Based on record review and interviews conducted during the Recertification Survey from 07/09/2024 through 07/16/2024, the facility did not ensure that the Infection Preventionist had completed specialized training in infection prevention and control. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. The findings are: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality Safety by Oversight Group Ref: QSO-19-10-NH dated 03/11/2019 documented that effective 11/28/2019 the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's infection prevention and control program. The facility's policy titled Infection Preventionist with a reviewed date of 02/01/2024 documented that the Infection Preventionist is responsible for coordinating the implementation and updating of the facility's established infection prevention and control policies and practices. The Infection Preventionist's must have completed a specialized training for infection preventionists such as specialized Infection Control Training for New York state Healthcare Professionals. There was no documented evidence that the facility's Infection Preventionist had completed specialized training in infection prevention and control. During an interview on 07/15/2024 at 12:07 PM, the Director of Nursing, who was also the acting Infection Preventionist stated their full time Infection Preventionist had been out sick for 4 months. They stated they both had taken 4 contact hours of infection control training in October 2022. The Director of Nursing stated they are not aware they have to complete a specialized infection prevention and control training. During an interview on 07/16/2024 at 12:12 PM, the Administrator stated they were not aware that the Infection Preventionist need more than 4 contact hours to function as Infection Preventionist for the facility. 10 NYCRR 415.19

483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Observations: Based on record review and interview conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. This was evident during review of the Water Management Plan for Legionella. Specifically, the facility did not have a facility-specific water management plan for Legionella with mandatory components including but not limited to a description of the facility's water distribution system; temperature profile of the water system; control measures, and actions to be taken if control measures are not met. The findings are: The facility policy titled Legionella Water Management Program with a revised date of 06/13/2024 documented that the facility would maintain and monitor the facility's water system for Legionella. There was no documentation within the policy to indicate the document served as a site-specific water management plan for Legionella. Statements of prevention, surveillance, and reporting did not account for the actual design and operation of the facility's water system. The facility's Water Management Plan for Legionella had the following missing components: a description of the facility's water distribution system; temperature profile of the water system; facility-specific personnel roles and responsibilities; and control measures and actions to be taken if control measures not met. An environmental risk assessment form was not available for review. During an interview on 07/11/2024 at 1:50 PM, the Administrator stated they would ensure that the water management plan includes all the required components. 10 NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a Recertification survey from 9/29/22 to 10/06/22, the facility did not ensure resident were free of accident hazards. This was evident for 2 (Resident #35 and #40) of 25 sampled residents. Specifically, Residents #35 and #40 resided in a shared room with a tampered bathroom doorknob that could not be opened in an emergency. The findings are: The facility policy titled Fall and Accident Preventions dated 04/1/2019 and last revised 06/01/22 documented the facility ensures the resident's environment remains as free of accident hazards as is possible, and each resident receives adequate supervision. Resident #35 had diagnoses of non-Alzheimer's dementia and psychotic disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #35 had mild cognitive impairments and was independent in Activities of Daily Living (ADL). Resident #40 had diagnoses of anxiety disorder and depression. The MDS dated [DATE] documented Resident #40 was cognitively intact and independent in ADLs. Comprehensive care plan (CCP) related substance abuse initiated 3/25/22 documented Resident #40 had a history of substance abuse. On 10/04/22 at 03:20 PM, the shared bathroom door in Resident #35 and #40's room was observed with a tampered doorknob. The inner cylinder containing a mechanism to unlock the door was not present. The bathroom door handle was locked from the outside of the bathroom and could not be pressed down to open the door from the outside of the bathroom. Certified Nursing Assistant (CNA) #4 was present during the observation and stated this bathroom door has always been like that, and they were not sure if they had reported it the maintenance director. The C.N.A stated that this door cannot be opened with a coin like the other bathroom doors in the resident rooms. On 10/04/22 at 02:14 PM, CNA #2 was interviewed and stated if the bathroom door is found locked, staff could open the bathroom door with coin. On 10/04/22 at 05:15 PM, an interview conducted with the Maintenance Director who stated resident bathroom doors can be opened with a coin in case of an emergency. The Maintenance Director became aware of the bathroom door in Resident #35 and #40's room that had a missing handle cylinder. The bathroom door handle was replaced On 10/04/22 at 05:40 PM, the Director of Nursing (DON) was interviewed and stated that there has not been any incident related to bathroom doors. There was no policy related to opening of bathroom door with coins, but all staff know what to do in an emergency. 415.12(h)(2)

Based on observation, interviews, and record review conducted during the Recertification survey from 09/27/22 to 10/06/22, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during review of the Infection Control Task. Specifically, the facility did not have a qualified IP with specialized education, training, experience, or certification and in infection prevention and control. The findings are: The facility policy titled Infection Control-General dated 10/27/18 and last revised on 03/29/22 documented the facility has established and maintains an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. The Infection Control Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data and implementation. On 09/29/22 at 09:52 AM and 09/30/2022 at 11:34 AM, the Director of Nursing (DON) was interviewed and stated Registered Nurse (RN) #3 was the facility IP responsible for overseeing the facility's IPCP. The DON was aware that specialized infection control training was required but not aware of the date IPs were required to have the training completed. The DON was interviewed and stated that they know that training is required but do not know the deadline. The facility's IP did not have the required ICPC training and certification. On 10/04/2022 at 11:34 AM, RN #3 was interviewed and stated they are responsible for training and inservicing the facility staff re: infection control and ensuring facility staff adhere to infection control protocols. RN #3 was informed they were the facility IP at the beginning of the recertification survey. RN #3 informed the Administrator that the facility's designated IP was required to complete the proper training. On 10/04/2022 at 11:43 AM, a follow-up interview was conducted with the DON who stated the DON and RN #3 are the facility's IPs and have not received specialized education, ICPC training, and did not receive the required certification. The facility's former IP left the position, and the facility is unable to hire a replacement. On 10/06/2022 at 4:08 PM, the Administrator was interviewed and stated that the DON is the facility's IP. The Administrator was not aware an IP required specialized education, training, and certification to qualify as the IP for the facility. The Administrator was not aware the DON did not have the necessary training and certification to be the facility's IP. 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a physician reviewed a resident's total program of care at each visit. Specifically, an attending physician did not review and document the clinical rationale for continued use of an antipsychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #31). The findings are: A facility policy and procedure related to Antipsychotic Medication Monitoring was undated and documented that the Psychiatrist can prescribe an antipsychotic medication can be prescribed to treat dementia with associated psychotic and/or agitated features. The Psychiatrist is to lower the dosage when clinically indicated and documents such efforts. Resident #31 was admitted to the facility on [DATE] with a diagnosis of Unspecified Psychosis not due to a substance or known physiological condition and Unspecified Dementia with behavioral disturbance. The resident's admission Minimum Data Set 3.0 (MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on Zyprexa, and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a diagnosis of psychosis and received Zyprexa. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to Psychotropic Drug Use was initiated on 6/28/19 and documented that the resident is receiving Zyprexa for psychosis. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of psychotropic meds to evaluate for med reduction by decreasing dosage. The Physician's Orders, renewed 12/4/19, documented orders for Zyprexa 5mg once daily for Psychosis. This medication was originally ordered on 6/28/19. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on Olanzapine (Zyprexa) with no clear diagnosis to support current use. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalizations in the past. The PNP recommended to continue Zyprexa 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the diagnosis associated with the Zyprexa order. The MRR documented that the Zyprexa has been ordered to treat psychosis; however, the most recent psychiatry consult documented that the diagnosis is dementia. The physician documented that he disagreed, but he did not document the clinical rationale. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving encephalopathy causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. On 10/29/19 the MD note documented that the resident had questionable organic mental illness versus personality disorder, not yet established. None of the MD notes documented any reference to inappropriate behaviors displayed by the resident or that the resident was experiencing any hallucinations, delusion, or other psychotic symptoms. The MD Notes do not contain any documented evidence that the physician evaluated the continued use of Zyprexa for Dementia. A Psychiatry Assessment completed by the PNP on 12/2/19 documented that the resident had an uneventful last period free from behavioral issues and free from psychosis. The PNP documented that the resident sleeps well at night and keeps to himself most of the time. The recommendation was to continue Zyprexa 5mg once daily for dementia related to a medical condition and substance abuse disorder. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on 6/28/19. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and is not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed Zyprexa to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment by the PNP, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continues to have bouts of psychosis, is only oriented to himself, and does not know the time or date. The Zyprexa is also used to help the resident sleep and he sleeps well at night currently because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment and that he had no expression on his face. The resident's eyes would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to cognitive impairments. The PNP stated that according to her assessments, the resident has severe cognitive impairment and had scored a 9-20 on Montreal Cognitive Assessment (MOCA). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she is not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. The PNP stated that this was the reason she recommends that the resident continue to receive Zyprexa. The PNP stated that Zyprexa is an antipsychotic medication that is used to treat psychosis, a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with dementia. The Federal Drug Administration (FDA) has recommended that Zyprexa be used to treat psychosis. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of Zyprexa, that she decided to continue prescribing the Zyprexa to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to psychosis. She does not recall the resident having any of these concerns. She did determine that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the diagnosis of dementia, but dementia can include psychosis and can be caused by a substance abuse history. Nonpharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, she has not specifically spoken to the MD about Resident #31. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD has been assigned to oversee the resident's care since his admission to the facility. The MD stated that Resident #31 has an odd personality but does not exhibit any inappropriate or negative behaviors at all. The resident is not aggressive. The MD stated that he assessed the resident's cognition when he was first admitted to the facility and the resident scored a 25 out of 30 on the mini-mental exam. There was some discussion of whether he has schizophrenia or schizoaffective disorder, but this has not been determined as of yet. The resident receives a low dose of Zyprexa and consistently does well on mini-mental exams used to test his cognitive status. The facility determined that he was safe to go Out on Pass independently without supervision or escort. The resident is complaint with his medication regime and has never exhibited or reported any delusions or hallucinations. The MD stated that the resident is just odd. The resident answered appropriately when asked what state he was currently in; but, Resident #31 responded inappropriately when asked what country he resided in. The MD stated he got the impression that the resident was playing with me. The resident was admitted from the hospital with an order for Zyprexa and the MD believes that schizoaffective disorder may be a possible diagnosis. It is difficult to obtain the psychiatric history for residents when they are admitted to the facility. Resident #31 does not have any involved family members that the MD is aware of and was unable to provide any history of his psychiatric treatment prior to admission. The resident has a current diagnosis of dementia related to a medical condition; however, the MD disagrees with this diagnosis. The MD stated that the resident might have a personality disorder or a mood disorder; however, the resident does not display any symptoms of mood issues and more likely has a personality disorder because he is odd. Resident #31 has no issue with conversing with the MD when approached. The MD stated that although the resident's record indicates that the resident has a diagnosis of dementia, the MD believes that the resident is asymptomatic. If the resident has a diagnosis of dementia, the MD stated that he would expect to see some level of cognitive impairment. He does confer with the PNP but did not do so in this case. He would have communicated to the PNP that he does not believe that Resident #31 has dementia. The resident is on Zyprexa because the PNP must have seen something during her evaluation to warrant the use of an antipsychotic medication. If the resident has not displayed any aggressive behavior or disordered thought process, then the Zyprexa can be discontinued. According to the PNP, the Zyprexa has been ordered for this resident to treat a diagnosis of dementia. The MD stated that he does not necessarily support that conclusion. The MD stated that he reviews the consults that the psychiatrist writes after seeing a resident and then determines if there should be any changes to the recommendations made; but he did not confer with the PNP in regard to Resident #31. The MD stated that Zyprexa can be used to treat psychosis, thought disorders, and dementia with agitation, delusions. The MD stated that he reviews the monthly Medication Regimen Review (MRR) from the pharmacist. The MD then documents his response as to whether he agrees or disagrees with the MRR. The MD reviewed the MRR from 6/30/19 and stated that he disagreed with the pharmacist's recommendation to obtain a psychosocial history of the resident to determine causes of the resident's behavior and to taper the Zyprexa if behavior monitoring reveals no significant behaviors. He stated that he disagreed because the resident was just admitted to the facility and he bases his decision on the information that he received from the hospital. The MD stated that he needs to be able to take time to evaluate the resident and then make a decision. The Pharmacist asked for the diagnosis Zyprexa is being used to treat, but he was unable to make that determination because the resident was new. The MD stated that he assigned a diagnosis to the resident because the Electronic Medical Record prompts him to when he orders a medication for the resident. The diagnosis that is on the resident's chart related to the Zyprexa use may not coincide perfectly with what the resident's condition actually is, but he needs to put something in. The MD then stated that he disagreed with the MRR dated 7/11/19 pharmacy review recommending clarification of the condition that the Zyprexa is being used to treat. The MRR documented that the MD ordered the Zyprexa to treat psychosis but the PNP documented that the Zyprexa was being used to treat dementia. The MD stated that he disagreed because the resident could have a diagnosis of dementia with psychosis. He further stated that even though the psychosis is not overt, and he does not agree with the dementia diagnosis, he did not feel the need to clarify this in the MRR. The MD stated that he needs more time to evaluate the resident and make a determination. He did not order a neuropsychology exam to determine whether there was a dementia diagnosis. Since the PNP thinks there is some dementia, the MD will have to collaborate and confer with her. It may be that Resident #31 does not need an antipsychotic medication, but the MD stated that was not ready yet to say either way. The MD stated that he is now more confident that the resident does not have a diagnosis of dementia but cannot be certain whether the resident has a diagnosis of psychosis because he has not observed any symptoms of psychosis and the nurses have not reported any symptoms of psychosis to him. The MD stated that it may be best to just take Resident #31 off the antipsychotic medication. The MD stated that he did not write a response to the MRR after he checked the disagree box because he did not feel it was warranted or necessary. 415.15(b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that the attending physician documented a rationale for his response to the pharmacist's Medication Regimen Review. Specifically, the physician did not document the clinical rationale for disagreeing with the Pharmacist's recommendations for a resident receiving an antipsychotic medication for an unclear diagnosis. this was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #31). The findings are: An undated policy and procedure related to Drug Regimen Review-Monthly documented that the attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible. The Prescriber or Licensed Designee shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation, and provide a brief clinical rationale if no change is to be made. Resident #31 was admitted to the facility on [DATE] with a diagnosis of Unspecified Psychosis not due to a substance or known physiological condition and Unspecified Dementia with behavioral disturbance. The resident's admission Minimum Data Set 3.0 (MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on Zyprexa, and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a diagnosis of psychosis and received Zyprexa. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to Psychotropic Drug Use was initiated on 6/28/19 and documented that the resident is receiving Zyprexa for psychosis. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of psychotropic meds to evaluate for med reduction by decreasing dosage. The Physician's Orders, renewed 12/4/19, documented orders for Zyprexa 5mg once daily for Psychosis. This medication was originally ordered on 6/28/19. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on Olanzapine (Zyprexa) with no clear diagnosis to support current use. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalizations in the past. The PNP recommended to continue Zyprexa 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the diagnosis associated with the Zyprexa order. The MRR documented that the Zyprexa has been ordered to treat psychosis; however, the most recent psychiatry consult documented that the diagnosis is dementia. The physician documented that he disagreed, but he did not document the clinical rationale. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving encephalopathy causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on 6/28/19. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and was not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed Zyprexa to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continued to have bouts of psychosis, is only oriented to himself, and does not know the time or date. The Zyprexa is also used to help the resident sleep, and he sleeps well at night because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment, and that he had no expression on his face. The resident would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to the cognitive impairments. The PNP stated that according to her assessments, the resident had severe cognitive impairment and scored a 9-20 on the Montreal Cognitive Assessment (MOCA). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she was not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. This was the reason she recommended that the resident continue to receive Zyprexa. The PNP stated that Zyprexa is an antipsychotic medication that is used to treat psychosis, a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with dementia. The Federal Drug Administration (FDA) has recommended that Zyprexa be used to treat psychosis. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of Zyprexa, that she decided to continue prescribing the Zyprexa to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to psychosis. She does not recall the resident having any of these concerns. She determined that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the diagnosis of dementia, but dementia can include psychosis and can be caused by a substance abuse history. Non-pharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, but she has not specifically spoken to the MD about Resident #31. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD stated Zyprexa is ordered because the PNP must have seen something during her evaluation to warrant the use of an antipsychotic medication. If the resident has not displayed any aggressive behavior or disordered thought process, then the Zyprexa can be discontinued. According to the PNP, the Zyprexa has been ordered for this resident to treat a diagnosis of dementia, but he does not necessarily support that conclusion. The MD stated that he reviews the consults that the psychiatrist writes after seeing a resident and then determines if there should be any changes based on the recommendations made. He did not confer with the PNP about Resident #31. The MD stated that Zyprexa can be used to treat psychosis, thought disorders, and dementia with agitation, delusions. The MD stated that he reviews the monthly Medication Regimen Review (MRR) from the pharmacist. The MD then documents his response as to whether he agrees or disagrees with the MRR. The MD reviewed the MRR from 6/30/19 and stated that he disagreed with the pharmacist's recommendation to obtain a psychosocial history of the resident to determine causes of the resident's behavior and to taper the Zyprexa if behavior monitoring reveals no significant behaviors. He stated that he disagreed because the resident was just admitted to the facility and he bases his decision on the information that he received from the hospital. The MD stated that he needs to be able to take time to evaluate the resident and then make a decision. The MD stated that the MRR asks for an appropriate diagnosis that the Zyprexa is being used to treat, but the MD is unable to make that determination because the resident is new. The MD stated that he assigned a diagnosis to the resident because the Electronic Medical Record prompts him to when he orders a medication for the resident. The diagnosis that is on the resident's chart related to the Zyprexa may not coincide perfectly with what the resident's condition actually is, but the MD stated that he needs to put something in. The MD then stated that he disagreed with the MRR dated 7/11/19 recommending clarification of the condition that the Zyprexa is being used to treat. The MRR documented that the MD ordered the Zyprexa to treat psychosis but the PNP documented that the Zyprexa was being used to treat dementia. The MD stated that he disagreed because the resident could have a diagnosis of dementia with psychosis. He further stated that even though the psychosis was not overt and he did not agree with the dementia diagnosis, he did not feel the need to clarify this in the MRR. The MD stated that he needs more time to evaluate the resident and make a determination. He did not order a neuropsychology exam to determine whether there was a dementia diagnosis. Since the PNP thinks there is some dementia, the MD will have to collaborate and confer with her. It may be that Resident #31 does not need an antipsychotic medication, but the MD stated that was not ready yet to say either way. The MD stated that he is now more confident that the resident does not have a diagnosis of dementia, but he cannot be certain whether or not the resident has a diagnosis of psychosis. He has not observed any symptoms of psychosis, and the nurses have not reported any psychosis symptoms. The MD stated that it may be best to just take Resident #31 off the antipsychotic medication. The MD stated that he did not write a response to the MRR after he checked the disagree box because he did not feel it was warranted or necessary. An interview with the Director of Nursing (DON) was conducted on 12/05/19 at 12:30 PM. The DNS stated that when there are MRR recommendations from the pharmacist regarding antipsychotic medication use and GDR, the PNP is responsible for documenting a response. The Medical Director oversees the PNP and the MD but does not review all of their documentation unless there is an identified issue. The DON stated that if a resident is not displaying any behaviors associated with a psychiatric diagnosis, then the PNP needs to question why they may be on an antipsychotic medication and justify a reason that the resident is still on it. If the MRR from pharmacist includes recommendations, then there needs to be a response from the PNP or the MD as to the reason they do not agree. An interview was conducted with the Medical Director on 12/05/19 at 01:35 PM. The Medical Director stated that the facility has decided to link with a Psychiatrist to bolster their efforts to have a Psychiatrist oversee the tapering of antipsychotic medications. Whenever the pharmacist submits a monthly MRR related to antipsychotic medications, the PNP is made aware. The PNP then communicates her recommendations with the MD. The DON and the Medical Director also get a copy. The Medical Director stated that he reviews all of the MRR. A response to the MRR must always be given in writing. The standard practice is for the MDs and/or the PNP to write a response as to why they disagree with the MRR in the same box where they check of the disagree option. The MD and/or PNP then hands the MRR back to the DON. After the Medical Director reviewed the MRR for Resident #31, he stated that there should be a response somewhere in the resident's chart since it is not written directly on the MRR. The Medical Director stated that he does review the MRR after the MD signs off on it and was under the impression that the MD documented his rationale in the chart. If there is no documentation regarding the MD's disagreement with the MRR recommendation, then it must have been missed. The Medical Director does not review the MD's progress notes unless there is an identified issue. 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that a resident remained free of unnecessary psychotropic medication. Specifically, a rationale was not provided for the continued use of an antipsychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medications (Resident #31). The findings are: A facility policy and procedure related to Antipsychotic Medication Monitoring was undated and documented that the Psychiatrist can prescribe an antipsychotic medication to treat dementia with associated psychotic and/or agitated features. The Psychiatrist is to lower the dosage when clinically indicated and document such efforts. Resident #31 was admitted to the facility on [DATE] with a diagnosis of Unspecified Psychosis not due to a substance or known physiological condition and Unspecified Dementia with behavioral disturbance. The resident's admission Minimum Data Set 3.0 (MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on Zyprexa, and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a diagnosis of psychosis and received Zyprexa. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to Psychotropic Drug Use was initiated on 6/28/19 and documented that the resident is receiving Zyprexa for psychosis. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of psychotropic meds to evaluate for med reduction by decreasing dosage. The Physician's Orders, renewed 12/4/19, documented orders for Zyprexa 5mg once daily for Psychosis. This medication was originally ordered on 6/28/19. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on Olanzapine (Zyprexa) with no clear diagnosis to support current use. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalizations in the past. The PNP recommended to continue Zyprexa 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the diagnosis associated with the Zyprexa order. The MRR documented that the Zyprexa has been ordered to treat psychosis; however, the most recent psychiatry consult documented that the diagnosis is dementia. The physician documented that he disagreed, but he did not document the clinical rationale. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving encephalopathy causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. On 10/29/19 the MD note documented that the resident had questionable organic mental illness versus personality disorder, not yet established. None of the MD notes documented any reference to inappropriate behaviors displayed by the resident or that the resident was experiencing any hallucinations, delusion, or other psychotic symptoms. The MD Notes do not contain any documented evidence that the physician evaluated the continued use of Zyprexa for Dementia. A Psychiatry Assessment completed by the PNP on 12/2/19 documented that the resident had an uneventful last period free from behavioral issues and free from psychosis. The PNP documented that the resident sleeps well at night and keeps to himself most of the time. The recommendation was to continue Zyprexa 5mg once daily for dementia related to a medical condition and substance abuse disorder. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on 6/28/19. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview with the Certified Nursing Assistant (CNA #1), the resident's assigned CNA, was conducted on 12/04/19 at 03:03 PM. CNA #1 stated that the resident has not exhibited any inappropriate behaviors, and he likes to keep to himself and stay in his room. The resident is very compliant with care and showers. He has never exhibited any agitation or aggression towards any other residents. CNA #1 stated that when she starts her shift, she checks in on Resident #31 during rounds and then observes him while he is ambulating on the unit. The resident does not require assistance with any other activities of daily living. Resident #31 leaves the unit to go to the smoke room and interacts with a few of other residents. He is peaceful and has never been observed hallucinating or having delusions. CNA #1 stated that Resident #31 is able to have very good conversations with her, and he is one resident that she can communicate with. He has never been disrespectful, keeps himself clean, has a good appetite, and does not wander at night or have difficulty sleeping. The CNA stated that she is not aware of any special precautions besides ensuring monitoring the resident for safety. On 12/04/19 at 02:33 PM, an interview was conducted with the Licensed Practical Nurse (LPN #2), the LPN assigned to the resident's unit. LPN #2 stated that the resident does not currently display any inappropriate behaviors, hallucinations, or delusions. The resident also does not have any history of displaying any inappropriate behaviors. LPN #2 stated that the resident has good conversations with him and self-reported to the nurse that he does not hear voices. Resident #31 keeps to himself, displays no agitation or aggression, and has not attempted to harm himself or others. LPN #2 stated that the resident may have a diagnosis of psychosis or schizophrenia since the resident did report hearing voices prior to admission to the facility. Resident #31 is very respectful, compliant, and responds to questions appropriately. LPN #2 was not aware of activities the resident attended, but he stated the resident is usually out of the room when he does rounds. The resident was recently approved to go Out on Pass independently, meaning that he could leave the facility without any escort or supervision from a responsible party. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and was not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed Zyprexa to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment by the PNP, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continued to have bouts of psychosis, is only oriented to himself, and does not know the time or date. The Zyprexa is also used to help the resident sleep, and he sleeps well at night because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment and that he had no expression on his face. The resident would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to the cognitive impairments. The PNP stated that according to her assessments, the resident had severe cognitive impairment and scored a 9-20 on the Montreal Cognitive Assessment (MOCA). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she was not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. This was the reason she recommended that the resident continue to receive Zyprexa. The PNP stated that Zyprexa is an antipsychotic medication that is used to treat psychosis, a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with dementia. The Federal Drug Administration (FDA) has recommended that Zyprexa be used to treat psychosis. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of Zyprexa, that she decided to continue prescribing the Zyprexa to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to psychosis. She does not recall the resident having any of these concerns. She determined that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the diagnosis of dementia, but dementia can include psychosis and can be caused by a substance abuse history. Nonpharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, she has not specifically spoken to the MD about Resident #31. On 12/05/19 at 10:23 AM, an interview was conducted with the resident's assigned SW who has been working in the facility for 14 years. The SW stated that Resident #31 is a very pleasant resident and complies with his full plan of care. The SW stated that although there is no documented evidence in the resident's medical record, she believes that he has a diagnosis of schizophrenia. The resident receives disability from the Social Security Administration and the SW stated that a representative verbally told her that it was for schizophrenia. No documented evidence was provided to support this diagnosis or claim. The resident displays a very introverted personality but does not display any negative or inappropriate behaviors. Resident #31 does interact well with other and attend activity programs but prefers to be alone in his room. The resident has not displayed any aggressive or agitated behavior towards staff or other residents. He is always very respectful. When the resident was first admitted to the facility, his communication was tangential, and the resident would speak in a word salad with incomplete sentences. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD has been assigned to oversee the resident's care since his admission to the facility. The MD stated that Resident #31 has an odd personality but does not exhibit any inappropriate or negative behaviors at all. The resident is not aggressive. The MD stated that he assessed the resident's cognition when he was first admitted to the facility and the resident scored a 25 out of 30 on the mini-mental exam. There was some discussion of whether he has schizophrenia or schizoaffective disorder, but this has not been determined as of yet. The resident receives a low dose of Zyprexa and consistently does well on mini-mental exams used to test his cognitive status. The facility determined that he was safe to go Out on Pass independently without supervision or an escort. The resident is compliant with his medication regimen and has never exhibited or reported any delusions or hallucinations. The MD stated that the resident is just odd. The resident answered appropriately when asked what state he was currently in, but he responded inappropriately when asked what country he resided in. The MD stated he got the impression that the resident was playing with me. The resident was admitted from the hospital on Zyprexa, and the MD believes that schizoaffective disorder may be the diagnosis. It is difficult to obtain the psychiatric history for residents when they are admitted to the facility. Resident #31 does not have any involved family members, and the resident was unable to provide any history of his psychiatric treatment prior to admission. The resident has a current diagnosis of dementia related to a medical condition, but the MD disagrees with this diagnosis. The MD stated that the resident might have a personality disorder or a mood disorder. The resident does not display any symptoms of mood issues. He stated it is more likely has a personality disorder because the resident is odd. Resident #31 has no problem conversing with the MD when approached. The MD stated that although the resident's record indicates that the resident has a diagnosis of dementia, the resident is asymptomatic. The MD stated that if the resident had Dementia, he would expect to see some level of cognitive impairment. He does confer with the PNP, but he did not do so in this case. He would have communicated to the PNP that he does not believe that Resident #31 has a diagnosis of dementia. The resident has been receiving Zyprexa because the PNP must have seen something during her evaluation to warrant the use of an antipsychotic medication. If the resident has not displayed any aggressive behavior or disordered thought process, then the Zyprexa can be discontinued. According to the PNP, the Zyprexa has been ordered for this resident to treat a diagnosis of dementia. The MD stated that he does not necessarily support that conclusion. The MD stated that he reviews the consults that the psychiatrist writes and determines if there should be any changes based on the recommendations made. The MD stated that Zyprexa can be used to treat psychosis, thought disorders, and dementia with agitation and delusions. 415.12(l)(2)(ii)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that drugs and biological's were stored in accordance with Federal and State regulations. Specifically, 4 pre-filled syringes, containing expired Influenza Vaccine Afluria Quadrivalent 2018-2019, were in the medication refrigerator. This was evident for 1 of 9 areas observed for Medication Storage and Labeling (Nurse Staffing Coordinator's Office). The finding is: The facility policy titled, Expired Medications dated 4/22/19 documents: It is the policy of the Highbridge Woodycrest Center to require the return of any expired medications to the pharmacy. Outdated (expired) drugs will be discarded and/or returned to the pharmacy per the manufacturers expiration date. All stock medications will be reviewed monthly to ensure that there are no expired drugs available for administration. The Charge Nurse will check the labels on the item each time prior to medication administration. The Nursing Supervisor will review stock items monthly to ensure there are no expired drugs available for use. On 12/3/19 at 3:35PM the facility medication storage task was performed in the Nurse Staffing Coordinator's Office. It was observed that one box of Influenza Vaccine Afluria Quadrivalent 2018 - 2019 Season which contained 4 pre-filled syringes each containing a single 0.5 ml dose was stored in the medication refrigerator. The box was labeled with Lot number -YF41008 and an expiration date of June 30, 2019. On 12/3/19 at 3:42PM the Director of Nursing was interviewed and stated, This refrigerator contains active stock medications. In this refrigerator we store Tuberculin Purified Protein Derivative (PPD), Influenza vaccine and Pneumovax vaccine. You just showed me a box of Influenza vaccine that contains 4 pre-filled syringes which are expired. The expiration date says June 30, 2019. Today's date is December 3, 2019. So this Influenza vaccine is 156 days past its expiration date. It is the responsibility of the Nursing Supervisor on the day shift to check this refrigerator to make sure there are no expired medications in this refrigerator. This was probably overlooked as it is stored with the other in date Influenza vaccines. She will inservice the Nursing Supervisors and make sure, they check this refrigerator on a daily basis. The syringes will be discarded. No resident received the outdated Influenza vaccine this flu season. The dedicated Licensed Practical Nurse (LPN #1) that administers vaccines to the resident used the 2019-2020 vaccine. On 12/05/19 at 11:15 AM the LPN#1 was interviewed and stated, I usually administer the Influenza to all the residents in the facility. I go to the Nurse Staffing Coordinator's Office where the Influenza vaccine is given to me by the Nursing Supervisor on duty. I never go into the Nurse Staffing Coordinators Office to take any Influenza vaccine out of the refrigerator they keep there. I take the vaccine and I check the expiration date. I make sure the resident has a consent form. I will will do vital signs and administer the Influenza vaccine. I document the date administered and the site where it was injected. I take the extra sticker off the pre-filled syringe and paste it onto the vaccine administration record. The pre-filled syringe sticker shows you the Influenza vaccines lot number as well as the dates 2019-2020 documenting it is the new vaccine and not last year's expired vaccine. 415.18(d) .