**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's policy titled, Abuse Prevention, the facility's investigation file, and Resident Identifier (RI) #48 and RI #56's medical record, the facility failed to ensure Employee Identifier (EI) #4, a Registered Nurse (RN) did not take for personal use and without the residents' permission narcotic pain medication which belonged to RI #48 and RI #56, two of four residents reviewed for narcotic pain medication. Findings include: The facility's policy titled, ABUSE PREVENTION, dated 11/28/2016, documented . IV. IDENTIFICATION . 3. Staff are trained on actual activities that would constitute abuse and they are but not limited to: . b. Misappropriation of resident property- The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without their consent . On 3/2/2021, the facility's Administrator reported to the State Agency an incident of misappropriation of resident property. According to the report, EI #4, a Registered Nurse (RN) took prescription medication that belonged to RI #48 and RI #56. The facility's INVESTIGATIVE SUMMARY, dated 3/1/2021, documented . CONCLUSION: Because (EI #4) failed her drug test through the Alabama Board of Nursing. Because (EI #4) admitted that since January 2021, she has been taking Norco and Percocet prescribed to residents (RI #56) and (RI #48) whom both reside at [NAME] Health Care, the allegation of Misappropriation of Resident Property is substantiated . RI #48 was admitted to the facility on [DATE], with diagnoses to include pain, dorsalgia (back pain) and collapsed vertebra. RI #48's Medication Administration Record for February 2021 revealed the resident had an order for Percocet 5 milligrams (mg) to be administered one tablet by mouth at 5:00 AM, 1:00 PM and 8:00 PM for pain. RI #56 was readmitted to the facility on [DATE], with diagnoses to include other chronic pain, gout, and spondylosis (osteoarthritis of the spine). RI #56's Medication Administration Record for January 2021 and February 2021 revealed the resident had an order for Norco 10 mg to be administered one tablet by mouth every 12 hours at 6:00 AM and 6:00 PM for pain. In an interview on 4/15/2021 at 11:36 AM, EI #1, the Director of Nursing (DON), was asked how she became aware of this incident. EI #1 stated that she received a text from EI #4, a RN. EI #1 said she called EI #4 back and EI #4 told her that she (EI #4) had failed her drug screen done by the Alabama Board of Nursing. According to EI #1, EI #4 was instructed by the Alabama Board of Nursing to call the facility to make them aware. EI #1 stated she called EI #4's probation officer at the Alabama Board of Nursing and was told the drugs EI #4 took came from the facility. According to EI #1, she and the Administrator, called EI #4 back and asked who she took the drugs from and EI #4 replied it was RI #48 and RI #56. During a telephone interview on 4/16/2021 at 12:24 PM, EI #4 stated she had worked in the facility since December 2020 during the 11:00 PM to 7:00 AM shift. EI #4 stated she resigned her position with the facility on 3/1/2021. When asked did she take narcotics belonging to any residents while employed at this facility, EI #4 said she did. When asked what medications she took from the residents, EI #4 stated she took RI #56's Norco and RI #48's Percocet. EI #4 was asked when she took these residents narcotic medications. EI #4 stated it started in January 2021. EI #4 was asked what it was considered when she took narcotics belonging to the residents. EI #4 answered, diverting drugs. When asked what it was considered if she took narcotics or anything else belonging to a resident, EI #4 replied, stealing and misappropriation of property. ************************* Once the facility became aware that EI #4, a RN, had admitted she took prescription medication that belonged to RI #48 and RI #56, the facility implemented the following corrective actions: * EI #4 was suspended and not allowed back to work pending the investigation findings. EI #4 last worked in the facility on 2/26/2021. EI #4's employment with the facility was terminated on 3/5/2021. * The facility timely reported the allegation and the subsequent findings to the Alabama Department of Public Health, the Alabama Board of Nursing, the local Police Department, the facility's Medical Director and the representatives of the residents involved. * The facility's licensed staff assessed the residents involved on 3/1/2021, for signs and symptoms of pain and none were voiced and/or observed. All other residents were assessed and interviewed with no concerns noted. * On 3/1/2021, the Director of Nursing reconciled all narcotic and all medications were accounted for. * The facility conducted staff in-service regarding Abuse Prevention, specific to Misappropriation of Resident Property. * The facility's Quality Assessment and Assurance Committee was made aware of the incident and will monitor the process of administering narcotics. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, and observation of the facility's acquisition, disposition and reconciliation of controlled and non-controlled medications, the facility implemented corrective actions from 3/1/2021 to 3/5/2021. This deficiency was cited as a result of the investigation of complaint/report number AL00041308.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and review of facility policy titled, CAPILLARY BLOOD SAMPLING, the facility failed to ensure Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN), wore gloves when she performed a fingerstick blood sugar (FSBS) on Resident Identifier (RI) #62, one of two residents observed for medication administration. Findings include: The facility's undated policy titled, CAPILLARY BLOOD SAMPLING, documented: . Procedure 1. Perform hand hygiene. 2. Wear gloves . RI #62 was admitted to the facility on [DATE]. RI #62 has a medical history to include a diagnosis of Type II Diabetes Mellitus. During medication administration observation on 4/14/2021 at 5:17 PM, EI #3, a LPN, was to obtain RI #62's FSBS with her bare hands. EI #3 pricked the resident's forefinger with a lancet, wiped blood from resident's finger with a tissue, squeezed blood from RI #62's finger and then wiped it with an alcohol wipe, and removed the strip from the glucometer. EI #3 was then observed to wipe RI #62's abdomen with an alcohol wipe and inject Insulin into RI #62's abdomen without wearing gloves. On 4/14/2021 at 5:59 PM, an interview was conducted with EI #3, a LPN. When asked when she should wear gloves during medication pass, EI #3 stated she had been working with the residents for a long time and felt comfortable with them. EI #3 was asked how many residents she felt comfortable enough with not to wear gloves. EI #3 replied she did sometimes, but she just messed up. When asked what she was taught about wearing gloves during med pass, EI #3 stated she should put them on before she gave the medications, before she touched any medication, before any injection or FSBS or before touching the resident. EI #3 was asked did she apply gloves before giving RI #62 an insulin injection. EI #3 replied she did not. EI #3 was asked did she apply gloves before obtaining RI #62's FSBS. EI #3 responded no. EI #3 was asked what the concern was with not applying gloves when giving injections and obtaining FSBS. EI #3 said possible contamination and transmission of pathogens. In an interview on 4/15/2021 at 4:12 PM, EI #2, the Infection Preventionist acknowledged the nurse should wear gloves during a FSBS check. When asked what it would be considered when gloves were not worn, EI #2 responded infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and a review of the facility's policy titled, Incontinence Care - ., the facility failed to ensure staff separated and thoroughly cleaned Resident Identifier (RI) #19's perineal area. This affected RI #19, one of one resident observed during incontinent care. RI #19 is a resident identified by the facility as having a history of Urinary Tract Infections ( UTIs). Findings Include: A review of the facility's policy titled, Incontinence Care - . dated 8/1/17, revealed the following: .PURPOSE: Good incontinence care helps prevent infection, irritation, and skin breakdown . RI #19 was admitted to the facility on [DATE], with diagnoses to include Constipation, Unspecified Urinary and Hypothyroidism. A review of RI #19's Significant Change Minimum Data Set (MDS) dated [DATE], revealed RI #19's Brief Interview for Mental Status (BIMS) score of 3, indicating cognition was severely impaired. The MDS also revealed RI #19 was totally dependent on staff for toilet use and personal hygiene and had a history of UTIs. On 9/06/18 at 11:20 AM, (EI) Employee Identifier #1, Certified Nursing Assistant (CNA) and EI #2, CNA were observed performing incontinent care for RI #19. EI #1 performed the incontinent care for RI #19, while EI #2 assisted with positioning the resident. RI #19 had an incontinent bowel movement. EI #1 performed incontinent care for RI #19, but did not open the perineal area and clean. On 9/06/18 at 11:35 AM, the surveyor asked EI #1 if she was finished with the incontinent care for RI #19 and EI #1 said yes. The surveyor asked EI #1 if RI #19 was clean and she said, Yes. EI #1 was asked if she visualized RI #19's perineal opening and she said she did. The surveyor asked EI #2 if EI #1 visualized RI #19's perineal opening. EI #2 said, She (EI #1) did not separate as much as she should have to see it. EI #1 was asked what should be done since RI #19 had an incontinent bowel movement and she did not separate the perineal area and wipe. EI #1 said, Redo the incontinent care. EI #1 separated RI #19's perineal area and wiped with a wash cloth. The surveyor observed a discoloration was present to the wash cloth after EI #1 wiped RI #19's perineal area. The surveyor asked EI #1 what the discoloration was and she said, A little bowel movement. On 09/07/18 at 10:01 AM, EI #3, Director of Nursing (DON), and the surveyor reviewed the perineal care/incontinence care check-off sheet and the policy for incontinence care. The surveyor asked where in the policy did it instruct staff to wipe or observe the perineal opening. EI #3 stated, It just says to wipe downward stroke on the right and left (perineal area) and the meatus, if the right and left (perineal area) is spread to see the meatus, then the perineal opening would be visible. The surveyor informed EI #3 that the CNA did not have RI #19's legs separated to visualize the meatus or the perineal opening. The surveyor asked where on the skills check-off sheet did it indicate for staff to wipe the perineal opening or what should should be done in order to view it. EI # stated, It does not.