**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy review and Pharmacist interview, the facility failed to assure narcotic medication was in a secure location and not accessible to a dependent resident resulting in the possible ingestion of up to 18 Hydrocodone/APAP (Tylenol) 5-325 milligrams (MG) unsupervised in less than 24 hours for 1 of 1 residents with a history of drug seeking behavior (Resident #1). This failure resulted in 72 hours of monitoring of Resident #1 causing an Immediate Jeopardy (IJ) to the health, safety and security of the resident. The State Agency informed the facility of the IJ that began on April 27,2023 on September 13, 2023 at 4:30 PM. The facility staff removed the IJ on April 28, 2023 through the following actions: a. All team members from all departments will be educated as they come on for shifts starting immediately, including agency started 4/28/23 and ongoing. b. Daily huddles and shift to shift huddles- educate and obtain signatures with dates. Started 5/10/23 and ongoing. c. All team members in all departments will be educated if they note medications not properly stored in resident room in locked drawer or for narcotics double locked in medication room they are to notify their supervisor. Completed 4/28/23 and ongoing. d. All facility leaders will be educated by the Executive Director in the event of a concern with medication they are to immediately report to the Director of Nursing (DON) and Executive Director. Completed 4/28/23. e. Resident care plan updated to have an opioid substance disorder. Completed 4/28/23. f. Director of Social Services will meet with resident to establish psychosocial needs- she will offer Encounter Telehealth. Completed 5/2/23. g. Resident will be monitored for 72 hours for signs and symptoms of lethargy change in condition related to medication. Started 4/28/23. h. Nurse Practitioner documented routine pain medication and review, due to diagnosis of opioid dependence. Completed 5/9/23. i. Staff A, Registered Nurse (RN) was educated and received a corrective action. Educated 4/28/23, Corrective Action 5/1/23. j. Medication was replaced by the facility and the facility responsible for costs. Completed on 4/28/23. k. Continue to audit medication laptop cart and resident medication drawers. Started 5/1/23 and continues 3x weekly minimum and PRN. i. Created a binder with self-report, all policies, communication/education with team and signatures. Completed 5/4/23. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 34 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating moderate cognitive impairment. The MDS further indicated the resident was independent with transfers, locomotion on the unit and in the corridor and had diagnosis including opioid dependence, anxiety disorder, depression, wedge compression fracture of second lumbar vertebrae and chronic pain syndrome. The MDS documented the resident received scheduled and PRN pain medication. The MDS also documented she received opioid pain medication 7 days of the last 7 day look back period. The Care Plan initiated 12/21/22 revealed Resident #1 was on pain medication therapy related to chronic pain and used as needed opioid (narcotic) pain and non-opioid pain medication. The Care Plan had a goal for the resident to be free of any discomfort or adverse side effects from pain medication and directed staff to administer analgesic medications as ordered by physician, monitor for increased risk for falls, monitor for adverse reactions to analgesic therapy including mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus (itching), respiratory distress, decreased respirations, sedation and urinary retention. The Care Plan initiated 4/28/23 documented Resident #1 was at risk for substance abuse disorder of opioids. The Care Plan directed staff as follows: -resident seeks out opioids and other analgesics. Monitor for seeking behavior. -remain non-judgmental. Be alert to changes in behaviors (restlessness, increased tension). -offer quiet space to reduce stimuli. The April 2023 Medication Administration Record (MAR) for Resident #1 documented the following orders: a. Acetaminophen (APAP) 500 MG 1 tablet three times a day *max 4 grams (GM)/24 hours start 3/7/23 6:00 AM. b. Hydrocodone/APAP tab 7.5-325 MG 1 tablet every 4 hours as needed for pain start 3/21/23 at 12:00 AM. The MAR documented the resident received Hydrocodone/APAP 7.5-325 mg at the following times: On 4/27/23 at 7:02 AM and at 2:20 PM. On 4/28/23 at 7:22 AM. Review of facility Incident Report #1083 dated 4/2023 revealed Staff B, the previous Assistant Director of Nursing (ADON) and the DON searched Resident #1's room and a missing narcotic card was found in the resident's dresser drawer folded up in fourths inside a pocket of a pair of jeans. The resident stated she had never seen the medication before and did not know what they were. Review of Resident #1's Progress Notes revealed the following documentation: -On 3/27/23 at 5:44 AM resident observed by nurse with at least 8-10 Tylenol tablets attempting to take them back to her room. Resident educated on not taking pills without the knowledge of the nurse. -On 3/27/23 at 6:23 AM resident observed by RN with a handful of Tylenol that she took from the medication cart attempting to take them back to her room. Resident stated she had a headache. PRN Hydrocodone 7.5 mg offered to the resident. Resident educated on the importance of asking for PRN medications instead of attempting to take them. DON and oncoming staff informed of the incident. Will continue to monitor resident. -On 4/28/23 at 7:50 PM Physician notified of 18 tabs of Hydrocodone/APAP 5-325 MG missing and possibly consumed by the resident and directed staff to monitor the resident and send to the hospital if necessary. -On 4/28/23 at 9:08 PM son made aware of stolen narcotics and possible consumption. Son voices understanding and denies questions or concerns. Review of facility policy titled, Controlled Substances Distribution and Administration, approved 7/2016, documented the purpose of the protocol was to ensure the proper distribution and administration of controlled substances (CIO medications) and revealed all controlled substances will be stored, distributed and administered in compliance with all applicable laws and regulations. Review of facility policy titled, Medication Administration, Storage, Disposal and Nurse Review, approved 9/2020, documented all prescription medication must be kept in a locked cabinet. All other medications must be stored in a locked area not accessible to persons other than employees responsible for administration and storage of medications. Narcotics shall be stored in a double locked area. During an interview on 9/13/23 at 5:27 AM, Staff A, RN revealed the pharmacy had delivered medications the evening of 4/27/23 around 8:30 PM while Staff A was in the middle of passing medications. Staff A revealed she delivered the medications to the locked cabinets in resident rooms around 10:00 PM and around midnight she was busy putting papers away when she checked the list of medications pharmacy had delivered that night and noticed a narcotic had been delivered. Staff A stated she checked the narcotic drawer and couldn't locate the narcotic that had been delivered. Staff A revealed she thought maybe she had misplaced the narcotic and went to every resident's room and checked every medication drawer and couldn't locate it. Staff A stated she then called the pharmacy to provide verification they had delivered the narcotic and she notified the DON. Staff A revealed she had set the medications that had been received from the pharmacy at the nurse's station unsupervised and unsecured for approximately one hour following their delivery. Staff A reported the normal protocol is to put narcotics in the locked medication room in a locked drawer in order to have the narcotics double locked. Staff A stated she had seen Resident #1 walking around when Staff A was looking for the narcotic around 1:00 AM or 2:00 AM after she had been looking for the narcotic and stated Resident #1 had a history of seeking out medication. Staff A reported the normal process for pharmacy deliveries is the pharmacy scans the medication on a mobile phone one at a time and then facility staff sign off after the medications are scanned. After signing, the pharmacy will fax a confirmation sheet of what had been delivered sometimes within 30 minutes and sometimes more than 30 minutes after delivery. During an interview on 9/12/23 at 12:22 PM, Staff D, Pharmacist revealed 4 GM of Tylenol in a 24-hour period of time would be the maximum dose. On 9/13/23 at 10:27 AM, the Clinical Quality Specialist revealed in April 2023 there were 6 residents that resided in the community of the facility where the incident occurred that wandered with purpose. During an interview on 9/13/23 at 12:59 PM, the DON reported the physician had reported to monitor Resident #1's breathing and somnolence (excessive drowsiness). The DON further revealed she was concerned the resident was going to go unresponsive and was thankful she had a high tolerance because of her history. During an interview on 9/13/23 at 1:13 PM, Staff B, the previous ADON stated she had general concerns for Resident #1's safety following the incident as it was very serious if someone ingests too many narcotics as they could overdose and die.