Every finding on record at Knollwood HSC

Based on record review and staff interviews for one (1) of eight (8) sampled residents, facility staff failed to adequately monitor and supervise a resident with a high fall risk. Subsequently, the Resident had three unwitnessed falls in the same month (02/07/25, 02/22/25, and 02/28/25). The unwitnessed fall on 02/28/25 resulted in a sustained injury. Resident #8The findings included:A review of the facility's policies and procedures approved on 09/06/24, entitled, Fall Prevention Policy documented: Policy Goals: ' .To reduce the risk of falls and related injuries by addressing modifiable factors . Procedure: A fall risk assessment should be completed on admission and quarterly at a minimum. If the total score is 10 or greater, the resident should be considered at risk for falling. The pharmacy consultant should review each resident's medications to uncover potential drug-to-drug interactions and to make suggestions regarding inappropriate drug usage. This should result in written recommendations to the resident's primary care physician that could eliminate or reduce the dosage of medication that could predispose a resident to a fall. After a fall, the resident will be reassessed by the interdisciplinary team. Assessment will include the determination of possible causal factors, considering environmental factors, residents, medical condition, the resident's behavior, manifestation, medical or assistive devices.A review of the facility's policies and procedures approved on 09/06/24, entitled, Resident Monitoring and Rounding Policy, documented: Purpose: To ensure the safety, dignity, and well-being of residents through regular monitoring and timely response to their needs .Scope: This policy applies to all nursing and rehabilitation staff members, including registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), and support personnel 1. Resident Monitoring and Rounding procedures: 1.1 Frequency of Rounds- General Rounds: Nursing staff shall conduct rounds at least every two hours during the night shift to monitor residents who are unable to use signaling devices or who have specific care needs .2. Day and Evening Shifts: Rounds shall be conducted at regular intervals to ensure continuous monitoring and timely response to resident needs. 1.2 Documentation: A written log shall be maintained, recording the date and time of each round, the name of the staff member conducting the round, and any observations or actions taken. Logs shall be retained for a minimum of two years and be available for review buy DOH inspectors .Resident # 8 was admitted to the facility on [DATE] with diagnoses that included: Bilateral Primary Osteoarthritis of first Carpometacarpal Joints, Hypothyroidism, Psychotic disorder with delusions, Prediabetes, Syncope and collapse, Generalized Muscle Weakness, and Unspecified Multiple Injuries.A review of Resident #8's medical record revealed the following:A physician's order dated 10/21/24 that directed, Ambien (Zolpidem) [a hypnotic medication] - Schedule IV tablet; 5 mg (milligram) amt (amount): 1 tab oral. Special instructions: Ambien 5 mg po (by mouth) hs (at bedtime) dx (diagnosis); sleep at bedtime.A physician's order dated 11/05/24 that directed, Eliquis (Apixaban)[an anticoagulant//blood thinning medication] Tablet 5 mg 1 tablet, oral. Special instructions: Eliquis 5 mg po BID (twice) a day for LE (lower extremity), DVT (Deep Vein Thrombosis). Twice a day: 9:00 AM, 5:00 PM.A physician's order dated 1/16/ 24 that directed, Depakote (Divalproex )[an anticonvulsant medication] tablet, delayed release/enteric coated (DR/EC). 125 mg, amt: 1 tab oral; Special instructions: Begin Depakote 125 mg po, give 1 tab BID for Agitation,An annual Minimum Data Set (MDS) assessment dated [DATE] which documented that Resident #8, had a Brief Interview for Mental Status summary score of, 12, indicating that the Resident: had moderately impaired cognition, had displayed verbal behaviors towards others, required substantial/maximal assistance by staff for transfers, had received a hypnotic, an anticoagulant, and an anticonvulsant, within the last seven days of the assessment, and had received physical therapy.A physician's order dated 01/24/25 that directed, Clonazepam - Schedule IV tablet; 0.5 mg; amt: Give 1/2 (one half) tablet (0.25 mg); oral; Special instructions: Begin Depakote 125 mg po give 1 tab BID for Agitation.Fall #1 - Unwitnessed fall on 02/07/25A Nursing Progress Note dated 02/07/25 at 6:00 PM, that documented: At around 6:00 PM, this writer was called by staff to go in[to] [Resident #8's Room Number]. When questioned [asked] what happened, she said she fell. When questioned if she is in pain, she said her left knee, which has a history in the past of having pain and swelling to her left ankle due to decreased mobility, impaired gait balance, and multiple joint pain, with a h/o (history of) falls in the past with injury. ROM (range of motion) done to bilateral UE and LE (upper extremities and lower extremities), and able to move all extremities. With no problem. Neuro checks initiated. No bruises noted at this time. [Name of Physician] [was] notified about the fall with [an] order to continue monitoring [the] Resident and any changes to transfer to ER (Emergency Room) for further evaluation.A John Hopkins Fall Risk assessment dated [DATE] at 6:00 PM that documented that the Resident was on two (2) or more high fall risks drugs (anticoagulants, anticonvulsants, hypnotics) lacked understanding of one's cognitive limitations, and had a total falls risk score of,16, indicating that Resident #8 had a high fall risk.A care plan initiated on 02/07/25 that documented, Problem: [Resident #8's Name] experienced an unwitnessed fall and reports knee pain, with a history of impaired gait, joint pain, and past falls .Approaches included: Asses for injuries, swelling or changes in mobility; Implement fall precautions as per facility protocol; Remind resident on safety measures and encourage call bell use.During a face-to-face interview on 06/03/25 at 1:45 PM, Employee #4 (Certified Nurse Aide), stated the Resident would call often. Sometimes she would call to get help to go to the bathroom, and sometimes she would attempt to go by herself. She added, The CNAs would round on Resident #8 frequently-- at least every two hours. During rounds, we would ask the resident if she needed to go to the bathroom, and we (the CNAs) would make sure the call light and her belongings were nearby. The CNAs do not document rounds in the electronic health record; they just do their rounds. Of note, Resident #8 was receiving four medications identified as high fall risk medications (Ambien, Eliquis, Depakote, and Clonazepam), however, the interdisciplinary team made no recommendations to change her medications after her fall. In addition, per the facility's policy, there was no documented evidence of a written log that recorded the actual date, time and name of staff to show when the CNAs and the nurses conducted rounds at regular intervals during day and evening shift to ensure continuous monitoring and timely response to the Resident's needs. Fall #2 - unwitnessed fall on 02/22/25A Nursing Progress Note dated 02/22/25 at 10:38 PM, that documented: Resident was received this shift in a stable condition, sitting in her wheelchair. Dinner was served .The CNA (Certified Nurse Aide) assigned to her said she heard the chair alarm beeping, so she went to her room to check on her. Upon entering her room, she observed the Resident on the floor in a lying position beside her bed . Psychiatric referral and Rehab Referral were done. [The] Writer did a neurological assessment. She [was] alert, verbally responsive. She was able to move her upper and lower extremities, she did not complain of any pain while being assessed {the] Writer asked her what happened, she could not explain what happened, [Staff who was assigned to her reported that she saw her few minutes ago, about 15 minutes in her room sitting on her wheelchair prior to her being observed on the floor. [The] bed was in the lowest position, the call bell was beside her wheelchair, the night stand table was beside her, and other routine usable items were within close reach to her. ]A John Hopkins Fall Risk assessment dated [DATE] at 11:54 PM that documented that the Resident was on two (2) or more high fall risk drugs, was impulsive ,and had a total falls risk score of,19, indicating that Resident #8 had a high fall risk.A physician's order dated 02/23/24 that directed Psych consult referral s/p fall .A John Hopkins Fall Risk assessment dated [DATE] at 9:48 AM that documented that the Resident was on two (2) or more high fall risks drugs, lacked understanding of her cognitive limitations, and had a total falls risk score of ,21, indicating that Resident #8 had a high fall risk.A care plan initiated on 02/24/25 that documented, Problem: [Resident #8's Name] experienced an unwitnessed fall, .has a history of impaired gait, joint pain, and past falls .Approach: Consult the pharmacy for medication review. A Nursing Progress Note on 02/25/25 at 11:57 AM that documented: Resident seen Psych MD on shift, wrote new orders to discontinue Ambien, and to begin Seroquel 25 mg by mouth twice daily for psychotic agitation/hold if sleeping/drowsy. When entering Seroquel in [Name of electronic health record system ],[An] alert [was] received: Seroquel oral tablet 25 mg should be used with extreme caution when debilitation, a condition related to [the] need for assistance with personal care, exists. Reviewed with Psych MD, who gave an order to proceed with Seroquel as ordered.A physician's order dated 02/27/2025 that documented: Seroquel (Quetiapine) [an antipsychotic medication] tablet, 25 mg, amt: 1 tab oral; Special instructions: Dx: Pschotic Agitation once a day at 9:00 AMA Nursing Progress Note on 02/27/25 at 4:07 AM that documented, Listened to voice mail messages that [Name of Psychiatrist] discontinue (d/c) previous Seroquel 25 mg po order from bid and changed to daily for psychotic agitation. Will double check . then notify family, for the new order.During a face-to-face interview on 05/02/25 at 4:24 PM, Employee #5, (CNA), stated that she could not remember any specific fall but acknowledged that she had cared for Resident #8. When asked what interventions she provided when caring for residents to prevent falls, the Employee stated, We do regular rounds- regular checks, on the residents. When we come on shift, we go from room to room to see if the residents need anything, and then we get our resident assignments. We (the CNAs) make sure our assigned residents have what they need. When asked how often rounds were conducted on the residents, the Employee stated, I'm not sure when the nurses round, but the CNAs check the residents every hour. When asked where the CNAs document resident rounds, she said there is no place to document in [Name of electronic health record system], but we do our rounds.Fall #3 - unwitnessed fall with sustained injury on 02/28/25A Nursing Progress Note 02/28/2025 at 02:37 PM, that documented: Heard the chair alarm sounding on reaching Resident's room, [the] Resident observed on the floor in the bathroom, lying on her right side .[The] Resident reported she was going to the bathroom, and she did not ask for assistance. She was educated to call for assistance. [The] Resident c/o (complained of) pain to her right ankle. [The] Resident [was] medicated with prn (as needed) Tylenol, and started on neurological checks. Notified [Name of Nurse Practitioner], she ordered X-Ray to the right ankle . An x-ray report on 02/28/25 that documented, XR (X-ray) Right Ankle Complete 3 + views; Findings: There is an acute, mildly displaced fracture of the medial malleolus. There is an acute, mildly displaced fracture of the distal fibula . A John Hopkins Fall Risk assessment dated [DATE] at 3:51 PM that documented that the Resident was on two (2) or more high fall risks drugs, lacked understanding of her cognitive limitations, and had a total falls risk score of,21, indicating that Resident #8 had a high fall risk.A facility reported incident (FRI)(DC~13478), submitted to the State Agency on 03/01/25 that documented: .On 02/28/2025 [The] Resident's chair alarm was heard. Staff responded to the alarm in the Resident's room. The] Resident was observed lying on the floor in her restroom on her right side. Per nursing note on the day of fall, [The] Resident acknowledged that she did not call for help, and she attempted to go to the bathroom. [The] Resident was encouraged to call for assistance. [The] Resident denied hitting her head at [the] time of the fall. Neuro checks were initiated as per facility protocol and were noted within normal limits/as per the Resident's baseline. On the day of fall, [The] Resident complained of pain to the right ankle and routine Tylenol was given with effective results, [Name of Nurse Practitioner] was notified, with ordered X-ray of the right ankle received and ordered carried through as ordered. Today, 03/01/2025, the results came back .Impressions: acute, mildly displaced fracture of [the] medial malleolus, right, mildly displaced fracture of the distal fibula, mild soft tissue swelling, heel spur. [The] Right ankle x-ray [was] sent and reviewed via telephone with [Physician's Name], who then gave order for ER (Emergency Room) transfer for further evaluation and treatment .During a telephone interview on 05/03/25 at 1:00 PM, Employee #3,( Licensed Practical Nurse /LPN), stated that Resident #8 had several falls. She stated that for residents who were at high risk for things like falls, we checked more often-- every 1 - 2 hours. The CNAs, the nurses, and sometimes the charge nurses round on the residents. We do not document every hour that we round. Every shift, the nurses sign their initials on the treatment administration to record that we completed rounds.During a face-to-face interview on 05/03/25 at 1:15 PM, Employee #2/ Director of Nursing (DON), stated that the CNAs and the nurses round on residents every two hours. She added that Resident #8 was considered a high falls risk, so the CNAs and nurses rounded on the Resident frequently -- at least every two hours, or more often. When asked where the CNAs and nurses document their two-hour rounds for Resident #8, she acknowledged that CNAs had no place to document resident rounds. She added that the nurses documented once every shift that they provided falls precautions and made frequent safety checks for Resident #8 every shift, but not every two hours on the Resident's treatment administration record (TAR). The Employee then acknowledged that per the facility's policy, the CNAs and nurses did not have an actual written log that recorded the dates, times and names of staff to show that they conducted rounds at regular intervals during the day and evening shifts that ensured continuous monitoring and timely responses to the Resident's needs. The evidence shows that facility staff failed to adequately monitor and supervise Resident #8, a resident with a high fall risk. The Resident had three falls in February 2025 (02/07/25, 02/22/25, and 02/28/25). Of note, per the facility's policy there was no documented evidence before or after any of the falls, that facility staff had initiated or maintained a written log that recorded the actual date, time and name of staff to show that facility staff conducted rounds at regular intervals during day and evening shift to ensure continuous monitoring and timely response to the Resident's needs. In addition, despite medications being identified as a high falls risk factor for Resident #8, there was no change to Resident #8's medications until after the Resident's second fall on 02/22/25.Cross-reference Title 22B DCMR Chapter 32 Section 3211.1(d)

Based on record reviews and staff interviews, for one (1) of eight (8) sampled residents, the facility staff failed to implement its written policies and procedures for investigating incidents of abuse. Resident #4 The findings included:A review of the facility's policy titled Investigation of Incidents Abuse, Falls, Wounds, Reportable Events(effective date 09/2024), documented the following: 5. Procedure .C. Category Specific Guidance 1. Abuse Allegations: Remove alleged abuser from resident care pending investigation, Report to DC DOH per regulation, File with Adult Protective Services, if applicable, Submit findings to DOH .A review of a facility reported incident (FRI) (DC~12149) submitted to the State Agency on 07/31/23 at 4:31 PM documented the following: At 1:45 PM today (7.31.23), resident said to me that she has [had] a CNA (Certified Nurse Aide on evening shift (3-11 PM) this past Saturday (7/29) and Sunday (7/30) that was mean to her. I asked her, 'What made her mean?' She said she put the phone on the dresser hard for no reason and went on to say she was rough in the way she handled her. I asked her how. She said 'Everything she did and said - It's not a nurse. Normally, people say turn on the left side or the right side. This one is verbally rough, like she is taking care of a truck driver, not the patient.' I asked her about physical interaction. She said, 'She was ok, but she made me feel like I did something wrong and that I am against her. I thought maybe it was the age .when the younger age does not know how to take care of the elderly. A review of Resident #4's medical record revealed: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Diastolic Congestive Heart Failure, Schizophrenia, Unspecified Dementia, Major Depressive Disorder, and Tobacco Use. An admission MDS assessment dated [DATE],3,which documented that Resident #4 had a Brief Interview for Mental Status summary score of 13, indicating that the Resident had intact cognition and required extensive assistance by one staff member for bed mobility, transfers, and personal hygiene. A review of the facility's investigation documents for the alleged incident showed the following: 1. A written statement dated 07/31/23 from Employee #6, (Certified Nurse Assistant/ CNA), assigned to Resident #4 and alleged perpetrator in the incident that documented: [Name of Resident #4] was assigned to me on Saturday, 3:00 to 11:00, and Sunday 3:00 to 7:00 AM, Monday, 7/31/23. After Sunday evening, Resident #4] was my first resident to take care of. She was in bed while I was doing [her] care after washing her up. I wanted to put the wet diaper in the trash can. At the time, I noticed that the telephone cord and the oxygen cord was [were] wrapped under one of my feet, in the process of putting the wet diaper in the trash can. That's what caused her telephone to drop on the floor. I, [Name of Employee #6], was not verbally rough with the resident. [Name of Resident #4] asked me, 'What is that noise?' and I replied to her saying, 'It is the telephone which dropped on the floor.' Right away I took off my dirty gloves and put [the phone] back. where it was. I make [made] sure everything is cleared off [out of] my way before finishing care with her. Before leaving her room, I made sure I put everything by her reach.2. A typed statement dated 08/02/23, from Employee #7 (Former Director of Nursing/ DON) that documented: Conclusion to the investigation regarding report of staff caring for her being verbally rough [Name of Resident #4] reported 7/31/23 at 1:45 PM that the CNA who took care of her Saturday evening, 7/29/23 and Saturday night shift was verbally rough. [The] Resident was asked what happened on Saturday. She stated that the care was fine physically, and the CNA didn't say anything that was not kind, nor was she disrespectful. I asked her again if the CNA yelled at her, or if she was physically rough with her. She stated,' No.' She stated, that the CNA [placed] the phone hard on the dresser. Social Services also interviewed several residents on CNA's assignment, and there were no concerns about inappropriate interactions. Staff were reminded to be extra patient with her {Resident #4], and use please and thank you with requests. The allegation of being fairly rough could not be substantiated. A follow-up report was sent to the State Agency dated 08/02/23, which documented: Follow up to the Incident report sent 7/31/23 regarding resident [Name of Resident #4] report of staff being verbally rough and staff putting the phone hard on the dresser. The resident was interviewed by the social worker and DON (Director of Nursing), and she stated that the staff was not rude to her and didn't yell at her; she just didn't use please and thank you when communicating with her. The resident was also informed that the phone had fallen to the floor, which might be the noise that she heard. The staff that was mentioned in the concern was interviewed and stated that her interaction with the Resident didn't reflect the report. Several residents who were part of the C.N.A assignment were interviewed, as well, and they report[ed] just great interactions with staff. This allegation could not be substantiated.A review of the Nursing assignment sheets showed that Employee #6 worked on the unit on the following dates:07/29/23 3:00 PM-11:00 PM (assigned to resident)07/29/23 1;00 PM to 7:0 AM shift (assigned to resident07/30/23 3:00 -11 PM and 11:00 -7 AM Employee #6 was assigned to the Resident 07/31/23 from 3:00-11 PM showed that Employee #6 was assigned to Resident #4A review of Employee #6's timesheet from 07/29/23 to 8/2/23 showed that the Employee worked on the following days:07/29/23 from 2:39 PM to 11:07 PM 07/ 29/23 from 11:07 PM to 7:50 AM (Sunday)07/30/23 from 3:00 PM to 11:07 PM07/30/23 from 11:07 PM to 7:04 AM07/31/23 from 2:38 PM to 11:32 PMA review of the facility's nurse assignment sheets and a review of Employee #6's timesheet showed that facility staff failed to ensure the safety of Resident #4 during its investigation of an incident that alleged staff-to-resident verbal abuse, by failing to follow its policy to remove the alleged abuse [staff person] from the schedule during its investigation. During a telephone interview on 05/30/25 at 12:28 PM, Employee #6, stated, I really can't remember the incident. I know that when a staff person is named in any incident involving a resident, they are asked to leave and not report to work until further notified. I don't recall having to take time off for any alleged incident with Resident #4.During a face-to-face interview on 05/30/25 at 3:26 PM, Employee #2/, (Director of Nursing /DON), stated that during a facility's investigation of an incident between a resident and staff that involves abuse, the alleged staff is immediately removed from resident care, pending the final results of the facility's investigation. The Employee stated I was not the DON, and had no part in the investigation for the alleged abuse of Employee #6 to Resident #4. She then acknowledged that Employee #6 should have been removed from resident care during the facility's investigation period of the incident but was not.

Based on record review and staff interviews for one (1) of eight (8) sampled residents, facility staff failed to provide a physician discharge summary that included: a recapitulation of the resident's stay that includes, a final summary of the resident's status and reconciliation of all pre-discharge medications for a resident who was discharged home. Residents #4The findings included:Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Diastolic Congestive Heart Failure, Schizophrenia, Unspecified Dementia, Major Depressive Disorder, and Tobacco Use.A review of Resident #4's medical record showed the following:A Nursing admission Note dated 07/28/2023 at 1:04 PM that documented: New admission . Resident, well-kempt, prior stay in assisted living in this facility. Resident is on oxygen 3/liters/minute/min infusing as ordered. [The] Resident was treated at [Name of Local Hospital] for CVA (Cerebral Vascular Accident/stroke) and bilateral hip pain. She has orders for Apixaban 2.5 mg and Tylenol prn (as needed) at 9:00 PM, respectively, for pain. Her diet is soft and bite-sized, with thin liquids, diet slip in place. Resident is DNR (do not resuscitate) .Resident is incontinent of bowel, bladder. Ambulatory with walker with supervision according to report from [Name of Local Hospital] . Some historical diagnoses include Colon ca (cancer), Anemia, PVD, Peripheral Vascular Disease) .A Social Work Progress Note dated 08/03/2023 at 3:56 PM that documented: admission paperwork sent to son for completion - awaiting a response - also LCD (long-term care discharge) will be 8/7/23 - to return to AL (assisted living)/ The Terrace on 8/8/23.A Nursing Progress Note dated 08/08/2023 at 10:58 AM that documented: resident alert, verbally responsive. Review of discharge summary. No questions. Copy provided to [the] Resident. reviewed with [the] Resident that A.L. staff will continue to administer her meds (medications) as before. [The] Resident is currently sitting in a chair in the room. awaiting updates for AL staff as to the time of transfer.A Nursing Progress Note dated 08/08/2023 at 12:35 PM that documented: resident assisted to a.l. (assisted living) In stable condition via w/c (wheelchair)/c on routine oxygen. w/c and other personal belongings brought back to apt. dietary and clinical nurse updated re: discharge.A Social Work Progress Note dated 08/08/2023 at 2:03 PM that documented: Resident returned to her AL Apartment in the Terrace - son aware. Note paperwork has never been returned by the son - 6-108 completed.Of note, there was no documented evidence of a physician discharge summary that included: a recapitulation of the resident's stay that includes a final summary of the resident's status and reconciliation of all pre-discharge medications for Resident #4. The Social Worker and the Nurse who cared for the resident before discharge on [DATE] were no longer employed by the facility and were not available for interview during the survey.During a face-to-face interview on 05/03/25 at 4:00 PM, Employee #2, (/Director of Nursing/DON), acknowledged that there was no physician's discharge summary included in Resident #4's medical record. She then stated that she would speak with the medical team and the Medical Director to ensure that upon a resident's discharge, the physician provided a physician's discharge summary in the resident's medical record that included: a recapitulation of the resident's stay, a final summary of the resident's status and a reconciliation of all pre-discharge medications.

Based on record review and staff interviews for one (1) of eight (8) sampled residents, the facility staff failed to update care plan interventions for a resident with a history of aggressive behaviors. Subsequently, the resident had two staff-witnessed incidents of aggressive behavior towards another resident. Residents #1 and #2The findings included1. Incident #1A review of an incident report submitted on 01/29/25 at 4:34 PM to the State Agency, that documented the following: Staff reported that Resident [Resident #1] was hit on shoulder by another resident,[Resident #2] Per staff report, she[staff] was escorting {Resident #2] to hair salon, as [Resident #2] walked past resident [Resident #1], [Resident #2] hit resident [Resident #1] on left shoulder. [Resident #1] responded with pain cues. [The] writer followed up with the resident [Resident #1}, who declined. being hit by another resident, and appeared upset that someone would report that she was hit. Resident [Resident #1] denies pain/discomfort to left shoulder, able to raise left shoulder to 90 as per baseline, no noted redness/discoloration, bruising, or] swelling noted to left arm. [The] Residents' POAs (Power of Attorney) [were] updated re: (regarding) incident .[The] MD (Medical Doctor) for both residents was updated. Order for psych consult received for [Resident #2] .A. Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Bilateral Primary Osteoarthritis, Vascular Dementia, Major Depressive Disorder, Difficulty in walking, and Other Abnormalities of Gait and Mobility, and Pain in the Left Shoulder.A review of Resident #1's medical record revealed:An Annual Minimum Data Set (MDS) assessment dated [DATE] which documented that Resident #1, had a Brief Interview for Mental Status summary score of, 13, indicating that the Resident had intact cognition, In addition the Resident had: no display of verbal or physical behaviors towards other, lower extremity impairments on both sides, and used a manual wheelchair for mobility.A care plan initiated on 01/29/25 that documented: Problem: 01/29/25 [Resident #1] was hit by a fellow resident on the left shoulder. Goal: [Resident #1] will not show any signs and symptoms of injuries related to reported interaction. Approach: Administer prescribed pain relief if needed and apply ice to reduce swelling. Assess the injury dash. Check for bruising, swelling, pain or limited movement. Document findings. Monitor for changes dash Watch for increased pain, redness, or other signs of complications. Emotional support -Reassure [Resident #1] offer comfort and assess for emotional distress.SheDuring a face-to-face interview on 05/30/25 at 2:35 PM, Resident #1 stated, 'She [Resident #2] just pulled back and slapped me'. She further commented, 'She [Resident #2] hit me twice, once on the shoulder and another time across her face.' When asked if she felt safe at the facility, she stated, 'Yes, I just stay away from the Resident #2.B.Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, Peripheral Vascular Disease, Fibromyalgia, Depression, Insomnia, and Chronic Pain Syndrome.A review of Resident #2's medical record showed:A physician's order dated 12/12/24 that directed: Trazadone 50 mg tab; 1/2 tab = 25 mg; orally; Three times a day. Special Instructions: Give 1/2 tab = 25 mg by mouth at 8:00 AM, at 12:00 PM, and at 9:00 PM for Agitated Dementia. (***Hold if resident is drowsy or sleeping).An Annual Minimum Data Set (MDS) assessment dated [DATE], which documented that Resident #2 had severely impaired cognition. In addition, facility staff noted that the Resident showed signs of being short-tempered and easily annoyed, and had received an antidepressant medication within the last seven days of the assessment.A Physician/Psychiatrist Note dated 01/01/2025 at 09:57 PM that documented: For 12-31-2024 patient had just berated another patient who can be at times quite intrusive; however, when I met with her, she was very pleasant and cheerful. Indeed, we joked with one another. Her current dosage of Zoloft is somewhat sedating, and we may well have to consider switching her to a medication which is less sedating.A Physician/Psychiatrist Note dated 01/09/2025 at 10:30 PM that documented: Patient continues to exhibit aggressive behavior. In particular, after lunch. However, she can be distracted and engaged at times in a way that diminishes her anger and excitability.A Physician/Psychiatrist Note dated 02/04/2025 at 5:00 PM that documented: for 02-04-25 patient seen with her usual companion since transfer to unit from assisted living. She was calm and polite but volunteered little information to the questions she was asked. Staff, however, reports she can be very aggressive with aids and at times physically aggressive. She has a very quick temper and, at times has been aggressive with patients. This has been a persistent problem with this patient. She can be calm for extended periods and explosive at the drop of a hat. She gets an angry look in her eyes, and at these times should be left alone and have no further stimulation. She usually calms down. She still has a sense of humor and often responds to a joke about her past. [The] Patient always denies having been aggressive. Because her outbursts are random and infrequent,t medications on a regular basis have not been administered.A care plan revised on 01/29/25 that documented: Problem: [Resident #2] [Hit/Punch[ed] a fellow resident [Resident #1] on her left shoulder. Goal: Resident [2] not to show any inappropriate behavior to fellow resident [Resident #1]. Decrease inappropriate contact with fellow resident [Resident #1] through next review date. Approach: Psychiatrist consult to follow up on aggressive behavior. Of note, Resident #2 was on the Psychiatrist's case load for aggressive behavior before the incident with Resident #1 on 01/29/25. There was no documented evidence that facility staff updated or revised Resident #2's care plan with new approaches/interventions to prevent Resident #2 from acting inappropriately towards or having inappropriate contact with Resident #1 after the incident. Subsequently, the two residents had another altercation on 04/30/25, in which Resident #2 behaved aggressively toward Resident #1.During the survey, Resident #2 was not available for interview.2. Incident #2 A review of a facility reported incident (FRI) (Intake DC 00013644) submitted to the 'State Agency on 04/30/25 at 6:38 PM that documented: Submitted online on 4/30/25: [Name of Resident #1]Resident .with pertinent history of vascular dementia, psychotic disturbance, mood disorder, and anxiety. Today, at approximately 4:50 PM, activity assistance reported that at 4:30 PM, resident [Resident #1] reported that another Resident, [Name of Resident #2], slapped her on the face. [The] Writer followed up with Resident [1], who acknowledged the staff's statement. Assessment completed. No noted redness/discoloration, bruising, or swelling noted as per baseline. Resident [1] denies pain and no signs and symptoms of grimacing, guarding, crying, or other signs of trauma and injuries. The accuser [Resident #2] could not recall any inappropriate interaction. Resident [Resident #1]?s POA (Power of Attorney) updated. MD made aware. DON (Director of Nursing)/Administrator made aware. Staff to monitor resident and redirect resident as needed, and keep MD and family updated.[Name of Resident #2]Resident .with pertinent diagnoses of depression, agitated dementia, and taking routine Duloxetine for depressive episodes. Today, at approximately 4:45 PM, activity assistance reported that at 4:30 PM, [Name of Resident #1] reported that Resident [Name of Resident #2] slapped her on the face. [The] Writer followed up with the other resident, [Resident #1], who acknowledged the staff's statement. Assessment completed. No noted redness/discoloration, bruising, or swelling noted as per baseline. Resident [Resident #2] could not recall any inappropriate interaction. Resident [Resident #2]'S POA was updated, and verbalized appreciation for the update. NP (Nurse Practitioner) notified, order for psych evaluation.Resident #1 - FUP (Follow-up) received on 5/5/25 at 4:13 PM: **Follow-Up Report to Incident Report Submitted on April 30, 2025** A thorough investigation has been completed, during which staff and residents were interviewed, and statements were collected. According to a Certified Nursing Assistant (CNA), on April 30, 2025, at approximately 4:30 PM, she heard the accused resident tell [Resident #1], If you don?t shut up, I'm going to slap you. However, the accused resident [Resident #2] did not actually slap [Resident #1]. The staff member reported that she successfully separated both residents without any further incidents. [Resident #1] was monitored for a period of 72 hours, and no abnormal skin changes were observed. Staff will continue to monitor and redirect the residents as necessary and keep MD and RP (Resident Representatives/POAs) updated.A. A review of a care plan for Resident #1 updated on 04/30/25 that documented: Problem: resident reported that she was hit by a fellow resident [Resident #2]. Goal: [Resident #1] to remain free of injuries through the next review date. [Resident #1] will not show any signs and symptoms of injuries related to the reported interaction. Approach.:Monitor for signs and symptoms of abnormal changes and update the provider, psych consult, and follow recommendations.B. A review of a care plan for Resident #2 updated on 04/30/25 that documented: Problem: Fellow resident reported that resident slapped her on the face. Goal: Resident not to show any inappropriate behavior to fellow residents. Decrease inappropriate contact with fellow resident [Resident #1] through the next review date. Approach: New Psych consult for report of inappropriate contact with a fellow resident. Of note, there was no documented evidence that facility staff updated or revised Resident #2's care plan with new approaches/interventions after the second incident with Resident #1 on 04/30/25.During a face-to-face interview on 06/03/25 at 4:30 PM, Employee #2, (Director of Nursing//DON) , stated that it is the DON's responsibility to update residents' care plans. When asked about Resident#2's behavior, she acknowledged that Resident #2 had aggressive behaviors toward staff and other residents. She added that the Resident had seen the psychiatrist for aggressive behavior before and after the incidents with Resident #1. She then acknowledged that the facility staff should have updated Resident #2 's care plan with new approaches/interventions to prevent Resident #2 from acting inappropriately towards or having inappropriate contact with Resident #1 after each incident. Cross-reference Title 22B DCMR Chapter 32 Section 3210.4(c)

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.

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.

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.

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 45104 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 1/2 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 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.

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 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)

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. 45104 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 ,d+[DATE], 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 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.

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. 45104 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 ,d+[DATE], 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 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

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 ,d+[DATE], 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

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.

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.

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

Based on observation, record review, and staff interview, the facility's staff failed to ensure that Resident #5, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in actual harm to Resident #5. The findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (Assessment Reference Date of 11/25/2020), documented the following: In Section C0500 (Brief Interview for Mental Status), the resident had a summary score of 14, indicating the resident was cognitively intact. In Section I, -(Additional Active Diagnoses) coded the resident for Pressure Ulcer of Sacral Region, Stage 3. In Section G (Functional Status) coded the resident for extensive assistance with the assistance of one (1) person for bed mobility and personal hygiene. In Section H (Bladder and Bowel)- the resident was coded as frequently incontinent of both bladder and bowel. In section, M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage) coded the resident for having one (1) Stage 3 pressure ulcer. In section, M 1200 (Skin and Ulcer/Injury Treatments), coded the resident for pressure ulcer/injury care and applications of ointments/medications. Observation: On 05/25/21 at 2:45 PM, observation of Resident #5's sacral wound showed approximately three (3) pinpoint open areas, red in color, no drainage, no smell, no depth, surrounding tissue was pink and intact. Also noted was barrier cream on the resident's buttock area. At the time of the observation, Resident #5 was lying on an air mattress, awake, alert, oriented to name, denied pain and continent of bladder and bowel. Review of the resident's care plan revealed the following: Care Plan (Pressure Ulcer) with a start date of 03/10/20. Goal: will minimize skin irritation and skin will remain intact. Approaches (start date of 06/29/20) included: -Monitor for skin irritation, document, report. -Turn and reposition Q (every) 2 hrs (hours) and prn (as needed), maintain pressure relieving device in bed and in w/c (wheelchair) monitor for placement. -Provide gentle care avoid friction. Provide incont (incontinent) care q (every) 2 hrs (hours) and prn (as needed), keep skin dry and oder [odor] free, apply [cream], lotion with incont. (incontinent) care . review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] 06/24/2020, to 07/30/2020, (Wound/Skin Records) showed the resident had a Stage II (pressure ulcer) in the sacral area with a start date of 06/24/2020 and a healed date of 07/30/2020. 09/11/2020, to 10/26/2020 (Wound/Skin Records) showed that the resident had a Stage II (pressure ulcer) in the coccyx area with a start date of 09/11/2020, and a resolved date of 10/26/2020. The record included bi-weekly Bath/Shower Days Skin Observation Sheets where the facility's staff documented their observation of Resident #5's skin. However, there were no Bath/Shower Sheets to reflect observations of the resident skin integrity from 10/30/2020, to 11/04/2020. The medical record also lacked documented of staff observations of Resident #5 's skin during incontinent care. 11/05/20 (Wound/Skin Record) site - A (coccyx), stage - unstageable, size - 1.2 X 1.2 cm (centimeters), depth -, exudate - 0, odor - 0, wound bed - dark red, surrounding skin color - WNL (with in normal limits), surrounding tissue/wound edges - this area was left blank. A nursing note dated 11/05/2020, at 10:51 AM revealed .Resident noted with recurrent open are on coccyx approx (approximately)1.2 By 1.2 CM (centimeters) area with deep red appearance. At baseline, no significant muscle mass in sacral region (very boney). No active bleeding noted. Denies discomfort tx (treatment) order given . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/10/20 (Wound/Skin Record) site - A (coccyx), stage - unstageable, size - 3.5 X 3.5 cm (centimeters), depth - , exudate - small serous sanguenous (sp), odor - 0 ,wound bed - dark red [and] yellow 10%, surrounding skin color - this area left blank, surrounding tissue/wound edges- granulation tissue. The nursing note dated 11/10/2020, at 2:03 PM, revealed, Followed up with previously noted coccyx wound area is spreading toward left buttock. Cluster measurement of affected area is approx. approximately) 3.5 by 3.5 CM (centimeters). Small amt (amount) of serous sanquenous (sp) drainage noted. Denies discomfort. Center of wound bed with a deep red appearance and some yellow covering (10%) granulation tissue noted at edges .ADON (Assistant Director of Nursing) assessed, MD (physician) updated. TX (treatment) order written .ADON .request for full air mattress. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that facility's staff assessed and/or monitored Resident #5's skin to identify potential changes in the resident's skin from 10/30/2020, to 11/04/20, subsequently ten days (11/05/2020) after the sacral wound was resolved on 10/26/2020, the staff documented that Resident #5 had an unstageable wound in the same (coccyx) area. During a face-to-face interview on 06/02/2021, at approximately 2:30 PM, Employee #8 (Licensed Practical Nurse/Wound Nurse) stated that nurses and certified nursing assistants conduct observations (skin rounds) of the residents' skin twice a week (shower days). The staff then documents all observations on the Bath/Shower Days Skin Observation Sheets. During a face-to-face interview on 06/02/2021, at approximately 3:30 PM, Employee #2 (Director of Nursing) and Employee #3 (Assistant Director of Nursing) acknowledged the finding and stated that staff assessed Resident #5's skin frequently during incontinent care and shower days. However, they did not have documented evidence of the skin assessment(s) performed during shower day(s) from 10/30/2020, to 11/08/2020.

Based on record review and staff interview, for two (2) of 18 sampled residents, the facility's staff failed to provide adequate supervision and monitoring to prevent falls with major injuries (fractures) for Residents' #5 and #31. This failure resulted in actual harm to Residents' #5 and #31. The findings include: 1. The facility's staff failed to provide adequate supervision to prevent a fall with major injuries (fractures) for Resident #5. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, [CONDITION(S)], Coronary Artery Disease, [CONDITION(S)], [CONDITION(S)], and Spinal Stenosis. Review of a Quarterly Minimum Data Set with an 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 [CONDITION(S)], 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, [CONDITION(S)], and [CONDITION(S)]. And in Section J (Health Condition), - the resident was coded for having one (1) fall with major injury since admission/entry/reentry (9/5/2019). Review of the medical record revealed the following: 03/07/20 at 8:30AM (Nursing Note) documented, 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 Physician's order dated 03/09/2020 stipulated, bilateral rib xray (sp) and lubar [lumbar]/sacral spine xray to r/o (rule out) fracture Review of the radiology report dated 03/09/2020, at 6:47 PM, revealed, (Bilateral Ribs and AP [anteroposterior] chest) - 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 [x-ray] done, result of chest C-Rays (sp) shows fracture of right 2nd rib posteriorly . Review of the care plan section of the record revealed: The fall care plan with a start date of 03/10/2020. 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. The Activity of Daily Living (ADL)/ Rehabilitation Potential Self-Care care plan with a start date of 03/10/2020. 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 . mobility, transfers, and locomotion. Review of the nursing note dated 06/17/20 at 4:23 PM revealed .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 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 .]. The physician's order dated 06/18/20 directed, Transfer to [hospital's name] ER (emergency room ) for Further eval (evaluation) & TX (treat) left hip pain and fall. The Nursing Progress noted dated 06/21/20 revealed, 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. 2. The facility's staff failed to provide adequate supervision to prevent a fall with major injuries (fractures) for Resident #31. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses that included: Dementia, [CONDITION(S)], Hypertension, Diabetes Mellitus, Heart Failure, Ulcerative Blepharitis Right Eye and History of Repeated Falls. Review of the Quarterly Minimum Data Set, dated dated dated [DATE], showed the following: In Section C0500 BIMS (Brief Interview for Mental Status), the resident had a summary score of 4, indicating that the resident was severely cognitively impacted. Under Section G0110 (Activities of Daily Living Assistance), the resident was coded as requiring extensive assistance (two (2) person physical assist with bed mobility. Transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), the resident was coded as requiring one (1) person physical assist. Under section G0300 (Balance during transitions and walking), the resident was coded as not steady and required staff physical assistant for stability when moving from a seated to standing position. Under Section J1800 (Any Falls Since Admission/Entry or Reentry or Prior Assessment), the resident was coded as having one (1) fall. And under J1900 (Any Falls Since Admission/Entry or Reentry or Prior Assessment), the resident was coded as having one (1) fall without injury. Review of Resident #31's medical record revealed the following: 04/13/20 at 5:59 PM [Nursing Note] documented, Staff heard bed alarm, upon entering resident room, resident was observed sitting on floor in front of her bed .no injuries noted . 12/15/20 at 4:32 PM [Nursing Note] documented, Resident .loss her balance while trying to sit [in] wheelchair and then sat on floor .no injury and no c/o (complaint of) pain . 01/28/21 at 12:30 PM [Nursing Note] documented, At about 12:30 PM CNA (certified nursing assistant) reported that she observed resident lying on the floor in her room on her back .Upon assessment resident pointed to her r/arm (right arm). She did show facial grymasing (sp) for pain/discomfort .staff medicated resident with Tylenol 650 mg (milligrams) .for pain .order was obtained to transfer . to ER (emergency room ) to be evaluated for FX (fracture) . 01/28/21 at 8:27 PM [Nursing Note] documented, .Received a call from [hospital name] spoke with nurse . who stated, patient will be coming back after midnight with a sling to the right side due to clavicle displacement/fracture and antibiotic for [CONDITION(S)] (urinary tract infection) . 01/29/21 at 10:30 AM [Nursing Note] documented, Resident returned from [hospital name] . at 0800 (8:00 AM) . Resident is alert and verbally responsive and confused. Resident has a sling on the right upper extremity. ER (emergency room ) diagnoses revealed closed displaced fracture of unspecified part right clavicle . Review of the nurses progress notes from 04/13/2020, to 01/28/2021, lacked documented evidence of how staff were monitoring (type and frequency) and supervising the resident to ensure her safety from potential accidents (falls). Review of the care plan section of the record showed: The fall care plan with a start date of 01/16/20 and updated on the following dates: 2/4/20 and 7/21/20. Goal: resident will function safely within environment; injuries will be minimized. The care plan failed to include approaches or interventions of how staff was to supervise or monitor (to include type and frequency) the resident to mitigate or prevent falls (accidents) with or without injury. There was no update to the falls care plan between 7/21/20 to 1/27/21 ensuring that interventions are implemented correctly and consistently and were evaluated for the effectiveness. Subsequently Resident #31 fell and sustain a fractured right clavicle on 1/28/21. During a face-to-face interview on 06/02/2021, at 1:00 PM, Employee #12 (Registered Nurse] stated that the resident's fall [1/28/2021] was not witnessed by staff and she believed the fall was due to the resident's new slippers. Employee #12 then stated, She [Resident #31] refused therapy that is why she is not walking.