**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 12 of 25 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12) reviewed for drug diversion were free from misappropriation of their property when their medications were taken by a staff member. This resulted in diversion of 121 oxycodone tablets, one tramadol tablet and two doses of liquid lorazepam. The immediate jeopardy (IJ) began on 9/27/24, when registered nurse (RN)-A notified the director of nursing (DON) with her concerns that trained medication aide (TMA-A) had been signing controlled medications out of the narcotic logbook. However, TMA-A was not documenting medication in the medication administration record (MAR) as given. R1 and R2 notified RN-A and their provider they had not received as needed (PRN) medications. The facility initiated an internal investigation, which included additional narcotic record review and audits against electronic medical records. Discrepancies were found in the following records: R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12. Records indicated narcotics were signed out in the narcotic logbook to indicate removal from the medication cart but were not signed in the MAR to indicate medication was administered. Facility suspended TMA-A while they conducted their investigation. TMA-A was subsequently terminated and the facility notified law enforcement. The administrator was notified of the IJ on 10/3/24 at 5:01 p.m. The facility had implemented immediate corrective action on 9/27/24 to prevent recurrence, therefore the IJ was issued at past non-compliance. Findings include: Review of the facility narcotic record indicated the following medications were signed out as removed from the medication cart, however, were not documented in the MAR as administered: R1 - 23 oxycodone tablets R2 - six oxycodone tablets R3 - 18 oxycodone tablets R4 - 12 oxycodone tablets R5 - 15 oxycodone tablets R6 - three oxycodone tablets R7 - four oxycodone tablets R8 - 11 oxycodone tablets R9 - four oxycodone tablets and one tramadol tablet R10 - 20 oxycodone tablets R11 - four oxycodone tablets R12 - two doses of liquid lorazepam R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and diagnoses of acquired absence of right and left leg above knee, phantom limb syndrome with pain, muscles spasms, and unspecified pain. R1's Physician's Order Sheet printed on 10/1/24, indicated a physician order for oxycodone (an opioid medication used to treat moderate to severe pain) five milligrams (mg) by mouth every four hours as needed for moderate to severe pain with a pain rating of 7-10. R1's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A, was not documented as administered in R1's electronic health record. R1's record indicated no negative outcomes occurred from not receiving the narcotic medications. R2's Minimum Data Set (MDS) entry tracking record indicated admission date of 9/16/24, indicated moderate cognitive impairment, no disorganized thinking, no behavioral symptoms, upper extremity impairment on both sides, use of a wheelchair, and dependent on staff for eating, toilet use, dressing, and personal hygiene. R2's Physician's orders printed 10/1/24, indicated diagnoses of multiple fractures of ribs, anxiety, and amyotrophic lateral sclerosis (ALS). R2's pain assessment dated [DATE], indicated use of scheduled and as needed pain medications, frequent pain presence, and pain occasionally affecting sleep. R2's Medication Administration Record (MAR) printed 9/26/24, indicated physician's orders for scheduled acetaminophen and as needed oxycodone HCL five milligrams take one to two tablets by mouth every three hours (pain medication) as needed. R2's individual narcotic record indicated six doses of oxycodone were signed out of the log from 9/17/24 through 9/23/24. Facility MAR dated 9/1/24 through 9/30/24, indicated three doses of oxycodone administered during R2's stay. Facility investigation pain interview dated 9/25/24, indicated R2 reported pain managed well with acetaminophen and adamant about only taking one dose of oxycodone while at the facility. R2's Physician visit progress note dated 9/24/24, indicated R2 was not aware of oxycodone use when mentioned by his provider and again insisted only one dose was needed during the beginning of R2's stay due to rib pain. R2 requested the medication be discontinued as the acetaminophen was managing pain well. During interview on 10/2/24, R2 stated he had no pain concerns, continued to take acetaminophen, and did not take more than one dose of oxycodone in the month of September. R3's quarterly MDS dated [DATE], identified R3 had intact cognition and diagnoses of pain in right hip, cellulitis, and open wounds. R3's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone five mg by mouth every four hours as needed for severe pain related to hip prosthesis. R3's MAR indicated while the controlled medication that was signed out of the narcotic log book by TMA-A, it was not documented as administered in R3's electronic health record. R3's record indicated no negative outcomes occurred from not receiving the narcotic medications. R4's admission MDS dated [DATE], identified R4 had intact cognition and diagnoses of fracture of left femur, gout, fibromyalgia, and vertebral disc degeneration. R4's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone ten mg by mouth every four hours as needed for pain related to femur fracture. R4's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R4's electronic health record. R4's record indicated no negative outcomes occurred from not receiving the narcotic medications. R5's admission MDS dated [DATE], identified R5 had intact cognition and diagnoses of colon cancer, back pain, spinal stenosis, and radiculopathy. R5's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone five mg by mouth every six hours as needed for severe pain related to low back pain. R5's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R5's electronic health record. R5's record indicated no negative outcomes occurred from not receiving the narcotic medications. R6's discharge MDS dated [DATE], identified R6 had intact cognition and diagnoses of fracture of the right femur, pain in the right shoulder, unspecified pain, muscle spasms and senile degeneration of brain. R6's Physician's Order Sheet printed on 10/3/24, indicated a physician order for oxycodone five mg by mouth every six hours as needed for severe pain. R6's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R6's electronic health record. R6's record indicated no negative outcomes occurred from not receiving the narcotic medications. R7's quarterly MDS dated [DATE], identified R7 had intact cognition and diagnoses of chronic pain syndrome, major depressive disorder, low back pain, osteoarthritis, anxiety disorder and muscle spasms of the back. R7's Physician's Order Sheet printed on 10/3/24, indicated a physician order for oxycodone five mg - give two and a half mg by mouth as needed for moderate to severe pain. R7's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R7's electronic health record. R7's record indicated no negative outcomes occurred from not receiving the narcotic medications. R8's quarterly MDS dated [DATE], indicated intact cognition, scheduled and as needed pain medications, occasional pain that did not affect sleep, therapy, or daily activities. R8's Physician's orders printed 10/2/24, indicated diagnoses of chronic pain syndrome, left hip pain, and disc degeneration causing back pain. Medication order for pain management was oxycodone five milligram tablet take one tablet every six hours as needed for pain. Review of MAR and individual narcotic record dated from 5/1/24 through 8/31/24, indicated 11 doses of oxycodone five milligram tablets were signed out on the individual narcotic record but were not documented on the MAR as administered to R8. R8 no longer resided in the facility and did not respond to phone call for interview. R9's significant change MDS dated [DATE], indicated intact cognition, diagnoses of fracture of first and second cervical vertebra with routine healing, wedge compression fracture of fourth thoracic vertebra with routine healing, acute pain due to trauma, and chronic migraine headaches. R9's Physician's orders dated 8/28/24, included tramadol HCL oral tablet 50 milligrams give 50 milligrams by mouth two times per day as needed for pain related to chronic pain syndrome and oxycodone five milligram tablet give one half to one tablet every four hours as needed for pain. Review of R9's individual narcotic record and MAR dated from 8/1/24 through 9/30/2024, indicated four doses of oxycodone and one dose of tramadol documented on the individual narcotic record as removed but not documented on the MAR as administered. A facility document titled Pain Interview dated 9/25/24, indicated R9 reported headaches rated 10 out of 10 on a one through 10 pain scale and pain medication use four out of five days for headaches. During interview on 10/2/24 at 1:34 pm, R9 indicated no concerns with neck pain from fractures. R9 stated pain was from chronic migraines and not new. R9 further stated no concerns with getting tramadol or oxycodone pain medications when needed and reported a new medication order for celebrex oral capsule 100 milligram capsule every 12 hours as needed was working well and giving relief for headaches. R10's admission MDS dated [DATE], identified R10 had intact cognition and diagnoses of fracture of shaft of right tibia and fibula, fracture of right foot, mood disorder due to known physiological condition with depressive features, depression, anxiety disorder, and unspecified pain. R10's Physician's Order Sheet printed on 10/1/24, indicated a physician order for oxycodone five mg by mouth every four hours as needed for pain. R10's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R10's electronic health record. R10's record indicated no negative outcomes occurred from not receiving the narcotic medications. R11's discharge MDS dated [DATE], indicated intact cognition, diagnoses of sacral (lower back) fracture with routine healing, femur fracture with routine healing, chronic pain syndrome, and long term use of opiate analgesic (pain medication). MDS further indicated scheduled and as needed pain medication use, almost constant pain presence, pain frequently affecting sleep, therapy, and daily activities. R11's Physician's orders dated 8/28/24, included oxycodone HCL oral tablet 10 milligrams by mouth every six hours as needed for pain related to chronic pain syndrome. Review of R11's individual narcotic record and MAR dated 8/28/24 through 9/10/24 indicated four doses of oxycodone were signed out of the individual narcotic record but were not documented on the MAR as administered. R11 discharged from the facility on 9/10/24 and did not respond to phone call for interview. R12's significant change MDS dated [DATE], identified R12 had severe cognitive impairment and diagnoses of senile degeneration of the brain and anxiety. R12's Physician's Order Sheet printed on 10/2/24, indicated a physician order for lorazepam (antianxiety medication) 0.5 mg by mouth every four hours as needed for agitation related to senile degeneration of the brain. R12's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R12's electronic health record. R12's record indicated no negative outcomes occurred from not receiving the narcotic medications. When interviewed on 10/1/24, at 2:05 p.m. the director of nursing (DON) stated RN-B brought it to her attention. RN-B had been doing rounds with the provider. One of the residents insisted they were not taking that much Oxycodone. RN-B brought the narcotic book and noticed that the same staff member was signing the Oxycodone out of the narcotic book. The DON instructed RN-B to look for more incidents, after two more were brought to her a whole investigation was launched into all controlled medications. We completed pain assessments and found that no resident had uncontrolled pain due to not receiving their pain medication. During interview on 10/2/2024 at 1:43 p.m., R1 stated he was not receiving the amount of oxycodone that was documented. R1 stated he told the provider and RN-A that he took oxycodone approximately once a day if even and never three times a day. R1 stated he was told that oxycodone was signed out up to three times a day frequently and he knows that he did not receive those medications. R1 stated he thought it was strange when the TMA-B, that worked in the evenings, would come in and ask him how his pain was and when he asked why she was asking, TMA-B stated that she was following up on his pain following his pain medication to see if it was effective. R1 stated that he never received pain medication earlier with TMA-B stating it was signed off. R1 stated he bet that TMA-A signed it out and again stated that he never received those medications. R1 stated that occurred on several different occasions. During interview on 10/2/24 at 1:50 p.m., LPN-A stated when administering a PRN narcotic, she signed the narcotic out in the narcotic logbook and then would document the administration in the EMAR for that resident. During interview on 10/2/2024 at 2:17 p.m., R7 stated his pain was well-managed and would experience more pain when not positioned correctly in his wheelchair. R7 stated his pain medications are scheduled and that he had only needed to ask for an as needed dose one time since admission. During interview on 10/2/2024 at 3:19 p.m., RN-A stated she was rounding with the provider who asked RN-A how often R2 was taking his oxycodone. RN-A reviewed the narcotic logbook with the provider. RN-A stated the provider was asking R2 about constipation issues related to oxycodone use. R2 stated he had only taken one dose of oxycodone since his admission. RN-A informed R2 of the doses of oxycodone that were signed out with R2 responding if he was taking oxycodone, he was not aware of it. RN-A stated she updated the director of nursing (DON) thinking TMA-A may need re-education on administration of PRN medications. RN-A stated she then rounded with R1's provider who came in specifically for a medication visit and oxycodone renewal. Provider asked RN-A how many times R1 was taking oxycodone with RN-A reviewing the narcotic logbook which indicated R1 was taking the PRN oxycodone one to three times a day. R1 stated to provider and RN-A he took as needed oxycodone maybe once a day, sometimes two times but never three times. R1 asked if TMA-A was documenting the narcotic administration. R1 thought it was suspicious when TMA-B, who worked in the evenings, would come in and ask if the oxycodone was effective. R1 stated he told TMA-B that he never took an oxycodone. RN-A stated she notified DON who began investigation and found that there were 24 doses signed out of the narcotic logbook but was not documented on the EMAR. During interview on 10/2/24 at 4:26 p.m., TMA-A stated she documented the oxycodone in the narcotic logbook but would forget to document them in the EMAR. TMA-A stated the reason for forgetting to document them in the EMAR was that she got lazy with her job and become a disgruntled employee. During interview on 10/3/24 at 9:03 a.m., TMA-B stated that she would ask the resident what they wanted the narcotic for and get a specific reason and would always let her charge nurse know so they were aware of what occurred during her shift. TMA-B stated if a narcotic was administered during the day shift, she would follow up with the resident to see if the narcotic was effective or not. TMA-B stated she asked R1, several times towards the beginning of her shifts, if his oxycodone was effective with R1 stating that he did not receive the oxycodone. TMA-B stated she would tell him according to the record, TMA-A gave the oxycodone to R1. R1 was adamant he did not receive that dose of medication. TMA-B stated this started in September. TMA-B did not think anything of it due to TMA-A being pregnant and assumed not able to consume the narcotic. TMA-B stated looking back on it now, she realized she should have reported it sooner. TMA-B stated if she was suspicious of medication diversion, she would immediately go to the charge nurse and report it. When interviewed on 10/3/24, at 1:19 p.m. the DON stated, they had done re-education on the updated controlled substance policy, all staff that touch medications had been re-educated with exception of one nurse on vacation who will be re-educated upon return. Education included notifying the nurse or DON if a resident state they did not receive a medication despite documentation showing they did. They did not drug test the staff person, the evidence was so overwhelming the result would not have mattered, she started with a couple of pills here and there, in about August had significantly increased with the number of doses. In a subsequent interview on 10/3/24, 4:44 p.m. the DON stated the expectation was staff follow the policy, if residents requested an as needed (PRN) medication or it's identified they were having pain, the TMA would talk to the nurse who was responsible to assess the resident then direct the TMA on what medication to give. The nurse was expected to follow up with the resident to assess effectiveness of pain medication. The facility's Controlled Substances policy dated 9/24, directed controlled substances will be prepared following the guidelines within Medication Guidelines. Controlled substances will not be removed from their secure storage until ready to prepare for administration. Controlled substances will be documented at the time of removal from secure storage and will be administered immediately by the individual removing them from their secure storage. Controlled substance record will be thoroughly documented to include: a. Date and time of administration b. Dose being administered. c. Route of administration d. Signature of the authorized personnel e. Amount remaining Discrepancies of Controlled Substances - any controlled substances which are unaccounted for will be immediately reported to the director of nursing services and/or their designee. All authorized personnel that are present at the time of the discrepancy may be asked to remain in the facility until the discrepancy is resolved. The Director of Nursing Services and/or their designee will review the discrepancy and attempt to identify the cause of the discrepancy which may include bit is not limited to: recalculating the documented dose administered and amount remaining for that controlled substance, review and comparison of doses administered documented within the medication administration record for that resident and/or other residents with same/similar medications, review of controlled substance delivery records, communication with the providing pharmacy, etc. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a report of such findings. The facility's Medication Administration by Unlicensed Personnel policy dated 9/23, indicated the unlicensed personnel may administer PRN medications if approved by the licensed nurse. This Immediate Jeopardy (IJ) is being issued at Past noncompliance (PNC) after it was verified the facility put the following corrective action in place. -Staff education was initiated on 9/27/24 which included the following topics: Medication Administration by Unlicensed Personnel and Controlled Substances training including: Ensuring the meds are secure at all times, Every dose given must be documented in the narcotic record and the electronic medication administration record, At the time of follow up for a PRN medication, if a resident denies receiving the medication, immediately report it to the nursing supervisor for review. -AP was immediately suspended and then was terminated concluding investigation. -Management conducted audits on all residents with prescribed controlled medications to confirm medications were not diverted.