Inspection·January 26, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's physician orders indicated, on 1/10/24, she had a physician's order for oxycodone 5 milligrams (mg, unit of measurement), 1 tablet every 3 hours as-needed for moderate pain, and 2 tablets (10 mg) every 3 hours as needed for severe pain. A review of Resident 1's Controlled Drug Record (an inventory sheet that keeps record of usage) for oxycodone indicated the pharmacy sent 30 tablets on 1/10/24 with the direction of 1 tablet every 3 hours as needed for moderate pain, and 2 tablets (10 mg) every 3 hours as needed for severe pain. Further review of Resident 1's physician's orders indicated, on 1/11/24, the oxycodone order was changed to 2 tablets (10 mg) every 3 hours routinely for severe pain, to start on 1/11/24; and to keep 5 mg 1 tablet every 3 hours as needed for pain. A review of Resident 1's January 2024 Medication Administration Record (MAR) indicated the nursing staff scheduled the oxycodone 10 mg dose 8 times per day around-the-clock: at midnight, 3 a.m., 6 a.m., 9 a.m., 12 noon, 3 p.m., 6 p.m., and 9 p.m. The nursing staff started administering the oxycodone 10 mg every 3 hours starting at midnight on 1/11/24. It was given on such schedule until 1/12/24 at 5 p.m. Further review of Resident 1's MAR indicated the nursing staff did not administer the routine oxycodone 10 mg for 13 doses, starting at 9 p.m. 1/12/24 to 9 a.m. on 1/14/24. The MAR had the following documentation by the nursing staff related to the oxycodone 10 mg administration: - 1/12/24 9 p.m.: waiting for pharmacy to deliver; pain 0 (using 0-10 scale: 0 equals no pain, 10 equals worst pain) - 1/13/24 at midnight: Not administered (Order On Hold); pain 0 - 1/13/24 at 3 a.m.: Not administered (Order On Hold); pain 0 - 1/13/24 at 6 a.m.: Medication unavailable. Reported to DAY RN and pharmacy stated Pt [patient] needs new script; pain 0 - 1/13/24 at 9 a.m.: Meds not available at this time. still waiting pharmacy delivery; pain 0 - 1/1324 at 12 p.m.: not given d/t [due to] meds not available at this time. still waiting pharmacy delivery.; pain Not Completed (N/A During this shift) - 1/13/24 at 3 p.m.: not given d/t meds not available at this time. still waiting pharmacy delivery; pain 1 - 1/13/24 at 6 p.m.: meds not available; pain 0 - 1/13/24 at 9 p.m.: Not administered .; pain 0 - 1/13/24 at midnight: Not administered .; pain 7 - 1/14/24 at 3 a.m.: Not Administered .; pain 7 - 1/14/24 at 6 a.m.: Not Administered .; pain 7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 - 1/14/24 at 9 a.m.: Awaiting pharmacy script; pain 7 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON on 1/26/24 at 1:42 p.m., the DON stated she thought Resident 1's oxycodone 10 mg was ordered every 3 hours routinely when she was first admitted to the facility, and did not realize it was changed from as-needed to routinely on 1/11/24; that explained why the pharmacy only sent 30 tablets on 1/10/24. She reviewed Resident 1's MAR and confirmed 13 doses of routine oxycodone 10 mg were not given starting at 9 p.m. on 1/12/24 until 9 a.m. 1/14/24. She further reviewed Resident 1's clinical record and stated, I don't see that they called Dr. [Physician's name], and confirmed they should have notified the doctor when they were running low or out of the oxycodone supply. She stated the Administrator has been working with the registry agency to find out why the physician was not notified when they ran out of the oxycodone during that time period. Residents Affected - Few On 1/26/24, a review of the E-kit log indicated two oxycodone 5 mg tablets were removed for Resident 1 on 1/14/24 at 10:30 a.m. 1b. A review of Resident 1's physician's orders also reflected two orders, dated 1/10/24, for gabapentin (a medication for nerve pain) 300 mg: 2 capsules (600 mg) one time a day; and 3 capsules (900 mg) two times daily. A review of Resident 1's January 2024 MAR indicated gabapentin 600 mg was scheduled daily at 2 p.m.; and the 900 mg doses were scheduled daily at 8 a.m. and 8 p.m. The MAR also indicated the 900 mg doses were not administered: 1 dose on 1/14; 2 doses on 1/15, 2 doses on 1/16, and 1 dose on 1/17/24. The MAR reflected the nursing staff documentation of: Not administered, awaiting supply, will give when available, on order, and awaiting pharmacy supply on these days. During a concurrent interview and record review with the DON on 1/26/24 at 2:38 p.m., she reviewed Resident 1's MAR and verified the missing doses above. She reviewed Resident 1's clinical record and could not find evidence the nursing staff called the pharmacy to get a refill, or notifying the doctor when it was not available. She stated, It's an easy [to get] drug. During an email communication with the DON on 1/29/24 at 1:53 p.m., the DON stated the facility did not have any specific policy addressing the physician notification. During a telephone interview with Resident 1's attending physician (Physician) on 1/29/24 at 4:05 p.m., he stated he was informed about Resident 1 missing oxycodone for a day and half at 6:02 a.m. on 1/14/24 and wrote a new prescription on that day. He stated the nursing staff should have called him earlier to get new prescription. Regarding the gabapentin, the Physician stated he did not know she was missing gabapentin doses. He stated he was under the impression that she was receiving it regularly to control her nerve pain. During a telephone interview with the Pharmacist on 1/30/24 at 9:27 a.m., she stated the pharmacy received the direction for use of 1 tablet every 3 hours as needed for moderate pain, and 2 tablets every 3 hours as needed for severe pain; and dispensed 30 tablets of oxycodone 5 mg on 1/10/24 and on 1/14/24; and 80 tablets on 1/16/24. She stated the pharmacy received requests for stat delivery and e-kit codes on 1/14/24, but was not informed of the direction change. As of this interview, the Pharmacist said the pharmacy had no notification of direction change for oxycodone to every 3 hours routinely. As for the gabapentin, the Pharmacist stated the pharmacy received two orders, 600 mg daily and 900 mg twice daily. She explained the pharmacy only sent 28 capsules of gabapentin 300 mg (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 14-day supply) for the 600 mg order; and sent a fax request, on 1/10/24, for order clarification related to the 900 mg order, but never received the clarification from the facility. A review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving From Pharmacy Provider, dated 1/2023, indicated, Medications and related products are received from the provider pharmacy on a timely basis, All medication order changes . must be communicated to the pharmacy, timely, in order to provide the correct quantities and accurate labeling when doses or administration frequencies are modified and Timely delivery of new orders is required so that medication administration is not delayed . A medication form is also used to notify the provider pharmacy of changes in dosage, direction for use, discontinuation, etc. of current medications The P&P also indicated, The provider pharmacy is contacted if an emergency arises requiring pharmacist consultation regarding medications ordered and needed prior to the next scheduled pharmacy delivery . Prescribers are notified of the availability of emergency medication and supplies in the nursing care center. 2. During a visit to the medication room with the DON on 1/26/24 at 9:41 a.m., two sealed e-kits containing controlled medications were observed stored in an unlocked cabinet. The C-II (Schedule 2, a classification of controlled medication) E-kit contained 11 C-II medications; and the CIII-CV (Schedule 3 to Schedule 5) E-kit contained eight CIII - CV medications. The DON stated the cabinet should be locked. A review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 1/2023, indicated, The emergency medication kit may contain controlled substances in Schedules II - V as allowed by state regulations . Schedule II medications that are part of the emergency medication supply must be double locked and shall be stored in a locked cabinet or locked drawer separate from non-controlled medications. 3. During the medication room visit with the DON on 1/26/24 at 9:45 a.m., an IV Supply Emergency Kit was observed unsealed. A review of the Emergency Drug Kit Usage Report with the DON indicated a product was removed from the kit on 12/29/23 (almost a month ago). The DON acknowledged the kit should have been re-sealed and replaced. She stated used E-kit should be replaced within 72 hours. A review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 1/2023, indicated, Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used to an emergency kit log. One copy of this information should be immediately faxed to the pharmacy or placed within the resealed emergency kit until it is scheduled for exchange . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 did not recieve two routine pain medications as prescribed. The failure exposed Resident 1 to unnecessary pain. Residents Affected - Few Findings: a. During an interview with the Director of Nursing (DON) on 1/26/24 at 9:20 a.m., she stated Resident 1 was admitted to the facility on [DATE] with stage 4 cancer and required every-3-hour oxycodone (a potent narcotic for moderate to severe pain) routinely; she was also receiving methadone routinely for pain. The pharmacy only sent enough supply of oxycodone for 3 days. The medication ran out, and Resident 1 missed her first oxycodone dose on 1/12/14 in the evening. On 1/14/24, the night shift nurse texted her and the Administrator early in the morning letting them know he needed the oxycodone for Resident 1. The DON stated she called the physician and asked him to write a new prescription for oxycodone on that day, 1/14/24. After the physician wrote a new order, two doses of oxycodone were obtained from the emergency kit (a kit containing medications and supplies for emergency use), and the medication was sent later that day. She stated this happened on the weekend, during which it was staffed by registry nurses (individuals who receives compensation from a third party agency to work at a nursing care institution). The DON stated the facility is still working with the registry agency to find out why they did not call the doctor to get a new prescription when they were out of oxycodone to administer. A review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancer) of unspecified bronchus or lung, neoplasm related pain, low back pain, and neoplastic (malignant) related fatigue. A review of Resident 1's physician orders indicated, on 1/10/24, she had a physician's order for oxycodone 5 milligrams (mg, unit of measurement), 1 tablet every 3 hours as-needed for moderate pain, and 2 tablets (10 mg) every 3 hours as needed for severe pain. A review of Resident 1's Controlled Drug Record (an inventory sheet that keeps record of usage) for oxycodone indicated the pharmacy sent 30 tablets on 1/10/24 with the direction of 1 tablet every 3 hours as needed for moderate pain, and 2 tablets (10 mg) every 3 hours as needed for severe pain. Further review of Resident 1's physician's orders indicated, on 1/11/24, the oxycodone order was changed to 2 tablets (10 mg) every 3 hours routinely for severe pain, to start on 1/11/24; and to keep 5 mg 1 tablet every 3 hours as needed for pain. A review of Resident 1's January 2024 Medication Administration Record (MAR) indicated the nursing staff scheduled the oxycodone 10 mg dose 8 times per day around-the-clock: at midnight, 3 a.m., 6 a.m., 9 a.m., 12 noon, 3 p.m., 6 p.m., and 9 p.m. The nursing staff started administering the oxycodone 10 mg every 3 hours starting at midnight on 1/11/24. It was given on such schedule until 1/12/24 at 6 p.m. Further review of Resident 1's MAR indicated the nursing staff did not administer the routine oxycodone 10 mg for 13 doses, starting at 9 p.m. 1/12/24 to 9 a.m. on 1/14/24. The MAR had the following documentation by the nursing staff related to the oxycodone 10 mg administration: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 - 1/12/24 9 p.m.: waiting for pharmacy to deliver; pain 0 (using 0-10 scale: 0 equals no pain, 10 equals worst pain) Level of Harm - Minimal harm or potential for actual harm - 1/13/24 at midnight: Not administered (Order On Hold); pain 0 Residents Affected - Few - 1/13/24 at 3 a.m.: Not administered (Order On Hold); pain 0 - 1/13/24 at 6 a.m.: Medication unavailable. Reported to DAY RN and pharmacy stated Pt [patient] needs new script; pain 0 - 1/13/24 at 9 a.m.: Meds not available at this time. still waiting pharmacy delivery; pain 0 - 1/1324 at 12 p.m.: not given d/t [due to] meds not available at this time. still waiting pharmacy delivery.; pain Not Completed (N/A During this shift) - 1/13/24 at 3 p.m.: not given d/t meds not available at this time. still waiting pharmacy delivery; pain 1 - 1/13/24 at 6 p.m.: meds not available; pain 0 - 1/13/24 at 9 p.m.: Not administered .; pain 0 - 1/13/24 at midnight: Not administered .; pain 7 - 1/14/24 at 3 a.m.: Not Administered .; pain 7 - 1/14/24 at 6 a.m.: Not Administered .; pain 7 - 1/14/24 at 9 a.m.: Awaiting pharmacy script; pain 7 During a concurrent interview and record review with the DON on 1/26/24 at 1:42 p.m., the DON stated she thought Resident 1's oxycodone 10 mg was ordered every 3 hours routinely when she was first admitted to the facility, and did not realize it was changed from as-needed to routinely on 1/11/24; that explained why the pharmacy only sent 30 tablets on 1/10/24. She reviewed Resident 1's MAR and confirmed 13 doses of routine oxycodone 10 mg were not given starting at 9 p.m. on 1/12/24 until 9 a.m. 1/14/24. She further reviewed Resident 1's clinical record and stated, I don't see that they called Dr. [Physician's name], and confirmed they should have notified the doctor when they were running low or out of the oxycodone supply. She stated the Administrator has been working with the registry agency to find out why the physician was not notified when they ran out of the oxycodone during that time period. On 1/26/24, a review of the E-kit log indicated two oxycodone 5 mg tablets were removed for Resident 1 on 1/14/24 at 10:30 a.m. b. A review of Resident 1's physician's orders also reflected two orders, dated 1/10/24, for gabapentin (a medication for nerve pain) 300 mg: 2 capsules (600 mg) one time a day; and 3 capsules (900 mg) two times daily. A review of Resident 1's January 2024 MAR indicated gabapentin 600 mg was scheduled daily at 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few p.m.; and the 900 mg doses were scheduled daily at 8 a.m. and 8 p.m. The MAR also indicated the 900 mg doses were not administered: 1 dose on 1/14; 2 doses on 1/15, 2 doses on 1/16, and 1 dose on 1/17/24. The MAR reflected the nursing staff documentation of: Not administered, awaiting supply, will give when available, on order, and awaiting pharmacy supply on these days. During a concurrent interview and record review with the DON on 1/26/24 at 2:38 p.m., she reviewed Resident 1's MAR and verified the missing doses above. She reviewed Resident 1's clinical record and could not find evidence the nursing staff called the pharmacy to get a refill, or notifying the doctor when it was not available. She stated, It's an easy [to get] drug. During a telephone interview with Resident 1's attending physician (Physician) on 1/29/24 at 4:05 p.m., he stated he was informed about Resident 1 missing oxycodone for a day and half at 6:02 a.m. on 1/14/24 and wrote a new prescription on that day. He stated the nursing staff should have called him earlier to get new prescription. Regarding the gabapentin, the Physician stated he did not know she was missing gabapentin doses. He stated he was under the impression that she was receiving it regularly to control her nerve pain. A review of the facility's policy and procedure (P&P) titled Medication Administration General Guidelines, dated 1/2023, indicated: Medications are administered in accordance with written orders of the prescriber. A review of the facility's P&P titled Medication Ordering and Receiving From Pharmacy Provider, dated 1/2023, indicated, Medications and related products are received from the provider pharmacy on a timely basis, All medication order changes . must be communicated to the pharmacy, timely, in order to provide the correct quantities and accurate labeling when doses or administration frequencies are modified and Timely delivery of new orders is required so that medication administration is not delayed. The P&P also indicated, The provider pharmacy is contacted if an emergency arises requiring pharmacist consultation regarding medications ordered and needed prior to the next scheduled pharmacy delivery . Prescribers are notified of the availability of emergency medication and supplies in the nursing care center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. One of one medication refrigerator was identified unlocked when not in use; and its temperature was not being monitored and maintained twice daily as per facility policy and procedures (P&P). This failure could lead to loss of medications, and loss of drug potency due unmonitored temperatures; 2. An opened multi-dose vial did not have an open date. The failure had the potential for the medication being used past its effective date. Findings: 1. During a visit to the medication room with the Director of Nursing (DON) on 1/26/24 at 9:50 a.m., a a medication refrigerator was identified unlocked. A brief review of the contents inside revealed the refrigerator contained numerous medications include a bubble pack containing 30 dronabinol (a controlled medication [those with high potential for abuse and addiction] to treat nausea and vomiting) capsules for a resident, and an emergency kit (a kit/box containing medications and supplies for immediate use during a medical emergency) containing a vial of injectable lorazepam (a controlled medication to treat anxiety or agitation). The DON stated the medication refrigerator should be locked when not in use. She acknowledged the refrigerator contained controlled medications inside. On 1/26/24 at 9:55 a.m., the DON stated the nursing staff monitored the refrigerator temperature (temp) twice daily (AM shift and night shift) whenever there are vaccines. The refrigerator was observed to contain two boxes of flu vaccines inside. The temperature logs for October 2023 to January 2024 were requested for review. On 1/26/24 at 9:58 a.m., a review of the January 2024 with the DON reflected the nursing did not record the temperature monitoring during the AM shift on 1/6, 1/7, 1/8, 1/9, 1/13, 1/14, 1/20, and 1/21, or 8 days out of 26 days in January. A review of the November 2023 temp log had missing temp logging on three days during the AM shift: on 11/18, 11/19, and 11/26. The DON acknowledged this finding. A review of the facility's P&P titled Storage of Medication, dated 1/2023, indicated: Medication room, cabinet and medication supplies should remain locked when not in use . and The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. 2. On 1/26/24 at 9:50 a.m., an inspection of the medication refrigerator with the DON also identified an opened multi-dose vial of tuberculin (protein extract used in a skin test to help diagnose tuberculosis infection) which did not have an open date. A review of the manufacturer's carton label indicated to discard the vial 30 days after opening. The DON acknowledged and stated it should have an open date to know when it would expire. A review of the facility's Storage of Medication P&P, dated 1/2023, indicated: Medications and biologicals are stored properly, following manufacturer's . recommendations, to maintain their integrity and to support safe effective drug administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 8 of 8