**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure system was in place to prevent narcotic drug diversion (misappropriation of resident property) of 577 tramadol, 96 half tablets of oxycodone, 45 tablets of clonazepam, 19 tablets of hydromorphone, 83 tablets of hydrocodone, and liquid lorazepam that were diverted between 11/23/23 and 3/12/25 for 20 of 20 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20) resulting in an immediate jeopardy (IJ). In addtional, registered nurse (RN)-A was observed consuming R1's narcotic pain medication used to treat his discomfort related to cancer. The immediate jeopardy (IJ) began on 2/19/25 when registered nurse (RN)-A was witnessed swallowing R1's Tramadol instead of administering this to R1 resulting in R1 pain during cares. The facility did not have a secure system to prevent diversion of medication that was susceptable for misapproprition of property. The administrator and director of nursing (DON) were notified of the IJ on 3/11/25, at 5:00 p.m. The IJ was removed on 3/12/25 at 4:15 p.m. but non-compliance remained at the lower scope and severity of E, no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings Include: During an interview on 3/6/25 at 1:15 p.m., the hospice nurse indicated R1 was receiving hospice services for brain cancer with metastasis and had been experiencing more non-verbal signs of pain with movement. During her visit on 2/19/25, the hospice nurse requested registered nurse (RN)-A administer a PRN tramadol 50 mg tablet to R1 prior to providing cares to decrease R1's discomfort during the care and procedures that would be completed. The hospice nurse stated she was approximately five feet from RN-A when she observed RN-A unlock the med cart, unlock the narcotic drawer, remove a tramadol, put it into a clear med cup, fill a second clear med cup with applesauce, put the tramadol into her mouth, shook her head back (in a swallowing motion), get a cup of water from the water fountain, throw the med cup with the applesauce away, grabbed some gloves, stated she was ready to do R1's cares, and gathered urinary catheter supplies. The hospice nurse indicated RN-A did not administer any medications to R1. Hospice nurse stated she was shocked and in disbelief, did not know what to do. The hospice nurse and RN-A completed R1's catheter flush and repositioning but noted R1 to have facial grimacing indicating discomfort and pain. The hospice nurse further indicated because R1 was having more difficulty swallowing pills, she received a physician order to discontinue the tramadol 50 mg and start dilaudid liquid for pain control on 2/19/25. This information was relayed to RN-A, she left the facility and contacted her supervisors regarding her observations. R1's admission minimum data set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and included diagnoses of malignant melanoma of scalp/neck, and traumatic brain injury. R1 received hospice services at the facility. R1's Physician Order dated 2/10/25, indicated R1 received tramadol 50 milligram (mg), one tablet twice daily for pain and one tablet every four hours as needed for pain. R1's Pain Observation dated 2/13/25, indicated R1 received PRN (as needed) pain medication within last five days. R1 denied pain at the time of that observation. R1's Medication Administration Record (MAR) indicated R1 received PRN (as needed) tramadol on 2/11, 2/13, 2/14, 2/15, 2/16 but did not receive PRN tramadol on 2/19 and indicated the order had been discontinued. R1's Individual Narcotic Record identified on 2/19/25, RN-A withdrew one tramadol 50 mg tablet at 8:00 a.m. and one tablet of tramadol 50 mg at 5:00 p.m. which left 49 tablets remaining. R1's Certificate of the Inventory and Destruction of Controlled Medications indicated on 2/19/25, RN-A destroyed 49-50 milligram (mg) tablets of tramadol into the MedSafe receptacle. The form identified the initials of RN-A and an unidentified RN. The Police Department Complaint Report indicated they received notification of a potential diversion on 2/20/25 at 1333 (1:33 p.m.). The report further identified after a full inventory of discarded medications in the MedSafe, the discarded drugs that were missing were as follows: 577 tramadol pills, 96 half tablets of oxycodone, 45 clonazepam pills, 19 hydromorphone pills, and 53 hydrocodone pills. RN-A was found to have 28 tramadol 50 mg tablets at her home and admitted to taking only the tramadol from the facility. The report also noted that RN-A had signed the Certificate of Inventory and Destruction of Controlled Substances form indicating that she had destroyed 452 tramadol, 96 half tablets of oxycodone, 45 clonazepam, 19 hydromorphone, and 30 hydrocodone pills into the MedSafe. Criminal charges were filed. The facilities Victim Impact Statement dated 3/6/25, identified the facility is to meet the resident's physical, emotional, and social needs. Taking a resident's pain medication and leaving the resident in pain is cruel. The facilities Proof of Receipt and Treatment from the company that removes the contents of the MedSafe indicated the last time the contents of the MedSafe were removed was on 11/6/23. The following resident medications were identified as destroyed per the destruction logs and deposited into the MedSafe, however were not located in the MedSafe on 2/20/25. R2's Certificate of Inventory and Destruction of Controlled Substances indicated 23 tablets of hydroco/APAP (narcotic pain medication) 5-325mg were destroyed in MedSafe on 11/13/24. R3's Certificate of Inventory and Destruction of Controlled Substances indicated 8.5 tablets of oxycodone 5mg tablets were destroyed in MedSafe on 10/2/24 and 56 one-half tablets were destroyed into the MedSafe. R4's Certificate of Inventory and Destruction of Controlled Substances indicated 29 tablets of clonazepam 2mg tablets were destroyed in the MedSafe on 10/7/24. R5's Certificate of Inventory and Destruction of Controlled Substances indicated 60 tablets of tramadol were destroyed in MedSafe on 9/4/24. R6's Certificate of Inventory and Destruction of Controlled Substances indicated 31 one-half tablets of oxycodone were destroyed on 7/6/24, and 24 [one-half] tablets of oxycodone were destroyed in MedSafe on 1/12/25. R7's Certificate of Inventory and Destruction of Controlled Substances indicated 150 tablets of tramadol were destroyed in MedSafe on 7/28/24 and another 66 tablets of tramadol were destroyed in MedSafe on 8/25/24. R8's Certificate of Inventory and Destruction of Controlled Substances indicated 17 tablets of oxycodone 5mg were destroyed into MedSafe on 12/12/24. R9's Certificate of Inventory and Destruction of Controlled Substances indicated sixty tablets of tramadol were destroyed into MedSafe on 8/20/24. R10's Certificate of Inventory and Destruction of Controlled Substances indicated 90 tablets of tramadol were destroyed into MedSafe on 8/21/24 and 15 tablets of tramadol were destroyed into MedSafe on 8/25/24. R11's Certificate of Inventory and Destruction of Controlled Substances indicated two tablets of oxycodone 5mg were destroyed into MedSafe on 7/28/24 and two tablets of tramadol 50 mg tablets were destroyed into MedSafe on 10/8/24. R12's Certificate of Inventory and Destruction of Controlled Substances indicated 45.5 [ml] of hydromorphone liquid 1mg/ml was destroyed in MedSafe on 2/10/25. R13 Certificate of Inventory and Destruction of Controlled Substances indicated 19 hydromorphone 2mg tablets were destroyed into MedSafe on 2/10/25. R14's Certificate of Inventory and Destruction of Controlled Substances indicated 30 tablets of hydrocodone-acetaminophen 5-325mg were destroyed to MedSafe on 1/31/25. R15's Certificate of Inventory and Destruction of Controlled Substances indicated 45 clonazepam 5 mg tablets were destroyed in MedSafe on 1/19/25. R16's Certificate of Inventory and Destruction of Controlled Substances indicated 26 tablets of oxycodone 5mg tablets were destroyed in MedSafe on 12/24/24. R17's Certificate of Inventory and Destruction of Controlled Substances indicated five oxycodone tablets were destroyed in MedSafe on 7/28/24. R18's Certificate of Inventory and Destruction of Controlled Substances indicated 66 tablets of oxycodone 5mg tablets were destroyed in MedSafe on 9/13/24. R19's Certificate of Inventory and Destruction of Controlled Substances indicated 27 tablets of oxycodone 5mg tablets were destroyed in MedSafe on 10/11/24. R20's Certificate of Inventory and Destruction of Controlled Substances indicated 74 tablets of tramadol 50mg was destroyed in MedSafe on 7/29/24. During an interview on 3/10/25 at 9:30 a.m., the facility's contracted pharmacist indicated she participated in auditing the MedSafe receptacle for controlled substance medications that were documented as destroyed by placing in the MedSafe. The pharmacist further indicated the MedSafe receptacle was last emptied on 11/23/23 so the diversion of the medication could have occurred between 11/23/23 and 2/19/25. The meds identified as unaccounted for were hydrocodone/acetaminophen tablets, tramadol, clonazepam, oxycodone, and hydromorphone but did not have the exact numbers. During an interview on 3/10/25 at 11:35 a.m., the administrator identified did not know exact number of medications that were unaccounted for but thought approximately 400 tablets. They cannot identify who the unaccounted medications belonged to because the names and identifying information were removed but approximately 20 discharged and current residents had controlled substances disposed of in the MedSafe between 11/23/23 and 2/20/25. Further stated they only looked at the pill form and did not reconcile the controlled liquid medications or patches. The administrator indicated two nurses were always supposed to reconcile the controlled substance, witness the medications being placed in the MedSafe, and both sign the destruction form but that must not have happened. If the nurses followed the process, the diversion would not have happened. During an interview on 3/10/25 at 1:05 p.m., the chief of police indicated he assisted with the investigation and noted 577 tramadol, 96 one-half tablets of oxycodone, 45 tablets of clonazepam, 19 tablets of hydromorphone, and 83 tablets of hydrocodone were all unaccounted for. The chief of police further stated, they should have all been in the MedSafe according to the destruction logs and were not. During an interview on 3/13/25 at 9:00 a.m., RN-A stated she was an agency nurse but had worked at the facility since 2022. RN-A denied taking any controlled substances from the residents and denied every destroying medication without a second nurse present and co-signing for the destruction. During a follow-up interview on 3/13/25 at 9:42 a.m., RN-A indicated the tramadol that the police found on her person was her own but that on 2/19/25, she did destroy R1's tramadol independently without another nurse present. RN-A indicated she had forgotten to discontinue the tramadol order. RN-A did not address the second set of initials on the Certificate of Inventory and Destruction of Controlled Substances that indicated a second nurse was present during the destruction. During an interview on 3/11/25 at 11:40 a.m., the regional clinical quality director (RCQD) indicated she assisted with the investigation into the missing narcotic medications. The RCQD indicated it is the expectation that two licensed staff destroy the controlled substances into the locked MedSafe and witness the entire destruction process, both sign their names that they witnessed the destruction. During an interview on 3/12/25 at 1:40 p.m., the medical director indicated the facility notified her of the discrepancy in the narcotic counts and stated, the facility needs to come up with better processes on how they do the controlled medication destruction. Liquid and Emergency Kit narcotic accounting. The facilities undated, Emergency Medication Kit Usage Form indicated it contained the following controlled substances: hydrocodone/APAP (Norco) 5/325mg tablets; morphine 20 mg/ml oral solution; oxycodone 5mg tablets; tramadol 50 mg tabs; lorazepam 0.5mg tablets; and lorazepam 2mg/ml injection. During an observation on 3/10/25, at 2:00 p.m. The Daily E Kit Sign Off Forms reviewed between 2/11/25 and 3/10/25 identified no accounting/reconciliation of the E Kit on 2/12/25, 2/23/25, 2/24/25, and 3/3/25 through 3/9/25. R12's Individual Narcotic Record identified a prescription recorded for Ativan 0.25ml four times a day PRN sublingual. R12's last documented dose given was on 3/10/25 at 3:00 a.m. with amount remaining in bottle documented as 22.75 (ml). R12's bottle contained 16 ml in the bottle which is a discrepancy of 6.75 ml equal to 27 individual doses for R12. Additionally, the medication emergency kit (E-kit) was observed to have intact security tags that secured the contents of the box. R12's quarterly MDS dated [DATE], indicated R12 had intact cognition with diagnoses of Alzheimer's Disease, generalized abdominal pain, and anxiety disorder. R12 received hospice care in the facility. R12's Prescription Order dated 10/9/24, identified R12 received an order for lorazepam [Ativan] concentrate; 2mg/ml and amount to give is 0.25ml to equal 0.5mg every four hours PRN for anxiety/nausea. During an observation and interview On 3/10/25 at 2:05 p.m., RN-B and RN-C were observed doing shift to shift narcotic count verification. RN-B indicated R12's refrigerated lorazepam bottle had 16 milliliters (ml) of liquid in the bottle; RN-C identified the Individual Narcotic Record indicated it should contain 22.75 ml. RN-B indicated the the discrepancy was because sometimes the bottle spills, liquids are hard to count. Both RN-B and RN-C signed the Controlled Drugs Count Record, put the medication back in the fridge, and left the medication room. Neither RN reconciled the discrepancy in the Narcotic record nor reported the discrepancy to the director of nursing (DON). Also observed RN-B and RN-C took the E-kit out of the cupboard and verify the security tag number was the same as previously documented and both signed to verify. RN-B indicated that she was an agency nurse and not sure what the facility policy was for reconciling the narcotics but typically the E-kit security tag was checked between shifts to assure the E-kit was intact and with all the narcotics in it. RN-B looked at the E-Kit signature sheets and stated, does not look like they [this facility] do it everyday and indicated the last time the E-kit had been verified was eight days prior. During an interview on 3/11/25 at 11:40 a.m., the RCQD indicated she would have to check the facility policy regarding R12's liquid lorazepam discrepancy but, it would be her expectation that any amount of discrepancy of a controlled substance would be reported immediately to the DON for investigation. During an interview on 3/11/25 at 4:15 p.m., the contracted pharmacist addressed the liquid lorazepam discrepancy of 6.75 ml noted on 3/10/25, indicated a small amount of spillage may occur but not several ml. The pharmacist then indicated any losses of controlled substances should be reported to the DEA (Drug Enforcement Administration) because it was the law and felt 6.75 ml of a controlled substance was significant enough to be reported. The pharmacist further identified the E-kit contains oxycodone, morphine, lorazepam, tramadol, hydrocodone/acetaminophen and was unsure of the other controlled substances were in it. The E-kit is secured with a numbered tag and the pharmacy audits it monthly but not sure what the facility policy was to assure the E-kits security. During an interview on 3/12/25 12:14 p.m., the pharmacy consultant indicated if there was a discrepancy with a controlled substance count, the DON should be contacted and an investigation completed. The pharmacy consultant further indicated if a resident is only getting 0.25 ml of liquid lorazepam and there is a loss of 6.75 ml, she would consider that a significant discrepancy. Further identified that every controlled substance in the facility needs to be counting and checking to make sure that they have is secured. The pharmacy consultant stated it was her expectation that the E-kit should be checked at least daily. During an interview on 3/12/25 at 1:40 p.m., the medical director indicated the discrepancy in R12's liquid lorazepam was a significant discrepancy should have been reported to the DON for further investigation. During an interview on 3/11/24 at 2:50 p.m., the director of nursing (DON) verified R12's refrigerated Ativan bottle contained 16 ml of liquid and the count record indicated the remaining liquid should be 22.75 ml. The DON indicated she had not been notified of the discrepancy and would have expected to have been notified for any discrepancy with a narcotic. The DON further verified three nurses had the opportunity to report the discrepancy in the past 24 hours but had not. During an interview on 3/10/25 at 2:33 p.m., the facilities pharmacy consultant indicated she was not informed about the controlled substance discrepancies. The pharmacy consultant identified she does random audits of the narcotic counts and reviews the narcotic count books for missing signatures but cannot verify the validity of the signatures because there is not a master signature log, and the facility uses many different agency nurses. The pharmacy consultant further questioned why the facility nurses started to remove the identifiers from the medication cards prior to putting them into the MedSafe, stating, they do not need to do that. The immediate jeopardy that began on 2/19/25, was removed and the deficient practice corrected on 3/12/25, when the facility completed the following: -Updated current policies and developed a Controlled Drug Count/I-Kit Policy and Procedure and Discrepancies, Loss and/or Diversion of Medications Policy and Procedure. -The nurse on duty completed education and policy review and put a plan in place for nurses to complete the policy review and education prior to working their shift. The education was followed by a knowledge test. -The pharmacy consultant to set up an in-person education. -E-Kit contents verified secure by tag number with the pharmacy. -Controlled substance counts completed and reconciled. The facility policy titled, MedSafe Receptacle last updated on 3/3/25, indicates upon disposition the LTCF (long term care facility) must document the medications name, strength, prescription number, quantity, date, resident name, and the name of the staff performing the disposition. One supervisor level employee at the LTCF designated by the authorized collector may assist in changing the collection receptacle inner liner under the supervision of one employee of the authorized dealer. Accepted medications include prescription medications schedule II-V controlled substances and non-controlled substances; over the counter medications; liquid medications in the original bottle, if possible, up to 4 oz (ounces); powdered medication. The policy was revised on 3/3/25 to reflect the MedSafe is to be checked with Pharmacist quarterly visit to check amount in box and pull as needed. The facility policy titled, Narcotic Counting last updated 4/8/24, indicates controlled substance count verification should be done every shift by two (2) nurses (one from the previous shift and one from the oncoming shift). Your signature means that the narcotic count is accurate. If the count is incorrect, notify the director of nursing for immediate follow-up. E-kit needs to be signed off on every shift. E-kit needs to be signed and documented each time a medication is taken from the kit. Documentation of exchanging of E-Kits need to be recorded with new number each time an exchange is made. For discontinue/destruction: Chart on the Disposal of med form in the narcotic book and the narcotic destruction book with two (2) nurses. Signatures, the controlled substance, the amount, and the Rx number and dispose of it in the med safe by two nurses destroying the medication. If a small amount of the substance is left in the vial or container after the narcotic book shows none left, estimate amount remaining and alert the DON. Two nurses must verify and sign the Individual Narcotic Record page and place in double lock cabinet in locked med room to destroy. Med destruction of controlled substances is done by two licensed nurses.