facility staff failed to ensure that Resident #16 received pain management that was consistent with the standards practice. The findings included: Resident #16 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction, Hemiplegia, affecting Left Dominant Side, Dysphagia, Dementia with Behavioral Disturbances, Anxiety, and Depression. Review of Resident #16's medical record revealed the following: an Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded: severely impaired cognition; visual and hearing impairment; on a scheduled pain medication regimen; and having a life expectancy of less than six months. A Care plan initiated 06/17/22 documented, [Resident #16] is risk for pain related to generalized arthritis, new stroke with left side hemiplegia, decreased functional mobility, and peripheral neuropathy. Goal: [Resident #16] c/o (complaint of) pain will be alleviated within 30-45 minutes after intervention has been provided as evidenced by no expression of pain or discomfort . Approach: Administer pain medications as ordered and monitor for side effect and effectiveness .Assist and encourage resident to position for comfort, use distraction strategies .Complete pain assessment every shift and as needed per facility protocol. A Physician's Order dated 08/04/22 documented, Morphine (narcotic pain reliever) concentrate - Schedule II solution; 100mg/5 ml (20 mg/ml) amt; 0.25 ml (5 mg); oral. Special instructions: Give 0.25 ml (5 mg) po (by mouth) q 6 hrs (hours) prn (as needed) for pain /dyspnea (difficulty breathing)/RR (respiratory rate) greater than 20 br (breaths)/min (minute). Every 6 hours - prn . [Progress Note] 04/20/23 at 3:46 AM: Calling out loud help, help for no apparent (sp) reason . Breathing non-labored. Morphine given sublingual as ordered at this time. Will monitor for effectiveness. A review of the Medication Administration Record (MAR) dated from 04/01/23 to 04/21/23 documented that facility staff administered Morphine to Resident #16 in the following manner: 04/01/23 at 8:59 PM, for pain, effective 04/02/23 at 6:59 PM for pain, effective 04/05 at 1:39 PM for pain and at 10:05 PM for pain, effective 04/06/23 at 4:33 PM for pain, effective 04/07/23 at 2:55 AM for a behavior issue, effective 04/10/23 at 7:08 PM for pain, effective 04/15/23 at 1:18 AM for a behavior issue, effective 04/16/ at 11:03 AM for pain, effective 04/18/23 at 2:27 AM for other reason, effective 04/19/23 at 10:56 AM for pain, effective 04/20/23 at 3:46 AM for behavior issue, effective 04/20/23 at 10:52 PM for pain, effective. Resident #16's MAR revealed that facility staff documented that for 9 out of 20 days when they administered Morphine to the resident for pain, it was effective. However, there was no documented evidence that facility staff completed a pain assessment before or after administration in order to determine if the medication was effective. The MAR also revealed that facility staff administered Morphine to the resident for behavior issue not pain as indicated. During a face-to-face interview on 04/25/23 at 10:41 AM Employee #2 (Director of Nursing) stated for the prn (as needed) medications there is no option for a pain scale. There is no place to write a number for a pain rating. She then acknowledged that there was no way to determine if the medication was effective or not without a pain rating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, for two (2) of 22 sampled residents, facility staff failed to maintain Standards of Infection Control Practices when assisting the residents with their meals in the common dining area. Residents' #17 and #21. The findings included: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side and Acquired Absence of Left Leg Above Knee. A review of Resident #17's Significant Change Minimum Data Set (MDS) dated [DATE], showed that the resident required supervision and set up help when eating. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Heart Failure and Dysphagia. A review of Resident #21's Quarterly Minimum Data Set (MDS) dated [DATE], showed that the resident required extensive assistance with a one person physical assist for eating. During an observation on 04/19/23 at 12:43 PM, the Surveyor observed Employee #6 (Certified Nurse Aide) assisting Resident #21 to eat. Employee #6 was observed sitting beside Resident #21 and feeding the resident food from the resident's tray. Once Employee #6 was finished feeding the resident, she removed the resident's tray and then walked over to the table where Resident #17 was seated. Employee #6 lifted the lid off the meal tray and was about to proceed with assisting Resident #17 but was stopped by the surveyor. During a face-to-face interview at the time of observation, when asked why she did not perform hand hygiene between providing feeding assistance to the two residents, Employee #6 stated, I will go and wash my hands now. Cross Reference 22B DCMR sec 3217.6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility staff failed to provide care and services that met the professional standards of quality and practice as evidenced by one facility staff administering expired Influenza vaccines to ten (10) of 22 sampled residents. Residents' #11, #14, #22, #25, #27, #29, #31, #33, #35, and #44. The findings included: Review of a document provided by the facility titled, Medication Expiration and Beyond Use Dating dated 04/06/17 documented, Medications will be discarded according to .expiration date or according to the manufacturer's expiration date . Review of the facility policy Medication Administration - Guidelines for All Medications with a revised date of 06/01/22 directed, . Check expiration date on package/container . read medication label three times before pouring . after administration, return to cart and document administration in the MAR (medication administration record) . Sanofi, manufacturer of the Fluzone (influenza) vaccine, specifies, .Do not use after the expiration date shown on the label . https://www.sanofiflu.com/fluzone-quadrivalent-influenza-vaccine/ A Facility Reported Incident (FRI), DC00011037, received by the State Agency on 10/17/22 documented, Resident[s] received expired Fluzone Vaccine 0.7 ML (milliliters) in error on 10/17/2022 . 1. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Dementia and Hypertension. A FRI, DC00011052, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #11's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:35 PM [Nursing Progress Note] . T (temperature) -96.4 [degrees Fahrenheit] .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #11's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:56 PM [Nursing Progress Note] .Upon assessment no flu like sx (symptoms) noted. Temp 97.6, followed with Fluzone high-dose 0.7 ML vaccine administer to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & (and) EXP (expiration) date: 6/30/2023 . 2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included: Psychotic Disorder with Delusion, Vascular Dementia with Behavioral Disturbance, Insomnia and Hypertension. A FRI, DC00011054, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #14's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: moderately impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:37 PM [Nursing Progress Note] .T-96.9 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #14's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 1:58 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 3. Resident #22 Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia with Behavioral Disturbance, Alzheimer's Disease and Spinal Stenosis. A FRI, DC00011048, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #22's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:04 PM [Nursing Progress Note] .T-96.8 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #22's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:16 PM [Nursing Progress Note] .Staff obtained temperature 97.4 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 4. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuromuscular Dysfunction of Bladder, Nonrheumatic Mitral (valve) Insufficiency, Heart Failure and Cerebral Infarction. A FRI, DC00011046, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #25's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 1:48 PM [Nursing Progress Note] .T-96.7 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current [influenza] vaccine Fluzone hiogh (sp) -dose 0.7 ML IM when available. Writer informed POA (power of attorney) . Review of Resident #25's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:38 PM [Nursing Progress Note] . TEMP 97.8 . Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 5. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease and Dementia. A FRI, DC00011050, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #27's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 10, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:07 PM [Nursing Progress Note] . T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #27's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:45 PM [Nursing Progress Note] .Temp 97.6 followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 6. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included: Atrial Fibrillation, Essential (primary) Hypertension and Hyperlipidemia. A FRI, DC00011049, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #29's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:09 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #29's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:48 PM [Nursing Progress Note] .Temp 98.4 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 7. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Peripheral Vascular Disease and Unspecified Dementia. A FRI, DC00011051, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #31's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating cognitively intact; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 2:26 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #31's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:52 PM [Nursing Progress Note] Temp 97.4 . followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 8. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Moderate, Behavioral Disturbance; Major Depressive Disorder, Psychotic Disorder with Delusions; Anxiety Disorder and Personality Disorder. A FRI, DC00011047, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #33's medical record revealed the following: A physician's order dated 12/10/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 05, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 1:53 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #33's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:42 PM [Nursing Progress Note] .Temp 97.3 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 9. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Severe, with Psychotic Disturbance; Bipolar Disorder, Hypertension, Restlessness and Agitation. A FRI, DC00011053, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #35's medical record revealed the following: A physician's order dated 11/04/21 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:32 PM [Nursing Progress Note] .T-97.1 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #35's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:13 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 10. Resident #44 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, heart Failure, Hemiplegia and Hemiparesis. A FRI, DC00011045, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #44's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/08/21. 10/17/22 at 1:39 PM [Nursing Progress Note] .T-97.0 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current flu vaccine Fluzone high-dose 0.7 ML IM when available. Writer informed POA . Review of Resident #44's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:35 PM [Nursing Progress Note] .Temp 97.7 . Fluzone high-dose 0.7 ML administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . Review of email correspondences provided to this surveyor on 04/21/23 documented the following: From: [Employee #3 (Infection Preventionist)], sent: Wednesday, October 5, 2022 [at] 12:18 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . Thank you for our supply of High Dose Flu Vaccines. Please help me understand the dates on these vaccines as I am a bit confused. On each box there is the number uj765AB and date 30 June 22 . Are these vaccines safe to use . Pleas clarify . From: (Name of pharmacy presentative), sent: Wednesday, October 5, 2022 [at] 12:54 PM, to: [Employee #3, subject: RE Flu vaccine supply . Those would not be this years and should not be used .Can you please have nursing send the ones you have back with the driver . I've informed our inventory team and they are going to submit an incident report to our wholesaler . From: Employee #3, sent: Wednesday, October 5, 2022 [at] 2:15 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . this is very concerning. I prepared the vaccines for pick-up tonight. Please ensure that your driver takes them. We are under survey window and could be sited for so many expired medications on the premises . From: (Name of pharmacy presentative), sent: Thursday, October 6, 2022 [at] 11:54 AM, to: Employee #3, subject: RE Flu vaccine supply . Just confirming that we did deliver the 2033-2023 flu vaccine and picked up the previously delivered . From: Employee #3, sent: Thursday, October 6, 2022 [at] 2:58 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . [NAME] that. Vaccines were picked up and delivered. Thanks. A face-to-face interview was conducted on 04/21/23 at 1:31 PM with Employee #2 (Director of Nursing/DON) and Employee #4 (Licensed Practical Nurse/LPN who administered the expired vaccines). Employee #4 stated, The vaccines are individual doses of 0.7 ml and come in a box of ten. That day (10/17/22), I went and got the vaccines from the HSC (health services center) refrigerator. I work on the SCC (special care center) side. I saw the vaccines in a plastic bag and took out a box of ten. I should have double checked the dates then but I didn't. I was not aware that any expired vaccines had been delivered. After checking the resident's temperatures, I went to each resident's room and administered them the vaccine and then came to the computer to document. When asked why she did not document in each resident's chart after administering the vaccine, Employee #4 stated, I know I am supposed to sign it (the MAR) on or right after administration. I didn't do it. That's my fault. Employee #4 continued to say, When I went to document, I clicked on 'administer', a box comes up that prompts you to input the lot number, site and expiration date. That's when I realized that the vaccines I just administered (10 in total) had expired. I immediately made my DON aware. When asked if she followed the standards of professional practice for medication administration, Employee #4 stated, No. The evidence showed that facility staff failed to provide care and services that met the professional standards of quality and practice and to follow the facility's policy for medication administration by: 1. Not checking vaccine expiration dates prior to administration 2. Not documenting in each resident's MAR after each individual vaccine administration. Subsequently, on 10/17/22, Employee #4 (LPN) administered Influenza vaccines with an expiration date of 06/30/22 to ten residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. Facility staff failed to follow a physician's order to administer Resident #16's medication Morphine (Opiate Narcotic Analgesic) for pain as evidenced by the nurse documenting that the morphine was administered for behavior. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Cerebral Infarction, Hemiplegia, affecting Left Dominant Side, Dysphagia, Dementia with Behavioral Disturbances, Anxiety, and Depression. A review of the medical record revealed the following: A review of Resident #16's Face Sheet noted that the Resident was in hospice. An admission Minimum Data Set (MDS) dated [DATE] showed that the facility staff coded the resident as having severely impaired cognition, having visual and hearing impairment, being on a scheduled pain medication regimen, and having a life expectancy of less than six months. [Physician's Order] 11/19/22: Trazodone (Antidepressant) tablet; 50 mg; ant ½ tab = 25 mg: oral Special Instructions: Take1/2 tab= 25 mg po bis (twice a day) for Anxiety Twice a day;0 9:00 AM, 09: PM [Physician's Order] 06/15/22: Bupropion (Antidepressant) HCL tablet; 75 mg; amt (amount):1 tablet; oral Special Instructions Dx: Mood Once a morning; 06:00 AM A Care Plan initiated on 06/17/22 documented the following: [Resident #16] is risk for pain related to generalized arthritis, new stroke with left side hemiplegia, decreased functional mobility, and peripheral neuropathy. Goal: [Resident #16] c/o (complaint of) pain will be alleviated within 30-45 minutes after intervention has been provided as evidenced by no expression of pain or discomfort through next review. Approach: Administer pain medications as ordered and monitor for side effect and effectiveness.Assist and encourage resident to position for comfort, use distraction strategies such as watching TV, listening to music, reading and 1:1 visit .Complete pain assessment every shift and as needed per facility protocol. [Physician's Order] 08/04/22: Morphine concentrate (Opiate Narcotic, Analgesics.) schedule II solution; 100mg/5 ml (20 mg/ml) amt ; 0.25 ml (5 mg); oral. Special instructions: Give 0.25 ml (5 mg) po (by mouth) q 6 hrs (hours) prn (as needed) for pain /dyspnea (difficulty breathing)/RR(respiratory rate) greater than 20 br (breaths)/min (minute). Every 6 hours - prn . [Physician's Order] 08/24/22: Ativan (Lorazepam) - Schedule IV tablet; 0.5 mg; amt: 1 tab oral. Special Instructions: Give 1 tab po q 4 hrs prn for restlessness/anxiety, Every 4 hours . [Progress Note] 04/20/23 at 3:46 AM: Calling out loud Help, Help for no apparent (sp ) (apparent) reason .Breathing non-labored. Morphine given sublingual as ordered at this time . Will monitor for effectiveness. A Medication Administration Record (MAR) from 04/01/23 to 04/21/23 documented that facility staff administered Morphine to Resident #16 in the following manner: 04/01/23 at 8:59 PM, for pain. 04/02/23 at 6:59 PM for pain. 04/05 at 1:39 PM for pain and at 10:05 PM for pain. 04/06/23 at 4:33 PM for pain. 04/07/23 at 2:55 AM for a behavior issue. 04/10/23 at 7:08 PM for pain. 04/15/23 at 1:18 AM for a behavior issue. 04/16/ at 11:03 AM for pain. 04/18/23 at 2:27 AM for other reason. 04/19/23 at 10:56 AM for pain. 04/20/23 at 3:46 AM for behavior issue. 04/20/23 at 10:52 PM for pain, effective. A review of Resident #16's MAR revealed that for 3 out of 20 days Employee #8 (Registered Nurse Charge Nurse) administered Morphine to the Resident for a behavior issue and for 1 out of 20 days another facility staff administered Morphine for other reason. During a face-to-face interview conducted on 04/25/23 at 2:03 PM, Employee #8 stated, The morphine order is for pain. When the Resident kept calling out loudly in the middle of the night, or when the daughter was present and would ask if we could give pain medication to the Resident, we gave morphine. The Resident has dementia and has no way to describe pain. The Resident could not give me that answer. I documented that the medication was given for a behavior because the resident was crying out loud in the middle of the night, 'Help, Help, my leg, my leg.' To me that was a behavior. The surveyor asked if the Resident had other medication that could be administered for behaviors. The Employee acknowledged that the Resident had Ativan for anxiety and made no further comment. Cross Reference 3211.1 (a) Based on record review and staff interview, facility staff failed to ensure residents received treatment and care in accordance with the professional standards of practice for elevan (11) of 22 sampled residents as evidenced by one facility staff administering expired Influenza vaccines to 10 residents and failing to administer one residents pain medications as indicated and prescribed by the provider. Residents' #11, #14, #22, #25, #27, #29, #31, #33, #35, #44, and #16. The findings included: Review of a document provided by the facility titled, Medication Expiration and Beyond Use Dating dated 04/06/17 documented, Medications will be discarded according to .expiration date or according to the manufacturer's expiration date . Review of the facility policy Medication Administration - Guidelines for All Medications with a revised date of 06/01/22 directed, . Check expiration date on package/container . read medication label three times before pouring . after administration, return to cart and document administration in the MAR (medication administration record) . Sanofi, manufacturer of the Fluzone (influenza) vaccine, specifies, .Do not use after the expiration date shown on the label . https://www.sanofiflu.com/fluzone-quadrivalent-influenza-vaccine/ A Facility Reported Incident (FRI), DC00011037, received by the State Agency on 10/17/22 documented, Resident[s] received expired Fluzone Vaccine 0.7 ML (milliliters) in error on 10/17/2022 . 1. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Dementia and Hypertension. A FRI, DC00011052, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #11's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:35 PM [Nursing Progress Note] . T (temperature) -96.4 [degrees Fahrenheit] .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #11's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:56 PM [Nursing Progress Note] .Upon assessment no flu like sx (symptoms) noted. Temp 97.6, followed with Fluzone high-dose 0.7 ML vaccine administer to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & (and) EXP (expiration) date: 6/30/2023 . 2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included: Psychotic Disorder with Delusion, Vascular Dementia with Behavioral Disturbance, Insomnia and Hypertension. A FRI, DC00011054, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #14's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: moderately impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:37 PM [Nursing Progress Note] .T-96.9 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #14's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 1:58 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 3. Resident #22 Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia with Behavioral Disturbance, Alzheimer's Disease and Spinal Stenosis. A FRI, DC00011048, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #22's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:04 PM [Nursing Progress Note] .T-96.8 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #22's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:16 PM [Nursing Progress Note] .Staff obtained temperature 97.4 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 4. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuromuscular Dysfunction of Bladder, Nonrheumatic Mitral (valve) Insufficiency, Heart Failure and Cerebral Infarction. A FRI, DC00011046, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #25's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 1:48 PM [Nursing Progress Note] .T-96.7 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current [influenza] vaccine Fluzone hiogh (sp) -dose 0.7 ML IM when available. Writer informed POA (power of attorney) . Review of Resident #25's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:38 PM [Nursing Progress Note] . TEMP 97.8 . Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 5. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease and Dementia. A FRI, DC00011050, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #27's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 10, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:07 PM [Nursing Progress Note] . T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #27's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:45 PM [Nursing Progress Note] .Temp 97.6 followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 6. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included: Atrial Fibrillation, Essential (primary) Hypertension and Hyperlipidemia. A FRI, DC00011049, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #29's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:09 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #29's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:48 PM [Nursing Progress Note] .Temp 98.4 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 7. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Peripheral Vascular Disease and Unspecified Dementia. A FRI, DC00011051, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #31's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating cognitively intact; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 2:26 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #31's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:52 PM [Nursing Progress Note] Temp 97.4 . followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 8. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Moderate, Behavioral Disturbance; Major Depressive Disorder, Psychotic Disorder with Delusions; Anxiety Disorder and Personality Disorder. A FRI, DC00011047, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #33's medical record revealed the following: A physician's order dated 12/10/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 05, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 1:53 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #33's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:42 PM [Nursing Progress Note] .Temp 97.3 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 9. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Severe, with Psychotic Disturbance; Bipolar Disorder, Hypertension, Restlessness and Agitation. A FRI, DC00011053, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #35's medical record revealed the following: A physician's order dated 11/04/21 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:32 PM [Nursing Progress Note] .T-97.1 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #35's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:13 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 10. Resident #44 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, heart Failure, Hemiplegia and Hemiparesis. A FRI, DC00011045, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #44's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/08/21. 10/17/22 at 1:39 PM [Nursing Progress Note] .T-97.0 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current flu vaccine Fluzone high-dose 0.7 ML IM when available. Writer informed POA . Review of Resident #44's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:35 PM [Nursing Progress Note] .Temp 97.7 . Fluzone high-dose 0.7 ML administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . Review of email correspondences provided to this surveyor on 04/21/23 documented the following: From: [Employee #3 (Infection Preventionist)], sent: Wednesday, October 5, 2022 [at] 12:18 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . Thank you for our supply of High Dose Flu Vaccines. Please help me understand the dates on these vaccines as I am a bit confused. On each box there is the number uj765AB and date 30 June 22 . Are these vaccines safe to use . Pleas clarify . From: (Name of pharmacy presentative), sent: Wednesday, October 5, 2022 [at] 12:54 PM, to: [Employee #3, subject: RE Flu vaccine supply . Those would not be this years and should not be used .Can you please have nursing send the ones you have back with the driver . I've informed our inventory team and they are going to submit an incident report to our wholesaler . From: Employee #3, sent: Wednesday, October 5, 2022 [at] 2:15 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . this is very concerning. I prepared the vaccines for pick-up tonight. Please ensure that your driver takes them. We are under survey window and could be sited for so many expired medications on the premises . From: (Name of pharmacy presentative), sent: Thursday, October 6, 2022 [at] 11:54 AM, to: Employee #3, subject: RE Flu vaccine supply . Just confirming that we did deliver the 2033-2023 flu vaccine and picked up the previously delivered . From: Employee #3, sent: Thursday, October 6, 2022 [at] 2:58 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . [NAME] that. Vaccines were picked up and delivered. Thanks. A face-to-face interview was conducted on 04/21/23 at 1:31 PM with Employee #2 (Director of Nursing/DON) and Employee #4 (Licensed Practical Nurse/LPN who administered the expired vaccines). Employee #4 stated, The vaccines are individual doses of 0.7 ml and come in a box of ten. That day (10/17/22), I went and got the vaccines from the HSC (health services center) refrigerator. I work on the SCC (special care center) side. I saw the vaccines in a plastic bag and took out a box of ten. I should have double checked the dates then but I didn't. I was not aware that any expired vaccines had been delivered. After checking the resident's temperatures, I went to each resident's room and administered them the vaccine and then came to the computer to document. When asked why she did not document in each resident's chart after administering the vaccine, Employee #4 stated, I know I am supposed to sign it (the MAR) on or right after administration. I didn't do it. That's my fault. Employee #4 continued to say, When I went to document, I clicked on 'administer', a box comes up that prompts you to input the lot number, site and expiration date. That's when I realized that the vaccines I just administered (10 in total) had expired. I immediately made my DON aware. When asked if she followed the standards of professional practice for medication administration, Employee #4 stated, No. The evidence showed that facility staff failed to ensure residents received treatment and care in accordance with the professional standards of practice for medication administration by: 1. Not checking vaccine expiration dates prior to administration 2. Not documenting in each resident's MAR after each individual vaccine administration. Subsequently, on 10/17/22, Employee #4 (LPN) administered Influenza vaccines with an expiration date of 06/30/22 to ten residents. Cross Reference: 22B DCMR sec 3211.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility staff failed to ensure residents were free of medication errors as evidenced by the administration of expired Influenza vaccines to ten (10) of 22 sampled residents. Residents' #11, #14, #22, #25, #27, #29, #31, #33, #35, and #44. The findings included: Review of a document provided by the facility titled, Medication Expiration and Beyond Use Dating dated 04/06/17 documented, Medications will be discarded according to .expiration date or according to the manufacturer's expiration date . Review of the facility policy Medication Administration - Guidelines for All Medications with a revised date of 06/01/22 directed, . Check expiration date on package/container . read medication label three times before pouring . after administration, return to cart and document administration in the MAR (medication administration record) . Sanofi, manufacturer of the Fluzone (influenza) vaccine, specifies, .Do not use after the expiration date shown on the label . https://www.sanofiflu.com/fluzone-quadrivalent-influenza-vaccine/ A Facility Reported Incident (FRI), DC00011037, received by the State Agency on 10/17/22 documented, Resident[s] received expired Fluzone Vaccine 0.7 ML (milliliters) in error on 10/17/2022 . 1. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Dementia and Hypertension. A FRI, DC00011052, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #11's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:35 PM [Nursing Progress Note] . T (temperature) -96.4 [degrees Fahrenheit] .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #11's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:56 PM [Nursing Progress Note] .Upon assessment no flu like sx (symptoms) noted. Temp 97.6, followed with Fluzone high-dose 0.7 ML vaccine administer to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & (and) EXP (expiration) date: 6/30/2023 . 2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included: Psychotic Disorder with Delusion, Vascular Dementia with Behavioral Disturbance, Insomnia and Hypertension. A FRI, DC00011054, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #14's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: moderately impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:37 PM [Nursing Progress Note] .T-96.9 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . Review of Resident #14's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 1:58 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 3. Resident #22 Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia with Behavioral Disturbance, Alzheimer's Disease and Spinal Stenosis. A FRI, DC00011048, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #22's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:04 PM [Nursing Progress Note] .T-96.8 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #22's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:16 PM [Nursing Progress Note] .Staff obtained temperature 97.4 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 4. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuromuscular Dysfunction of Bladder, Nonrheumatic Mitral (valve) Insufficiency, Heart Failure and Cerebral Infarction. A FRI, DC00011046, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #25's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 1:48 PM [Nursing Progress Note] .T-96.7 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current [influenza] vaccine Fluzone hiogh (sp) -dose 0.7 ML IM when available. Writer informed POA (power of attorney) . Review of Resident #25's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:38 PM [Nursing Progress Note] . TEMP 97.8 . Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 5. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease and Dementia. A FRI, DC00011050, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #27's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 10, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:07 PM [Nursing Progress Note] . T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #27's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:45 PM [Nursing Progress Note] .Temp 97.6 followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 6. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included: Atrial Fibrillation, Essential (primary) Hypertension and Hyperlipidemia. A FRI, DC00011049, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #29's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:09 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #29's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:48 PM [Nursing Progress Note] .Temp 98.4 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 7. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Peripheral Vascular Disease and Unspecified Dementia. A FRI, DC00011051, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #31's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating cognitively intact; and that the Influenza vaccine was last received on 10/05/21. 10/17/22 at 2:26 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #31's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:52 PM [Nursing Progress Note] Temp 97.4 . followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 8. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Moderate, Behavioral Disturbance; Major Depressive Disorder, Psychotic Disorder with Delusions; Anxiety Disorder and Personality Disorder. A FRI, DC00011047, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #33's medical record revealed the following: A physician's order dated 12/10/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 05, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 1:53 PM [Nursing Progress Note] .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #33's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:42 PM [Nursing Progress Note] .Temp 97.3 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 9. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Severe, with Psychotic Disturbance; Bipolar Disorder, Hypertension, Restlessness and Agitation. A FRI, DC00011053, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #35's medical record revealed the following: A physician's order dated 11/04/21 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. 10/17/22 at 2:32 PM [Nursing Progress Note] .T-97.1 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #35's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/25/22 at 2:13 PM [Nursing Progress Note] .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . 10. Resident #44 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, heart Failure, Hemiplegia and Hemiparesis. A FRI, DC00011045, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #44's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/08/21. 10/17/22 at 1:39 PM [Nursing Progress Note] .T-97.0 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current flu vaccine Fluzone high-dose 0.7 ML IM when available. Writer informed POA . Review of Resident #44's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. 10/27/22 at 12:35 PM [Nursing Progress Note] .Temp 97.7 . Fluzone high-dose 0.7 ML administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . Review of email correspondences provided to this surveyor on 04/21/23 documented the following: From: [Employee #3 (Infection Preventionist)], sent: Wednesday, October 5, 2022 [at] 12:18 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . Thank you for our supply of High Dose Flu Vaccines. Please help me understand the dates on these vaccines as I am a bit confused. On each box there is the number uj765AB and date 30 June 22 . Are these vaccines safe to use . Pleas clarify . From: (Name of pharmacy presentative), sent: Wednesday, October 5, 2022 [at] 12:54 PM, to: [Employee #3, subject: RE Flu vaccine supply . Those would not be this years and should not be used .Can you please have nursing send the ones you have back with the driver . I've informed our inventory team and they are going to submit an incident report to our wholesaler . From: Employee #3, sent: Wednesday, October 5, 2022 [at] 2:15 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . this is very concerning. I prepared the vaccines for pick-up tonight. Please ensure that your driver takes them. We are under survey window and could be sited for so many expired medications on the premises . From: (Name of pharmacy presentative), sent: Thursday, October 6, 2022 [at] 11:54 AM, to: Employee #3, subject: RE Flu vaccine supply . Just confirming that we did deliver the 2033-2023 flu vaccine and picked up the previously delivered . From: Employee #3, sent: Thursday, October 6, 2022 [at] 2:58 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . [NAME] that. Vaccines were picked up and delivered. Thanks. A face-to-face interview was conducted on 04/21/23 at 1:31 PM with Employee #2 (Director of Nursing/DON) and Employee #4 (Licensed Practical Nurse/LPN who administered the expired vaccines). Employee #4 stated, The vaccines are individual doses of 0.7 ml and come in a box of ten. That day (10/17/22), I went and got the vaccines from the HSC (health services center) refrigerator. I work on the SCC (special care center) side. I saw the vaccines in a plastic bag and took out a box of ten. I should have double checked the dates then but I didn't. I was not aware that any expired vaccines had been delivered. After checking the resident's temperatures, I went to each resident's room and administered them the vaccine and then came to the computer to document. When asked why she did not document in each resident's chart after administering the vaccine, Employee #4 stated, I know I am supposed to sign it (the MAR) on or right after administration. I didn't do it. That's my fault. Employee #4 continued to say, When I went to document, I clicked on 'administer', a box comes up that prompts you to input the lot number, site and expiration date. That's when I realized that the vaccines I just administered (10 in total) had expired. I immediately made my DON aware. When asked if she followed the standards of professional practice for medication administration, Employee #4 stated, No. The evidence showed that facility staff failed to ensure residents were free of medication errors by: 1. Not administering the Influenza vaccine in accordance to the manufacture's specifications, . Do not use after the expiration date shown on the label . 2. Not checking vaccine expiration dates prior to administration 3. Not documenting in each resident's MAR after each individual vaccine administration. Subsequently, on 10/17/22, Employee #4 (LPN) administered Influenza vaccines with an expiration date of 06/30/22 to ten residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for ten (10) of 22 sampled residents, facility staff stored expired Influenza vaccines for use. Subsequently, on 10/17/22, these expired vaccines were administered to ten residents. (Residents' #11, #14, #22, #25, #27, #29, #31, #33, #35, and #44.) The findings included: Review of a document provided by the facility titled, Medication Expiration and Beyond Use Dating dated 04/06/17 documented, Medications will be discarded according to .expiration date or according to the manufacturer's expiration date . Review of the facility policy Medication Administration - Guidelines for All Medications with a revised date of 06/01/22 directed, . Check expiration date on package/container . read medication label three times before pouring . after administration, return to cart and document administration in the MAR (medication administration record) . Sanofi, manufacturer of the Fluzone (influenza) vaccine, specifies, .Do not use after the expiration date shown on the label . https://www.sanofiflu.com/fluzone-quadrivalent-influenza-vaccine/ A Facility Reported Incident (FRI), DC00011037, received by the State Agency on 10/17/22 documented, Resident[s] received expired Fluzone Vaccine 0.7 ML (milliliters) in error on 10/17/2022 . A. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Dementia and Hypertension. Review of Resident #11's medical record revealed a physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. A Nursing Progress Note dated 10/17/22 at 2:35 PM documented, . T (temperature) -96.4 [degrees Fahrenheit] .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . A FRI, DC00011052, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #11's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. A 10/27/22 at 12:56 PM [Nursing Progress Note] revealed, .Upon assessment no flu like sx (symptoms) noted. Temp 97.6, followed with Fluzone high-dose 0.7 ML vaccine administer to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & (and) EXP (expiration) date: 6/30/2023 . B. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included: Psychotic Disorder with Delusion, Vascular Dementia with Behavioral Disturbance, Insomnia and Hypertension. Review of Resident #14's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine. A Quarterly minimum data set (MDS) assessment dated [DATE] showed facility staff coded: moderately impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 2:37 PM [Nursing Progress Note] documented, .T-96.9 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA (power of attorney). Resident is not showing any adverse reaction at this time . A FRI, DC00011054, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #14's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. A 10/25/22 at 1:58 PM [Nursing Progress Note] revealed, .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . C. Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia with Behavioral Disturbance, Alzheimer's Disease and Spinal Stenosis. Review of Resident #22's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 2:04 PM [Nursing Progress Note] documented, .T-96.8 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . Review of Resident #22's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. A FRI, DC00011048, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM (intramuscular) with expiration date 6/30/22. V/S (vital signs) stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of a 10/25/22 at 2:16 PM [Nursing Progress Note] revealed, .Staff obtained temperature 97.4 prior to administering Fluzone high-dose 0.7 ML IM to L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . D. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuromuscular Dysfunction of Bladder, Nonrheumatic Mitral (valve) Insufficiency, Heart Failure and Cerebral Infarction. Review of Resident #25's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine. A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/05/21. A 10/17/22 at 1:48 PM [Nursing Progress Note] documented, .T-96.7 . Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current [influenza] vaccine Fluzone hiogh (sp) -dose 0.7 ML IM when available. Writer informed POA (power of attorney) . A FRI, DC00011046, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #25's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:38 PM [Nursing Progress Note] revealed, . TEMP 97.8 . Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . E. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease and Dementia. Review of Resident #27's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 10, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 2:07 PM [Nursing Progress Note] documented, . T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . A FRI, DC00011050, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #27's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:45 PM [Nursing Progress Note] revealed, .Temp 97.6 followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . F. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included: Atrial Fibrillation, Essential (primary) Hypertension and Hyperlipidemia. Review of Resident #29's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 09, indicating moderately impaired cognition; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 2:09 PM [Nursing Progress Note] documented, .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . A FRI, DC00011049, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #29's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:48 PM [Nursing Progress Note] revealed, .Temp 98.4 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . G. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Peripheral Vascular Disease and Unspecified Dementia. Review of Resident #31's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating cognitively intact; and that the Influenza vaccine was last received on 10/05/21. A 10/17/22 at 2:26 PM [Nursing Progress Note] documented, .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . A FRI, DC00011051, received by the state agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #31's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:52 PM [Nursing Progress Note] documented, Temp 97.4 . followed with Fluzone high-dose 0.7 ML vaccine administer IM to L/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . H. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Moderate, Behavioral Disturbance; Major Depressive Disorder, Psychotic Disorder with Delusions; Anxiety Disorder and Personality Disorder. Review of Resident #33's medical record revealed the following: A physician's order dated 12/10/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 05, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 1:53 PM [Nursing Progress Note] documented, .T-96.4 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . A FRI, DC00011047, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #33's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:42 PM [Nursing Progress Note] revealed, .Temp 97.3 .followed with Fluzone high-dose 0.7 ML vaccine administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . I. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Dementia, Severe, with Psychotic Disturbance; Bipolar Disorder, Hypertension, Restlessness and Agitation. Review of Resident #35's medical record revealed the following: A physician's order dated 11/04/21 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: severely impaired cognitive skills for daily decision making; and that the Influenza vaccine was last received on 10/04/21. A 10/17/22 at 2:32 PM [Nursing Progress Note] documented, .T-97.1 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor) and order given to monitor resident for fever > 99.5 for x 1 week. If no fever administer current high-dose Fluzone vaccine 0.7 ML IM after monitoring period. Writer informed POA. Resident is not showing any adverse reaction at this time . A FRI, DC00011053, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #35's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/25/22 at 2:13 PM [Nursing Progress Note] revealed, .Obtained temperature 97.5 prior to administering Fluzone high-dose 0.7 ML IM L/deltoid this shift. Staff to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . J. Resident #44 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, heart Failure, Hemiplegia and Hemiparesis. Review of Resident #44's medical record revealed the following: A physician's order dated 10/08/20 that directed, Influenza vaccine annually between October and April. Check temperature (temp) prior to vaccine if temp > (greater than) 100 [degrees Fahrenheit], hold vaccine A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; and that the Influenza vaccine was last received on 10/08/21. A 10/17/22 at 1:39 PM [Nursing Progress Note] documented, .T-97.0 .Resident received Fluzone vaccine 0.7 ML IM to L (left)/deltoid with expiration date 6/30/2022 in error. ADON (Assistant Director of Nursing) notified MD (medical doctor). MD indicated that resident could received current flu vaccine Fluzone high-dose 0.7 ML IM when available. Writer informed POA . A FRI, DC00011045, received by the State Agency on 10/19/22 documented, On 10/17/2022, around 7:30 am: resident received Fluzone vaccine 0.7ml IM with Expiration date 6/30/22. V/S stable, remains afebrile before and after administration. Resident will be monitored for fever and any adverse effect. x 7 days per facility protocol. Review of Resident #44's recorded temperatures and nursing progress notes from 10/17/22 to 10/24/22 showed no documented temperature greater than 99.5 degrees Fahrenheit and/or signs or symptoms of any adverse reaction after receiving the expired influenza vaccine. Review of a 10/27/22 at 12:35 PM [Nursing Progress Note] revealed, .Temp 97.7 . Fluzone high-dose 0.7 ML administer IM to R (right)/deltoid. Staff will continue to monitor resident for adverse effects . LOT # (number) UT7743BA & EXP (expiration) date: 6/30/2023 . Review of email correspondences provided to this surveyor on 04/21/23 documented the following: From: [Employee #3 (Infection Preventionist)], sent: Wednesday, October 5, 2022 [at] 12:18 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . Thank you for our supply of High Dose Flu Vaccines. Please help me understand the dates on these vaccines as I am a bit confused. On each box there is the number uj765AB and date 30 June 22 . Are these vaccines safe to use . Pleas clarify . From: (Name of pharmacy presentative), sent: Wednesday, October 5, 2022 [at] 12:54 PM, to: [Employee #3, subject: RE Flu vaccine supply . Those would not be this years and should not be used .Can you please have nursing send the ones you have back with the driver . I've informed our inventory team and they are going to submit an incident report to our wholesaler . From: Employee #3, sent: Wednesday, October 5, 2022 [at] 2:15 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . this is very concerning. I prepared the vaccines for pick-up tonight. Please ensure that your driver takes them. We are under survey window and could be sited for so many expired medications on the premises . From: (Name of pharmacy presentative), sent: Thursday, October 6, 2022 [at] 11:54 AM, to: Employee #3, subject: RE Flu vaccine supply . Just confirming that we did deliver the 2033-2023 flu vaccine and picked up the previously delivered . From: Employee #3, sent: Thursday, October 6, 2022 [at] 2:58 PM, to: (Name of pharmacy presentative), subject: RE Flu vaccine supply . [NAME] that. Vaccines were picked up and delivered. Thanks. A face-to-face interview was conducted on 04/21/23 at 1:31 PM with Employee #2 (Director of Nursing/DON) and Employee #4 (Licensed Practical Nurse/LPN who administered the expired vaccines). Employee #4 stated, The vaccines are individual doses of 0.7 ml and come in a box of ten. That day (10/17/22), I went and got the vaccines from the HSC (health services center) refrigerator. I work on the SCC (special care center) side. I saw the vaccines in a plastic bag and took out a box of ten. I should have double checked the dates then but I didn't. I was not aware that any expired vaccines had been delivered. After checking the resident's temperatures, I went to each resident's room and administered them the vaccine and then came to the computer to document. When asked why she did not document in each resident's chart after administering the vaccine, Employee #4 stated, I know I am supposed to sign it (the MAR) on or right after administration. I didn't do it. That's my fault. Employee #4 continued to say, When I went to document, I clicked on 'administer', a box comes up that prompts you to input the lot number, site and expiration date. That's when I realized that the vaccines I just administered (10 in total) had expired. I immediately made my DON aware. When asked if she followed the standards of professional practice for medication administration, Employee #4 stated, No. Employee #2 (DON) was asked how did the facility ensure that all the expired Fluzone vaccines had been picked up on 10/05/22, she stated, I don't believe the refrigerator was checked again after that to make sure that the [expired] vaccines had in fact been picked up. The IP (Infection Preventionist) prepared the expired vaccines and put them in the HSC refrigerator for pick up. It was communicated to the HSC night nurse to ensure that the expired vaccines were picked up when the driver came to deliver the new vaccines. That nurse was responsible for making sure the driver got the expired vaccines. Employee #2 added that all the vaccines that are delivered to the facility are initially checked by the night nurse, stored in the HSC refrigerator, checked again by the IP or herself and then disseminated to the rest of the facility. When asked if she, the IP or any other licensed nurse checked the refrigerator from 10/06/22 to 10/17/22 for expired medications, Employee #3 stated, I didn't check it. I can't say definitively if anyone else did or didn't. During a telephone interview conducted on 04/21/23 at 3:16 PM, Employee #3 (Infection Preventionist/IP) stated, I check the vaccines after they get delivered from the pharmacy. That is how I was able to see that the ones delivered were expired. When I realized this, I reached out to them (pharmacy) and let them know. I prepared the vaccines and put them into two (2) bags for pick up in the HSC refrigerator. I instructed the evening charge nurse and left a note. When asked how she ensured that all the expired vaccines were picked up and that the new vaccines were delivered as per her email correspondence on 10/06/22 to the pharmacy, Employee #3 stated, I didn't check the fridge. I took the nurses word for it. When the medication error occurred (on 10/17/22), that's when we realized that there was still one bag of the expired vaccines stored in the refrigerator. I am not sure what happened but both of the bags should've been picked up by the driver. When asked if she, the DON or any other licensed nurse checked the refrigerator from 10/06/22 to 10/17/22 for expired medications, Employee #3 stated, I did not and am unsure if anyone else did. Cross Reference: 22B DCMR sec 3227.12

Based on observation and staff interview, facility staff failed to store food in accordance with professional standards for food service safety. The findings included: During an initial tour of the facility's main refrigerator on 04/19/23 at 9:40 AM with Employee #5 (General Manager Dining Services), the following was observed: 1. Four (4) bags of chicken set out to thaw with no dated label; 2. One (1) package of diced ham with a label that showed, use by 4-18-23; 3. One (1) clear package of hot dogs with no dated label. At the time of the observation, Employee #5 acknowledged the findings, removed the packages of diced ham and hot dogs and stated, The chicken was taken out on Sunday (04/16/23) to thaw. The label sticker must've have fallen off. When asked if she could provide documented evidence that the chicken was in fact taken out to thaw on Sunday, 04/16/23, Employee #5 was unable to and stated, I know that's when it was taken out. Cross Reference: 22B DCMR sec 3219.1

Based on record reviews and staff interviews, facility staff failed to show documented evidence that the facility conducted quarterly QAPI (Quality Assurance & Performance Improvement) meetings to identify and evaluate quality activities for the year 2022. The resident census during the survey was 44. The findings included: A review of an email correspondence provided to the surveyor dated 06/09/22, showed in the subject line QAPI-1st Quarter 2022 Microsoft Teams Meeting. The facility staff was unable to show documented evidence that the QAPI committee met more than once in the year 2022. During a face-to-face interview conducted on 04/26/23 at 1:21 PM, Employee #1 (Administrator) stated that the facility had 2 meetings for the year 2022 (06/09/22) but that one of those meetings occurred in 2023 to discuss everything from June 2022 - December 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 18 sampled residents, facility's staff failed to accurately code a resident's Quarterly Minimum Data Set (MDS) to include a Stage 3 pressure ulcer. Resident #5. The findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, Parkinson's Disease, Coronary Artery Disease, Atrial Fibrillation, Legal Blindness, and Spinal Stenosis. Review of a Quarterly MDS (Assessment Reference Date of 05/24/2021), documented the following: In Section M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at each Stage), the resident was coded for having one (1) Stage 4 pressure ulcer. Review of the Wound/Skin Record documented the following: 05/13/21 site - A (coccyx), stage - Stage III, size - 5 X 5 cm (centimeters), depth - 0, exudate - 0, odor - 0, wound bed - redness with scattered pinpoint areas within, surrounding skin color - WNL (within normal limits), surrounding tissue/wound edges - this area was left blank. 05/20/21 site - A (coccyx), stage - Stage III, size - 5 X 5 cm (centimeters), depth -, exudate -, odor -, wound bed - red, surrounding skin color-, surrounding tissue/wound edges It should be noted that Resident #5's coccyx wound had an onset date on 11/05/2020. During a face-to-face interview conducted on 05/28/2021, at approximately 1:30 PM, Employee #11 (MDS Coordinator stated, I clicked Stage 4 pressure ulcer in error. The resident has a healing Stage 3 sacral (coccyx) pressure ulcer. I will correct the MDS right now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility staff failed to implement supervision as outlined in the Fall's Care Plan for one (1) of 18 sampled residents. Resident #5. The finding include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, Parkinson's Disease, Coronary Artery Disease, Atrial Fibrillation, Legal Blindness and Spinal Stenosis. Review of a Quarterly Minimum Data Set (Assessment Reference Date of 06/05/2020), documented the following: In Section C0500 (Brief Interview for Mental Status), the resident had a summary score of 12, indicating the resident was cognitively intact. In Section E (Behavior), resident was not coded for psychosis, rejection of care or wandering. In Section G (Functional Status), the resident was coded for needing extensive assistance with the assistance of one person for ambulation in room and toileting use. In Section H (Bladder and Bowel) - the resident was coded for frequent incontinence of both bladder and bowel. In Section I (Active Diagnosis)- the resident was coded for diagnoses of Dementia, Parkinson s Disease, and Manic Depression. And in Section J (Health Condition) - the resident was coded for having one (1) fall with major injury since admission/entry/reentry. Review of the resident's record revealed the following sequence of events: 03/07/20 at 8:30AM (Nursing Note) Resident observed sitting on the floor in bathroom. Alert, oriented, able to verbalize what happened. Resident stated she lost her balance while doing oral care in sink .Verbalized she hit right side of her head and right side of her shoulder in the toilet bowl . Review of the radiology report revealed: 03/09/20 at 6:47 PM (Bilateral Ribs and AP [anteroposterior] chest X-ray) - There is a diffuse sever bony demineralization, which limits the diagnostic capability of the study. There is a fracture of the 2nd right rib posteriorly with minimal displacement. No other acute bony abnormalities are seen. Irregularities are seen of the left ribs compatible with old fractures and there is an old fracture of the left clavicle. Impression: 1. Fracture of the right 2nd rib posteriorly. 2. No acute pulmonary infiltrates. 03/09/20 at 10:47 PM (Nursing Note) Resident alert and verbal. Xray done, result of chest C-Rays (sp) shows fracture of right 2nd rib posteriorly . Review of the care plan (fall) with a start date of 03/10/2020 revealed: Goal: will minimize injuries related to falls. The care plan outlined multiple approaches for the facility's staff to address the resident problem of falls that included: -Increased staff supervision with intensity based on resident's need. -Bed alarm in place. -Implement [an] exercise program that targets strength, gait, and balance. Care Plan (Activity of Daily Living (ADL)/ Rehabilitation Potential Self-Care) with a start date of 03/10/20. Goal: All her ASL (sp) will be anticipated and met by staff on daily basis. The care plan outlined multiple approaches for the facility's staff to address the resident problem with ADLs that included: -Assist with . personal hygiene . -Assist with . mobility, transfers, and locomotion. 06/17/20 at 4:23 PM (Nursing Progress Note)- This writer was at the end of the hall at 4:05 PM, Resident seen coming out of room. Upon getting closer to resident's room, a audible screeching sound heard. Upon entering resident's room, resident noted in supine position in entrance way of room door. Commented she was looking for bathroom assist and went to turn around and go into bathroom and fell on left hip. Resident c/o (complained of) left hip pain . 06/17/20 at 5:22 PM (Nursing Progress Note) - 2 Ambulance staff arrived. Resident transferred via stretcher, resident conversing with ambulance staff at this point. No change mentation. Scheduled to go to [hospital's name] for evaluation . 06/18/20 (Physician's Order)- Transfer to [hospital ' s name] ER (emergency room) for Further eval (evaluation) & TX (treat) left hip pain and fall. 06/21/20 (Nursing Progress Note)- admission Note: Resident alert and oriented to time, place and person, arrived on the unit at 1:15PM accompanied by 2 paramedics, readmitted to room [room number] .left hip noted with two surgical incision sites, upper left hip site with six intact staples and slight serosangenous (sp) exudate, lower left hip with nine intact staples with no drainage noted, resident is non weight bearing at this time . Review of nursing notes, medication and treatment records from 03/10/2020, to 06/17/2020, lacked documented evidence that facility staff provided intense supervision (to include to type and frequency) based on the resident's assessed needs to minimize injuries related to falls, as outlined in the previously mentioned care plan. During a face-to-face interview on 06/02/2021, at approximately 3:00 PM, Employee #5 (RN/ Unit Charge Nurse) stated that intense supervision is every two hours. She also said that nurses may or may not document supervision in their nursing notes.

Based on observation, record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to ensure a resident receiving enteral feedings received appropriate care to prevent complications. Resident #10. The findings include: Resident #10 was admitted to the facility 03/11/2020, with diagnoses that included: Anemia, Hypertension, Dysphagia (Oropharyngeal Phase), and Gastrostomy Status. A physician's order dated 03/11/2020, revealed, Enteral Feeding: Change G [gastrostomy] Tube irrigation set QD [every day] Once a Day 09:00 AM. Review of Resident #10's care plan for the focus area, Feeding Tube created on 11/04/2020, revealed the approach, change feeding syringe label with date and time daily. During an observation inside of Resident #10's room on 05/25/2021, at approximately 11:15 AM, it was noted that there was an unlabeled syringe irrigation set at the resident's bedside. During a face-to-face interview conducted on 05/25/2021, at approximately 11:15 AM with Employee #4 (Licensed Practical Nurse), when asked if she used the irrigation set observed at Resident #10's bedside, she stated that she did use that syringe irrigation set to feed and administer Resident #10's morning medications and feeding. At the time of the interview, Employee #4 acknowledged the findings and proceeded to change and label a new syringe irrigation set.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to provide the specialized care needs for a resident receiving nebulizer treatments in accordance with the professional standards of practice. Resident #19. The findings include: Resident #19 was admitted to the facility on [DATE], with diagnoses that included: Asthma, Hyperlipidemia, Muscle Weakness, and Hypertension. A physician's order dated 03/09/2021, revealed, Start Date Change neb [nebulizer] mask every week on Wednesdays (3-11 PM shift) . Review of the Treatment Administration Record for May 2021 revealed that facility staff signed off in the area that documented, Change neb [nebulizer] mask every week on Wednesdays (3-11 PM shift) indicating that it was done on the date 05/26/2021. During an observation of Resident #19's room on 06/02/2021, at approximately 10:30 AM, revealed a nebulizer treatment set at the resident's bedside with a pink label that was dated, 5/19/21. During a face-to-face interview conducted with Employee #5 (Charge Nurse) on 06/02/2021, at approximately 10:35 AM, she stated, The nebulizer mask should have been changed. There's an order to it change every Wednesday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for two (2) of 18 sampled residents, the facility staff failed to ensure that the pharmacist progress notes mentioned whether there were irregularities and recommendations for the Monthly Medication Regimen Review (MRR). Resident's #28 and #31. The findings include: 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including Dementia, Depression, Anemia, Hyperlipidemia, Hypertension, Diabetes Mellitus, Gastro Esophageal Reflux Disease, and Osteoporosis. A review of the Medication Regimen Review progress notes dated 02/08/2021, to 05/10/2021, noted by the Pharmacist stated Medication Regimen Review completed however, there was no mention on whether there were any irregularities found and recommendation given. During a face-to-face interview on 05/12/21, at approximately 10:30 AM, Employee #12 reviewed the previously mentioned documents and acknowledged the finding. 2. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses including Dementia, Depression, Parkinson, Disease, Hypertension, Diabetes Mellitus, Gastroesophageal Reflux Disease, Heart Failure, Acute Bronchitis, Ulcerative Blepharitis Right Eyes and History of Repeated falls. A review of the MRR progress notes dated from 04/20/2020, to 05/10/2021, revealed the pharmacist documented, Medication Regimen Review completed for each month reviewed; however the document failed to include if the pharmacist found irregularities or had recommendations. During a face-to-face interview conducted on 05/27/2021, with Employee #2 (Director of nursing) at 10:00 AM, she acknowledged the findings. During a face-to-face interview on 05/27/2021, at approximately 11:00 AM, Employee #12 (Registered Nurse) acknowledged the finding.

Based on record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to ensure that a resident's monthly Medication Regimen Review (MRR) was conducted on a monthly basis. Resident #31. The findings include: Resident #31 was admitted to the facility on 10/15/ 2019, with multiple diagnoses that included: Dementia, Depression, Parkinson, Disease, Hypertension, Diabetes Mellitus, Gastro Esophageal Reflux Disease, Heart Failure, Acute Bronchitis, Ulcerative Blepharitis right eyes and History of Repeated falls. A review of Resident #31's medical record lacked documented evidence the pharmacist conducted a MRR for July 2020. During a face-to-face interview conducted on 06/02/2021, at approximately 11:00 AM, Employee #12 (Registered Nurse) acknowledged the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, in one (1) of one (1) observation, facility staff failed to maintain infection control prevention practices in accordance with standards of practice to minimize the potential spread of infections. The findings include: Review of the facility's document entitled, Respiratory protection program dated 03/30/2021, revealed, .HCP [health care professional] will have an N95 and a face shield when in resident's area or within 6 feet of a resident . During an observation on 05/25/2021, at approximately 2:00 PM, Employee #6 (Private Duty Aide) was observed in resident room [ROOM NUMBER] A, sitting in a chair beside the resident (less than six feet away), wearing a N95 face mask but not wearing a face shield. It should be noted that the resident was not wearing a face mask or a face shield. During a face-to-face interview conducted on 05/25/2021, at approximately 2:00 PM, Employee #6 stated, I put it [face shield] back on when I am doing care. During a face-to-face interview conducted on 06/02/2021, at approximately 2:20 PM, Employee #2 (Director of Nursing) stated, The private duty aides receive the same infection control information as the facility staff. PPE (personal protective equipment) is provided to all the private duty aides and they are aware that the requirement in the facility is to have to on an N95 mask and a face shield at all times while on the units.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 32 sampled residents, the facility staff failed to ensure that Resident #38's advance directive was placed on her active clinical record. Findings included . Resident #38 was admitted to the facility on [DATE], with diagnoses, which included Chronic Pain, Gastro-Esophageal Reflux Disease, Vascular Dementia with Behavioral Disturbance, Hypertension, and Spinal Stenosis. The Advance Directive/Living Will and Durable Power of Attorney Policy and Procedures signed March 27, 2018, stipulated, Upon admission, the Social Services Department at Knollwood will inquire and document whether a resident has executed an Advance Directive, Living Will or Durable Power of Attorney . Review of the End of-Life Program Planning form dated May 18, 2019, (which serves the staff, residents, responsible parties, and family members in preparation for the time of a resident's passing), stipulated that the resident had Advance Directives, however, the Code Wishes/Preferences and Spiritual Needs sections were blank. Continued review of the Resident #38's active clinical record lacked evidence of the aforementioned Advance Directives. On June 25, 2019, Employee #8 provided the surveyor with a copy of Resident #38's advance directive. Facility staff failed to ensure that Resident #38's advance directive was placed on the active clinical record. During a face-to-face interview on June 28, 2019 at 10:43 AM Employee #8 acknowledged the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 32 sampled residents, the facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) resident death, for one (1) resident receiving hospice care and for one (1) resident diagnosis of Macular Degeneration. Residents' #1, #9 and #29 Findings included . 1. Facility staff failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) assessment at the time of the Resident #1's death. Review of the resident's clinical record on [DATE], showed significant change MDS dated [DATE] when the resident entered the Hospice Program. Further review of the record failed to show evidence that an MDS was completed when the resident expired on February 21, 2019. A face-to-face interview was conducted with Employee #9 at approximately 3:30 PM on [DATE]. During the interview, the employee acknowledged that an MDS was not completed at the time of the resident's death. 2. Facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) resident receiving hospice care. Resident #9 Resident #9 was admitted to the facility on [DATE] with diagnoses which include: Unspecified Atrial Fibrillation, Retinal Edema, Primary Open-Angle Glaucoma Right Eye and Essential Hypertension. On [DATE] at 10:00 AM a review of the physician's order dated [DATE] at 2:00 PM showed Admit to Capital Caring Hospice for hospice . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed under Section C [Cognition], Brief Interview for Mental Status [BIMS] Resident #9 was coded as 99 which indicate unable to complete the interview. Under Section O [Special Treatments, Procedures and Programs] Hospice care was left blank which indicates resident is not receiving hospice care. During a face-to-face interview on [DATE] at 11:00 AM with Employee #9 she stated yes, Resident #9 is receiving hospice services I will make the change now. Employee #9 acknowledged the finding at the time of the review. 3. Facility staff failed to accurately code the [Minimum Data Set] MDS for a diagnosis of Macular Degeneration for one (1) resident. Resident #29. Resident #29 was admitted to the facility on [DATE], with diagnoses that included Anemia, Chronic Kidney Disease, Chronic Respiratory Failure, Hypertension, Heart failure, and Myestinea Gravis. A review of the Ophthalmologist Report of Consultation for an appointment dated [DATE], at 9:30 AM showed, Findings: Pt reports stable vision since last year, no current issues VA (visual Acuity) 20/100 both eyes stable clinical exam . Diagnosis: nonexudative AMD (Aged-related Macular Degeneration) OU (both eye) Recommendation: 1. Continue AREDS (eye multivitamin) (1 caps (capsules)) daily 2. Annual FU (follow up) advised. A review of the Physician Order sheets from [DATE], to [DATE], showed Ocuvite Eye + Multi Tab, Give 2 tablets by mouth twice daily for eye health. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #29 scored 12 on the Brief Interview for Mental Status in Section C (Cognitive Patterns) indicating moderately impaired cognitive skills for daily decision making. Section B (Hearing, Speech, and Vision) B1000 ability to see in adequate light (with glasses or other visual appliances) coded as 0 indicating Adequate- sees fine detail, such as regular print in the newspapers/books. Section I (Active Diagnoses) showed the space allotted for coding Macular Degeneration was left blank indicating not coded. The medical record lacked evidence that the MDS was coded to accurately reflect the resident's diagnosis of Macular Degeneration. A face-to-face interview was conducted with Employee #9, [MDS Coordinator] on [DATE], at approximately 11:30 AM. Employee #9 reviewed the MDS information and acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 32 sampled residents facility's staff failed to ensure the resident received treatment and care in accordance with professional standards of practice as evidenced by failing to provide evidence of collaboration with the hospice team for one (1) resident and to develop one (1) residents care plan and to accurately assess a residents neurological status after a fall. Residents' #9 and #32. Findings included . 1.Facility staff failed to devlop a care plan in collaboration with the hospice team. Record review of the facility's undated policy titled Hospice Procedures showed resident's care plan of care is in collaboration with hospice to attain and maintain the resident's highest practical physical, mental and psychological well-being. Resident #9 was admitted to the facility on [DATE] with diagnoses which include: Unspecified Atrial Fibrillation, Retinal Edema, Primary Open-Angle Glaucoma Right Eye and Essential Hypertension. On 6/27/19 at 10:00 AM a review of the physician's order dated 3/5/19 at 2:00 PM showed Admit to Capital Caring Hospice for hospice . Review of the Hospice care plan showed Hospice care-resident has terminal condition and will maintain a quality of life, dignity and comfort with limitations of disease process. Approach: administer pain meds, oxygen as ordered, coordinate residents care with Hospice as appropriate, honor food preferences, assist with meal intake as needed encourage fluids, provide pressure relieving devices, provide support to resident as needed . Facility staff failed to show evidence of collaboration with hospice to develop goals and approaches to care for a resident receiving hospice services. During an interview on 6/27/19 at 12:30 PM with Employee #8, stated this is not a collaborative care plan, but I have hospice coming in to make changes to the care plan. Employee #8 acknowledged the finding at the time of the review. Facility staff failed to accurately assess a resident's pupil response after a fall. 2. The facility staff failed to accurately assess the resident's neurological status (pupil response to light) after a fall, as evidenced below: Resident #32 was admitted to the facility on [DATE] with diagnoses, which included Repeated Falls, Muscle Weakness, Parkinson's Disease, Contracture of Right Elbow, and Alzheimer's Disease. The nursing note dated 05/16/19 at 10:00 AM, documented, Found resident sitting on the floor with his back to the lower side of the bed. Continued review of the active clinical record revealed a physician's order dated 05/16/19 at 10:00 AM, that directed [neurological] checks for 72 hours. Review of the Neurological Assessment Flow Sheet dated 05/16/19, instructed .for Pupil Response - staff was to Check PERL (pupil equal and reactive light) if applicable or enter appropriate code for each eye in the pupil response column. Additionally, for Motor Functions - staff was to Enter the appropriate code in the hand grasp column. The key listed at the bottom of the form indicated that the equal sign should be documented if the resident's hand grasp are equal. Staff assessment on the form showed the following: On 05/16/19 Employee #17(the assigned Licensed Nurse) documented the equal sign eleven times from 9:00 AM to 3:00 PM under the pupil response column; and the hand grasp column was blank the aforementioned times. 05/16/19 at 4:00 PM pupil response was documented as equal and reactive to light and hand grasp were equal; 05/16/19 at 8:00 PM pupil response was documented as equal and reactive to light and hand grasp were equal; 05/17/19 at 12:00 AM to 4:00 PM pupil response was documented as equal and reactive to light and hand grasp were equal; and 05/18/19 at 12:00 AM to 4:00 PM pupil response was documented as equal and reactive to light and hand grasp were equal. The was no evidence that facility staff accurately assessed Resident #32's pupil status for seven hours on May 16, 2019. According to the clinical record, Resident #32 had no untoward affects after the fall. During a face-to-face interview on 06/26/19 at approximately 11:30 AM, Employee #13 acknowledged the findings.

Based on record review and staff interviews for one (1) of (2) nursing units, the facility staff failed to ensure the system used for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed by staff. The census was 59 on the first day of the survey. Findings included . Review of the Controlled Drug Shift Change Audit Sheet instructions showed controlled drugs (scheduled II to schedule V) must be counted by two nurses at the change of shift, the nurse going off duty and the nurse coming on. Review of the Controlled Drug Shift Change Audit Sheet showed the spaces allotted for nurse signature going off duty to reconcile the narcotic count for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift for 6/20/19 were left blank indicating the reconciliation of controlled medication was Not Done. The evidence showed that the system use for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was not followed by staff. A face-to-face interview was conducted with Employee #15 on 6/26/19, at 9:30 AM; she acknowledged the finding at the time of the review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for four (4) of 32 sampled residents, facility staff failed to develop baseline care plans with goals and approaches to properly care for four (4) newly admitted residents. Residents' # 38,53, 62 and 160. Findings included . 1. Facility staff failed to ensure that Resident # 38 had a baseline care plan completed within 48 hours of admission. Resident #38 was admitted to the facility on [DATE], with diagnoses, which included Chronic Pain, Gastro-Esophageal Reflux Disease, Vascular Dementia with Behavioral Disturbance, Hypertension, and Spinal Stenosis. Review of the facility's 48-hour baseline care plan showed the care plan was signed by the resident and the facility on May 14, 2019 (seven days after admission). There was no evidence that facility staff ensured that Resident # 38 had a Baseline Care Plan completed within 48 hours of admission. The findings were acknowledged during a face-to-face interview with Employee #2 on June 27, 2019 at approximately 2:45 PM. 2. Facility staff failed to ensure that Resident #53 had a baseline care plan completed within 48 hours of admission. Resident #53 was admitted to the facility on [DATE], with diagnoses to include Essential Hypertension, Unspecified Atrial Fibrillation, Heart Failure and Cerebral Infarction. Review of the facility's 48-hour baseline care plan showed the care plan was signed by the resident and the facility staff on 6/5/19 (five days after admission). There was no evidence that facility staff ensured that Resident # 53 had a baseline care plan completed within 48 hours of admission. During a face-to-face interview conducted on 6/26/19 at approximately 10:00 AM Employee #2 acknowledged the findings. 3. Facility staff failed to ensure that Resident # 62 had a baseline care plan completed within 48 hours of admission. Resident #62 was admitted to the facility on [DATE], with diagnoses to include Congestive Heart Failure, Pulmonary Edema, Muscle Weakness and Hypoxemia. Review of the facility's 48-hour baseline care plan showed the care plan was signed by the resident and the facility on April 2, 2019 (seven days after admission). There was no evidence that facility staff ensured that Resident # 62 had a baseline care plan completed within 48 hours of admission. During a face-to-face interview on June 27, 2019 at approximately 4:45 PM, Employee #2 acknowledged the findings. 4. Facility staff failed to ensure that Resident #160 baseline care plan was developed within 48 hours of admission. A review of the medical record showed Resident # 160 was admitted to the facility on [DATE], with diagnoses to include: Malignant Pleural Effusion, Chronic Kidney Disease, Age-related Osteoporosis, Anemia, and Hypertension. A review of Resident #160's 48-hour baseline care plan showed the care plan was signed by the resident and designated staff on June 18, 2019 (five days after admission). The evidence showed that the resident baseline care plan was not developed within 48 hours of the resident's admission to the facility. During a face-to-face interview on June 26, 2019, at approximately 10:45 AM, Employee #14 acknowledged the findings.

Based on observations and interview, the facility failed to provide an environment free from accident hazards as evidenced by frayed remote bed controller cords in 12 of 20 resident's rooms. Findings included . During an environmental tour of the facility on June 25, 2019, at approximately 11:00 AM, remote bed controllers' cords in 12 of 20 resident's rooms were frayed. The uncovered, exposed electrical wires created a potential electrical shock hazard to residents, staff and the public. During a face-to-face interview on June 25, 2019, at approximately 12:30 PM, Employee #6 acknowledged the findings.

Based on observations and interview, facility staff failed to maintain electrical equipment in good condition as evidenced by frayed remote bed controller cords in 12 of 20 resident's rooms. Findings included . During an environmental tour of the facility on June 25, 2019, at approximately 11:00 AM, remote bed controllers' cords in 12 of 20 resident's rooms were frayed. During a face-to-face interview on June 25, 2019, at approximately 12:30 PM, Employee #6 acknowledged the findings.

Based on observations and interview, the facility failed to store, serve and distribute foods under sanitary conditions as evidenced by staff who were observed serving breakfast foods to residents before food temperatures were completed, soiled equipment such as four (4) of four (4) convection ovens, one (1) of one (1) deep fryer, one (1) of one (1) grill and the interior of one (1) of one (1) oven, 20 of 20 six-inch, one-third steam pans that were stored wet, four (4) of 20 six-inch one-third pans that were dented throughout. Findings included . The following observations were made during a walkthrough of the kitchen on the Special Care Center (SCC) on June 23, 2019, at approximately 8:15 AM. 1. Breakfast food temperatures from the Special Care Center (SCC) kitchen were not completed before foods were served to residents on June 23, 2019, at approximately 8:10 AM. Employee #4 was asked why food temperatures were not taken before residents were served and she explained that someone had removed the thermometer from the kitchen and she did not have one. Employee #4 was asked if she could get another thermometer and check food temperatures. Employee #4 left and came back in about five (5) minutes and proceeded to check the temperature of foods on the tray line. All food items tested above 135 degrees Fahrenheit. A review of the food temperature logs for the previous week confirmed that food temperatures were completed for breakfast, lunch and dinner throughout the week. Employee #4 acknowledged the findings during a face-to-face interview on June 23, 2019, at approximately 8:20 AM. During a walkthrough of the main kitchen on June 23, 2019, at approximately 8:30 AM: 2. Four (4) of four (4) convection ovens, one (1) of one (1) deep fryer, one (1) of one (1) grill and the interior of one (1) of one (1) oven were soiled. 3. 20 of 20 six-inch, one-third steam pans stored on a shelf in the clean, and ready-for-use area were stored wet, one on top of the other. 4. Four (4) of 20 six-inch one-third pans were dented throughout. Employee #4 acknowledged the findings during a face-to-face interview on June 23, 2019, at approximately 9:15 AM.