**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility staff and consulting staff interviews, record review, and facility policy review, the facility failed to provide adequate supervision for a severely cognitively impaired resident, to ensure the resident did not have access to medication from an unsecured medication cart, for one (1) of five (5) residents reviewed for accidents and hazards, Resident #41. On [DATE] at 6:45 PM, Resident #41 was observed opening the drawer of the A Wing medication cart (Cart #1), which contained the significant medications Insulin and Nitroglycerin tablets, along with other medications. The failure to provide adequate supervision, to ensure Resident #41 and the other five (5) residents identified with severe cognitive impairment, did not have access to remove medications from an unsecured medication cart, placed these residents in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE], when facility staff became aware that the medication cart had a drawer that would not lock and did not correct the situation. Resident #41, a resident with severe cognitive impairment, was observed to open the unsecured medication cart drawer, with accessible medications, on [DATE]. On [DATE] at 6:50 PM, the State Agency (SA) notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CRF(s) 483.25 (d)(2)-Supervision, F689, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy titled Security of Medication Cart, revised 4/2007, revealed the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. A review of the facility's policy titled, Safety and Supervision of Residents, with a revision date of [DATE], revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Observation on [DATE] at 6:45 PM, revealed Resident #41 opened the uppermost right top medication cart drawer as the surveyor was walking down A-wing 100 hallway. The primary medication nurse was not present, or in sight of, the medication cart at this time. Registered Nurse (RN) #3 was walking down the hallway and met the resident at the medication cart and redirected his right hand away from the cart. Shortly after, the primary medication nurse and the Director of Nursing (DON) came to the cart. The primary medication nurse verified that the drawer contained the following medications: three (3) insulin pens, one (1) Scopolamine patch, one (1) tube of Glucagon, one (1) 2.5 milliliter (ML) bottle of Latanoprost eye drops, one (1) bottle of Prednisone eye drops, one (1) bottle of Original eye drops, one (1) bottle of Nitroglycerin 0.4 milligram (MG) tablets (which contained 25 tablets), six (6) 2 ML vials of Zofran, one (1) 20 ML bottle of 1 percent (%) Lidocaine with approximately 15 ML remaining in the bottle, and one (1) tube of oral pain relief medication. On [DATE] at 8:30 PM, an interview with the DON revealed, We have been trying to get that medication cart fixed for the past month or so. On [DATE] at 8:40 PM, an interview with Licensed Practical Nurse (LPN) #10 revealed the facility had been having trouble with this medication cart drawer since she started to work at this facility, in [DATE]. Review of the Electronic Medication Administration Records (MARs) revealed LPN #10 first documented medication administration on [DATE] for the 100 hall. On [DATE] at 8:50 AM, an interview with the Director of Nursing (DON) revealed, RN #3 moved the resident's hand away from the medication cart. The DON also stated the medication cart lock had been broken for at least the past two (2) weeks. She stated the medication carts are usually kept in the medication room or in the hallway with the lock turned towards the wall. She also stated Resident #41 could have gotten an alcohol pad from the medication cart, because he is cognitively impaired. The DON stated there was some Insulin in the drawer, but it was in a bag, and the eye drops were in a box. She stated the resident could have taken the Nitroglycerin from the drawer and could have been sent to the hospital. Observation and interview on [DATE] at 9:00 AM, revealed Resident #41 lying in bed awake and getting ready to receive Activities of Daily Living (ADL) care. This Surveyor asked Resident #41 to make a fist and he stated, Do you mean make a fist like this and proceeded to open and close both of his hands demonstrating a fist five (5) times very quickly. He demonstrated the ability to follow a command. Observation on [DATE] at 9:30 AM, revealed LPN #9 pulled on each medication drawer of the A-wing medication cart, while it was in the locked position. Only the uppermost top right drawer would open. The same medications, including Insulin and Nitroglycerin tablets, remained in the unsecured medication drawer at this time. During observation, on [DATE] at 9:35 AM, LPN #9 emptied the Nitroglycerin tablets from the bottle (from the unsecured medication cart) into a plastic 30 Cubic Centimeter (CC) medication cup. LPN #9 approached Resident #41 and asked the resident to open the empty Nitroglycerin bottle. The resident twisted the cap off of the Nitroglycerin bottle easily. This was demonstrated in the presence of two (2) surveyors. Observation on [DATE] at 10:05 AM, revealed LPN #9 counted the Nitroglycerin tablets that were in the bottle from the top right drawer of A-wing medication cart. There were a total of 25 0.4 MG tablets in the bottle. Interview on [DATE] at 10:55 AM, revealed LPN #9 had not redirected any resident away from the medication cart before. She denied any problems with residents getting into the medication cart. LPN #9 stated no resident has been harmed from any medications and she has not seen any medications in any resident hands. She also stated, she was just made aware of the medication cart not locking as of last week. She stated she had called the pharmacy this past weekend and told them the top right medication cart drawer had problems with locking and the response was they would have to give her a call back. LPN #9 stated the pharmacy had not called her back as of today ([DATE]). She stated she had told her Charge Nurse, LPN #4 or LPN #5 about the medication cart drawer not locking; she was not sure which one of those Charge Nurses she had told. LPN #9 stated she never had gotten a chance to report the drawer not locking to the DON, because she had just discovered it over the weekend. On [DATE] at 11:05 AM, an interview with RN #6 revealed she had not had any residents attempting to open her medication cart. She stated she tried to anticipate what the residents need to help prevent the residents from trying to get a medication themselves. On [DATE] at 11:15 AM, an interview with the DON revealed she had not had any problems with residents trying to get into medication carts. She stated she was about to intervene when she had seen Resident #41 open the medication cart drawer. The DON stated that if the medication cart would have been turned around towards the room, the resident would not have been able to open the drawer. On [DATE] at 11:28 AM, an interview with RN #5 revealed the nurses try to keep the medication cart within eye's view. She stated the nurses started calling last week to let the pharmacy know that the lock was broken on the A wing medication cart. On [DATE] at 11:40 AM, an interview with the DON revealed the facility should receive a new medication cart tonight from Omnicare. (Medications still remained in the cart at this time). On [DATE] at 3:04 PM, an interview with LPN #10, via telephone, revealed the medication cart drawer had been broken for a couple of weeks. She stated she told the pharmacy people about the medication cart being broken. She also stated she had gone to the DON. LPN #10 stated the DON told her to call the pharmacy initially, and she had started calling them last week. She also stated Maintenance attempted to fix the medication cart the day before (referring to [DATE]). LPN #10 stated she was on the hallway and had just came out of room [ROOM NUMBER]. She stated the medication cart was parked between room [ROOM NUMBER] and room [ROOM NUMBER]. She also stated she was able to see the resident in room [ROOM NUMBER] and the medication cart at the same time. On [DATE] at 3:15 PM, LPN #10 disconnected the telephone call. On [DATE] at 3:18 PM, LPN #10 called back to continue the interview. During this interview LPN #10 stated, Yes, I said it had been broken, and I think I told you since [DATE]th (referring to how long the A-wind medication cart 1 had been broken). LPN #10 stated the cart was broken when she first started working (verified by the initials on the Electronic Medication Administration record as [DATE]). She stated when she first identified the lock was broken, she asked Maintenance if they could fix the lock. She stated Maintenance said they do not look at medication carts; she would have to call the people they (referring to the medication carts) had come from. She also stated the DON told her to call the pharmacy. LPN #10 stated she would keep the medication cart in view and/or turn it around. She stated when the surveyors had come to the facility, she was just finishing her medication pass. She then stated, she was able to see the medication cart, but could not see the resident. She also stated she had seen RN #3 intervene, but she (LPN #10) did not. LPN #10 then stated, the lock was facing her and she could see the lock. She stated the medication cart was close to rooms [ROOM NUMBERS] and it was facing towards the middle of the hallway. She stated the resident could have side effects if he had taken some of the medications. She also stated the resident could have heart problems and could have died. LPN #10 stated if she was giving medications to a resident and had the privacy curtain pulled, she would pull the medication cart to the door and she could hear if someone opened the drawer to the cart. She stated they would have to totally move the cart. She also stated, We have to keep the medications separated, so she could not have moved the medications to another drawer. She stated sometimes the other drawers would not lock and it's possible the resident could have gotten into another unlocked drawer. LPN #10 stated she tried several times to get the medication cart drawer fixed. On [DATE] at 4:08 PM, an interview with the DON revealed the staff reports to maintenance or puts the problem in the maintenance book for any broken equipment. She stated the Maintenance Supervisor or Maintenance Staff #2, are always on call even for equipment that need to be reported immediately. On [DATE] at 4:35 PM, an interview with Maintenance Staff #2 revealed he first became aware of the medication cart lock being broken on [DATE]. He stated as he was walking down the hallway, he was flagged down by RN #1 to talk to the pharmacy. Maintenance Staff #2 stated Omnicare staff asked him to check out the lock on the medication cart. He stated he and the Maintenance Supervisor were unable to fix the medication cart lock. He stated he called back and the lady on the phone stated she would send a technician out to the facility. He stated he had gotten the lady's first name but he was unable to get her last name. He also stated he does not know if the pharmacy sent the technician out to the facility or not. On [DATE] at 4:40 PM, an interview with the Maintenance Supervisor, revealed, Maintenance Staff #2, told her about the medication cart not being able to be locked on [DATE]. She stated, they (referring to her and her assistant) tried to work on it (referring to A-wing medication cart 1 lock) and could not get it fixed. She stated Maintenance Staff #2 called Omnicare. She stated the top right drawer would not lock. During an interview on [DATE] at 4:45 PM, Maintenance Staff #2 revealed the A-wing medication cart (Cart #1) measured 40 and ¼ inches in height. This was observed to be easily accessible to any resident, even a resident who used a wheelchair. On [DATE] at 5:47 PM, an interview with Consultant Pharmacist #2, revealed Omnicare (pharmacy) was first notified on Monday ([DATE]), of the facility having a medication cart that would not lock. She stated the facility emailed Pharmacy Staff #1 on Monday, [DATE], at 5:08 PM. She also stated she was not aware that the medication cart had been broken for two (2) weeks. She stated she called the facility Tuesday [DATE], to see if the maintenance man could fix the cart. She also stated if a resident took 25 0.4 MG Nitroglycerin tablets, she believed they would have a headache and Hypotension. She also stated that 25 Nitroglycerin tablets would be a higher than indicated dose. She stated it is not an indicated dose, and could lead to Hypotension, Headache, and falls. On [DATE] at 5:57 PM, an interview with the Medical Director revealed she was made aware of this incident (A-wing medication Cart 1 drawer lock being broken) today when she walked through the door at 2:00 PM. She stated there was a plan of correction in place. She also stated the Pharmacist is a major issue here at the facility. She stated if a resident had taken 25 of the 0.4 Mg Nitroglycerin tablets that could cause death. On [DATE] at 12:04 PM, an interview with RN #3 revealed she was making rounds and when she headed back, that's when she took the resident's hand and said, No, no, no, we can't do that (referring to Resident #41 opening the medication cart drawer). She stated Resident #41 said all he wanted was a pencil. RN #3 also stated she was headed back from the end of A-wing hallway to the nursing station. She stated the DON was coming from the opposite direction. RN #3 stated she had not had to redirect a resident away from a medication cart before. She also stated she does not remember any other resident opening the medication cart before. She stated she does not have a clue as to how long the medication cart lock had been broken. On [DATE] at 12:15 PM, observation revealed LPN #7 moved a Medication cart, just like the cart that had the broken drawer, to the middle of A-wing hallway between rooms [ROOM NUMBERS]. The medication drawers faced the center of the hallway, just as positioned on [DATE], when the resident was observed opening the medication cart drawer. The surveyor sat at the nursing desk on A-wing and the medication cart drawers were not visible from the nursing station with the medication cart being in this position. On [DATE] at 3:22 PM, an interview with Consultant Pharmacist #1 revealed there is some form of medication audit done monthly. He stated carts are checked basically once a quarter. He stated he was not aware and cannot recall the A-wing medication cart drawer being unable to be locked. On [DATE] at 11:32 AM, an interview with RN #3 revealed the staff could have supervised and redirected the resident to prevent this incident from occurring. On [DATE] at 1:28 PM, an interview with the Administrator revealed the DON notified him of the incident (A Wing top right medication cart drawer not locking) on [DATE]. He stated the expectation is not that the staff wait to report these types of issues. He stated he must be made aware for the safety and well-being of the residents. The facility identified five (5) residents, who had severe cognitive impairment and who were mobile in the facility. The facility provided the following Removal Plan: Brief Summary: At approximately 6:50 PM on [DATE], the facility was notified by the annual survey team that the facility was being placed in Immediate Jeopardy, due to the facility on [DATE] at approximately 6:45 PM, failed to adequately supervise to prevent a severely cognitively-impaired resident from opening a medication cart drawer where multiple medications, including 25 Nitroglycerin 0.4 milligram (mg) tablets were located. The facility failed to store medications safely to prevent a cognitively impaired resident from having access to the medication cart, and the medication cart drawer would not lock. Licensed Practical Nurse (LPN) #10 stated the cart did not lock properly and has malfunctioned since she started to work in the Facility on [DATE], at approximately 7:00 AM. On the evening of [DATE], Resident #41 was witnessed by a surveyor opening the malfunctioning drawer where medication was located. The cart was locked in the medication room once medication pass was completed. (The name of the Pharmacy Vendor) was contacted on [DATE] and a new cart was requested. The replacement cart arrived at the Facility on [DATE], and medications were transferred from the malfunctioning cart to the properly locking replacement cart. Corrective actions included: 1. On [DATE] at approximately 6:45 PM, Resident #41 was observed opening the malfunctioning drawer. This incident was witnessed by RN #3 and LPN #7. RN #3 immediately redirected resident. This incident was also witnessed by the annual survey team. The primary LPN #10 assigned to the cart was not present. 2. On [DATE] at approximately 1:00 PM, a new medication cart was delivered to the Facility. Medications were exchanged from the old cart into the new properly locking cart. 3. On [DATE] at approximately 2:00 PM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the RN Supervisor (RN) #1, and the Minimum Data Set (MDS) RN #2, audited medication carts regarding proper locking and storage. No issues were identified. 4. On [DATE] at approximately 2:30 PM, the Administrator held a Quality Assurance Performance Improvement (QAPI) meeting to discuss action plan and resolution steps. The members of the committee discussed the medication cart malfunction, proper storage of medication, necessary steps in reporting issues and an audit tool developed as a tracking mechanism to ensure medication carts are in proper working order. The Members in attendance were the Administrator, DON, ADON, Medical Director, Social Services Director, Dietary Manager, Activities Director, Director of Therapy, Staff Development Coordinator LPN #7, Maintenance Director, Business Office Manager, Human Resources Generalist, Housekeeping Manager, MDS RN #2, LPN #4, LPN #5, Risk Manager RN, and the RN Supervisor (RN #1). 5. On [DATE] at approximately 3:00 PM, the Staff Development Coordinator LPN #7 in-serviced Licensed Nursing Staff on the daily audit tool used to validate that all medication carts are in proper-working order, proper storage of medication to maintain a safe environment, and proper procedure for unavailable medications. 6. No nursing staff will be permitted to work until in-serviced. 7. The facility alleges that all corrective actions to remove the immediate jeopardy was completed as of [DATE], and the immediate jeopardy removed as of [DATE]. The SA validated the facility's Removal Plan and determined the facility had taken the following actions to correct the IJ: 1. Based on observations record review and staff interviews the State Agency (SA) validated Resident #41 had severe cognitive impairment and was observed opening the drawer of an unsecured medication cart. The SA validated the resident was redirected by RN #3. 2. The SA validated by interview with the Director of Nurses (DON) and observation on [DATE], that a new cart had been delivered and medications were exchanged from the old cart into the new cart on [DATE], and the cart properly locked. 3. The SA validated by interview with the DON that an audit was completed on [DATE], that all carts locked appropriately. The SA found no other carts that malfunctioned. 4. The SA validated through review of the sign-in sheet and interview with the Administrator, that a QAPI meeting was held on [DATE], with all stated members, in regards to the malfunctioning medication cart, storage of medications, reporting requirements if there's a malfunction, and a tracking/audit tool for ensuring medication carts were in proper working order. 5. The SA validated through random interviews with nursing staff and review of in-service sign in sheets, that the Staff Development Coordinator, LPN #7, initiated in-services regarding use of the audit tool, proper storage of medication to maintain a safe environment for residents, and procedures for medications not available. 6. The SA validated through interview with random nursing staff that no staff was allowed to work until they were in-serviced. 7. The SA validated that all corrective actions to remove the Immediate Jeopardy were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility staff and consulting staff interviews, record review, and facility policy review, the facility failed to provide safe medication storage and security of medications in a manner to prevent resident access, as evidenced by a drawer of the medication cart would not lock. As a result, on [DATE] at 6:45 PM, Resident #41 was observed opening the drawer of the A Wing Medication Cart 1, which contained significant medications including Insulin and Nitroglycerin tablets, as well as other medications. The facility was aware of the medication cart lock not functioning for approximately two (2) months prior to this incident, as evidenced by an interview with Licensed Practical Nurse (LPN) #10, who stated the drawer would not lock when she started to work on [DATE]. Resident #41 was observed opening the unsecured medication drawer on [DATE] at approximately 6:45 PM. The failure to provide adequate storage and locking of medications to ensure Resident #41 and the other five (5) mobile residents, identified with severe cognitive impairment, did not have access to remove medications from an unsecured medication cart, placed these residents in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE], when facility staff identified the A-Wing medication Cart 1 drawer, which contained Insulin and Nitroglycerin tablets, would not lock, allowing cognitively impaired residents to have access. On [DATE] at 6:50 PM, the State Agency (SA) notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.45(h)(1) F761, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's undated policy titled, Security of Medication Cart, revealed the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. A review of the facility's policy titled, Safety and Supervision of Residents, with a revision date of [DATE], revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On [DATE] at 6:45 PM, an observation revealed Resident #41 opened the uppermost right top medication cart drawer of a medication cart as the surveyor was walking down A-wing 100 hallway. The primary medication nurse was not in sight of the medication cart at this time. Registered Nurse (RN) #3 was walking down the hallway and met the resident at the medication cart and redirected his right hand away from the cart. Shortly after, the primary Medication Nurse and the Director of Nursing (DON) came to the cart. The primary Medication Nurse verified that the drawer contained the following medications: three (3) Insulin pens, one (1) scopolomine patch, one (1) Glucagon tube, one (1) 2.5 milliliter (ML) bottle of Latanoprost eye drops, one (1) bottle of Prednisone eye drops, one (1) bottle of Original eye drops, one (1) bottle of Nitroglycerin 0.4 milligram (MG) tablets (which contained 25 tablets), six (6) 2 ML vials of Zofran, one (1) 20 ML bottle of 1 percent (%) Lidocaine with approximately 15 ML remaining in the bottle, and one (1) tube of oral pain relief medication. During an interview on [DATE] at 8:30 PM, the DON revealed, We have been trying to get that medication cart fixed for the past month or so. In an interview on [DATE] at 8:40 PM, Licensed Practical Nurse (LPN) #10 revealed the facility had been having trouble with the Cart I medication cart not locking since she started to work at this facility, in [DATE]. She verified the cart drawer would not lock her first day on the cart on [DATE], and contained medications, which included the Insulin and Nitroglycerin tablets. (Review of the Electronic Medical Records revealed LPN #10 began signing the Medication Administration Record for hall 100 on [DATE]). In an interview on [DATE] at 8:30 AM, the DON stated that RN #3 moved the resident's hand away from the medication cart. The DON also stated, the medication cart lock had been broken for at least the past two (2) weeks. She stated the medication carts are usually kept in the medication room or in the hallway, with the lock turned towards the wall. She also stated Resident #41 could also have gotten alcohol pads from the medication cart, because he is cognitively impaired. The DON stated there was some Insulin in the medication cart, but it was in a bag, and the eye drops were in a box. She stated the resident could have taken the Nitroglycerin tablets and could have been sent to the hospital. On [DATE] at 9:00 AM, an observation revealed Resident #41 lying in bed awake and alert. This Surveyor asked Resident #41 if he could make a fist and he stated, Do you mean make a fist like this and proceeded to open and close both of his hands demonstrating a fist five (5) times very quickly. Resident #41 was able to follow the command. On [DATE] at 9:30 AM, an observation revealed LPN #9 pulled on each medication drawer of the A-wing medication cart, while it was in the locked position, and only the uppermost top right drawer would open. The medications remained in the unsecured medication drawer. This was done in the presence of two (2) surveyors. Observation on [DATE] at 9:35 AM, revealed LPN #9 emptied the 0.4 MG tablets of Nitroglycerin from the bottle into a plastic 30 Cubic Centimeter (CC) medication cup. This nurse then approached Resident #41 and asked the resident to open the empty Nitroglycerin bottle. LPN #9 handed Resident #41 the empty Nitroglycerin bottle and the resident twisted the cap off of the bottle easily. He had no difficulty in removing the cap, therefore allowing access to medication in the bottle. This was done in the presence of two (2) surveyors. Observation on [DATE] at 10:05 AM, revealed LPN #9 counted the Nitroglycerin tablets that were in the Nitroglycerin bottle from the top right drawer of the A-wing medication cart, with a total of 25 tablets in the bottle. This was done in the presence of two (2) surveyors. On [DATE] at 10:55 AM, interview with LPN #9 revealed she has not had to redirect any resident away from the medication cart before. She stated she has not had any problems with any resident getting into the medication cart. LPN #9 stated she had not seen any medications in any resident hands. She also stated she was just made aware of the medication cart not locking, as of last week. She stated she had called the pharmacy this past weekend and told them the top right medication cart drawer had problems with locking. LPN #9 stated the pharmacy had not called her back as of today ([DATE]). She stated she had told her Charge Nurse, LPN #4 or LPN #5, about the medication cart drawer not locking. LPN #9 stated she is not sure which of those Charge Nurses she had told. LPN #9 stated she never had gotten a chance to report the cart drawer not locking to the DON, because she had just discovered it over the weekend. On [DATE] at 11:05 AM, an interview with RN #6 revealed she had not had any residents attempting to open her medication cart. She stated she tries to anticipate what the residents need, to help prevent the resident from trying to get a medication themselves. RN #6 also stated she was not aware of any harm to residents from medications or any medications being in a resident's hands. On [DATE] at 11:15 AM, an interview with the DON revealed she had not had any problems with residents trying to get into medication carts. She stated she was about to intervene when she had seen Resident #41 open the medication cart drawer. The DON stated, if the medication cart would have been turned around towards the room, the resident would not have been able to open the drawer. On [DATE] at 11:28 AM, an interview with RN #5 revealed the nurses try to keep the medication carts within eye view. She stated the nurses started calling last week to let the pharmacy vendor know that the lock was broken on the A wing medication cart. On [DATE] at 11:40 AM, an interview with the DON revealed the facility should receive a new medication cart tonight from the pharmacy vendor. On [DATE] at 3:04 PM, an interview with LPN #10, per telephone, revealed the medication cart drawer had been broken for a couple of weeks. She stated she told the pharmacy people about the medication cart being broken. She also stated she had gone to the DON. LPN #10 stated the DON told her to call the pharmacy vendor initially, and she had started calling them last week. She also stated Maintenance attempted to fix the medication cart yesterday (referring to [DATE]). LPN #10 stated she was on the hallway and had just come out of room [ROOM NUMBER]. She stated the medication cart was parked between room [ROOM NUMBER] and room [ROOM NUMBER]. She also stated she was able to see the resident in room [ROOM NUMBER] and the medication cart at the same time. The call was disconnected at 3:15 PM, and LPN #10 called back to continue the interview. During this interview, LPN #10 stated, Yes, I said it had been broken and I think I told you [DATE]th (referring to how long the A-wind medication cart 1 had been broken). She stated when she first identified the lock was broken, she asked maintenance if they could fix the lock and Maintenance stated they do not look at medication carts; and she would have to call the people they (referring to the medication carts) had come from. She also stated she was told to call the pharmacy vendor by the DON. LPN #10 stated she would keep the medication cart in view and/or turn it around. She stated, when the surveyors had come to the facility, she was just finishing her medication pass. She then stated, she was able to see the medication cart, but could not see the resident. She also stated she had seen RN #3 intervene, but she (LPN #10) did not. LPN #10 then stated, the lock was facing her and she could see the lock. LPN #10 stated the resident used his right hand and opened the medication cart drawer. She stated the medication cart was close to rooms [ROOM NUMBERS] and it was facing towards the middle of the hallway. She stated the resident could have side effects if he had taken some of the medications. She also sated the resident could have heart problems and could have died. LPN #10 stated, if she was giving medications to a resident and had the privacy curtain pulled, she would pull the medication cart to the door and she could hear if someone opened the drawer to the cart. She stated they would have to totally move the cart. She also stated, We have to keep the medications separated, so she could not have moved the medications to another drawer. She stated sometimes the other drawers would not lock and it's possible the resident could have gotten into another unlocked drawer. LPN #10 stated she tried several times to get the medication drawer fixed. On [DATE] at 4:08 PM, an interview with the DON revealed the staff reports to Maintenance or logs the problem in the maintenance book for any broken equipment. She stated the Maintenance Supervisor or Maintenance Staff #2 are always on call, even for equipment that need to be reported immediately. On [DATE] at 4:35 PM, an interview with Maintenance Staff #2 revealed he first became aware of the medication cart lock being broken on yesterday (referring to [DATE]). He stated as he was walking down the hallway, he was flagged down by RN #1 to talk to the pharmacy vendor. Maintenance Staff #2 stated pharmacy staff asked him to check out the lock on the medication cart. He stated he and the Maintenance Supervisor were unable to fix the medication cart lock. He stated he called the pharmacy back and the lady on the phone stated she would send a technician out to the facility. He also stated he does not know if the pharmacy sent the technician to the facility or not. On [DATE] at 4:40 PM, an interview with the Maintenance Supervisor revealed Maintenance Staff #2 told her about the medication cart not locking on [DATE]. She stated they (referring to her and her assistant) tried to work on it (referring to A-wing medication Cart 1's lock) and could not get it fixed. She stated Maintenance Staff #2 called the pharmacy vendor. She stated the top right drawer of the cart would not lock. On [DATE] at 4:45 PM, an interview with Maintenance Staff #2 revealed the A-wing medication cart Cart 1, was 40 and ¼ inches in height. This was observed to be easily accessible to any resident in a wheelchair. On [DATE] at 5:47 PM, an interview with Pharmacist #1, revealed the pharmacy vendor was first notified on Monday ([DATE]), of the facility having a medication cart that would not lock. She stated the facility emailed Pharmacy Staff #1 on Monday, [DATE] at 5:08 PM. She also stated she was not aware that the medication cart had been broken for two (2) weeks. She stated she called the facility Tuesday [DATE], to see if the maintenance man could fix the cart. She also stated if a resident took 25 Nitroglycerin tablets, she believed they would have a headache and Hypotension. She also stated that 25 Nitroglycerin tablets would be a higher than indicated. She stated it is not an indicated dose, and could lead to Hypotension, Headache, and falls. On [DATE] at 5:57 PM, an interview with the Medical Director revealed she was made aware of this incident (the A-wing medication Cart 1 drawer lock being broken) today when she walked through the door at 2:00 PM. She stated there was a plan of correction in place. She also stated the Pharmacist is a major issue here at the facility. She stated if a resident had taken 25 of the 0.4 Mg Nitroglycerin tablets, that could cause death. On [DATE] at 12:04 PM, an interview with RN #3 revealed she was making rounds and when she headed back, that's when she took the resident's hand and said, No, no, no, we can't do that (referring to Resident #41 opening the medication cart drawer). She stated, the resident said, all he wanted was a pencil. She stated she was headed back from the end of A-wing hallway towards the nursing station. She stated the DON was coming from the opposite direction. RN #3 stated she had not had to redirect a resident away from a medication cart before. She also stated she does not remember any other resident opening the medication cart before. She stated she does not have a clue as to how long the medication cart lock had been broken. Observation on [DATE] at 12:15 PM, revealed LPN #7 moved a medication cart, just like the cart that had the broken drawer, to the middle of A-wing hallway between rooms [ROOM NUMBERS] with the medication drawers facing the center of the hallway, just as positioned on [DATE], when the resident was observed opening the medication cart drawer. The surveyor sat at the nursing desk on A-wing and the medication cart drawers were not visible from the nursing station, with the medication cart being in this position, indicating that the cart would have been unsecured without someone directly at the cart. On [DATE] at 3:22 PM, an interview with the Consultant Pharmacist revealed there is some form of medication audit done monthly. He stated carts are checked basically once a quarter. He stated he was not aware and cannot recall the A-wing medication cart drawer being unable to be locked. On [DATE] at 1:05 PM, an interview with the Administrator revealed the DON notified him of the incident (A Wing top right medication cart drawer not locking) on [DATE]. He stated staff should not wait to report these types of issues. He stated he must be made aware for the safety and well-being of the residents. The facility provided the following Removal Plan: Brief Summary: At approximately 6:50 PM on [DATE], the facility was notified by the annual survey team that the facility was being placed in Immediate Jeopardy, due to the facility on [DATE] at approximately 6:45 PM, failed to adequately supervise to prevent a severely cognitively-impaired resident from opening a medication cart drawer where multiple medications, including 25 Nitroglycerin 0.4 milligram (mg) tablets were located. The facility failed to store medications safely to prevent a cognitively impaired resident from having access to the medication cart, and the medication cart drawer would not lock. Licensed Practical Nurse (LPN) #10 stated the cart did not lock properly and has malfunctioned since she started to work in the Facility on [DATE], at approximately 7:00 AM. On the evening of [DATE], Resident #41 was witnessed by a surveyor opening the malfunctioning drawer where medication was located. The cart was locked in the medication room once medication pass was completed. (Name of Pharmacy Vendor) was contacted on [DATE] and a new cart was requested. The replacement cart arrived at the Facility on [DATE], and medications were transferred from the malfunctioning cart to the properly locking replacement cart. Corrective actions included: 1. On [DATE] at approximately 6:45 PM, Resident #41 was observed opening the malfunctioning drawer. This incident was witnessed by RN #3 and LPN #7. RN #3 immediately redirected resident. This incident was also witnessed by the annual survey team. The primary LPN #10 assigned to the cart was not present. 2. On [DATE] at approximately 1:00 PM, a new medication cart was delivered to the Facility. Medications were exchanged from the old cart into the new properly locking cart. 3. On [DATE] at approximately 2:00 PM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the RN Supervisor (RN) #1, and the Minimum Data Set (MDS) RN #2, audited medication carts regarding proper locking and storage. No issues were identified. 4. On [DATE] at approximately 2:30 PM, the Administrator held a Quality Assurance Performance Improvement (QAPI) meeting to discuss action plan and resolution steps. The members of the committee discussed the medication cart malfunction, proper storage of medication, necessary steps in reporting issues and an audit tool developed as a tracking mechanism to ensure medication carts are in proper working order. The Members in attendance were the Administrator, DON, ADON, Medical Director, Social Services Director, Dietary Manager, Activities Director, Director of Therapy, Staff Development Coordinator LPN #7, Maintenance Director, Business Office Manager, Human Resources Generalist, Housekeeping Manager, MDS RN #2, LPN #4, LPN #5, Risk Manager RN, and the RN Supervisor (RN #1). 5. On [DATE] at approximately 3:00 PM, the Staff Development Coordinator LPN #7 in-serviced Licensed Nursing Staff on the daily audit tool used to validate that all medication carts are in proper-working order, proper storage of medication to maintain a safe environment, and proper procedure for unavailable medications. 6. No nursing staff will be permitted to work until in-serviced. 7. The facility alleges that all corrective actions to remove the immediate jeopardy was completed as of [DATE], and the immediate jeopardy removed as of [DATE]. The SA validated the facility's Removal Plan and determined the facility had taken the following actions to correct the IJ: 1. Based on observations record review and staff interviews the State Agency (SA) validated Resident #41 had server cognitive impairment and was observed opening the drawer of an unsecured medication cart. The SA validated the resident was redirected by RN #3. 2. The SA validated by interview with the Director of Nurses (DON) and observation on [DATE], that a new cart had been delivered and medications were exchanged from the old cart into the new cart on [DATE], and the cart properly locked. 3. The SA validated by interview with the DON that an audit was completed on [DATE], that all carts locked appropriately. The SA found no other carts that malfunctioned. 4. The SA validated through review of the sign-in sheet and interview with the Administrator, that a QAPI meeting was held on [DATE], with all stated members, in regards to the malfunctioning medication cart, storage of medications, reporting requirements if there's a malfunction, and a tracking/audit tool for ensuring medication carts were in proper working order. 5. The SA validated through random interviews with nursing staff and review of in-service sign in sheets, that the Staff Development Coordinator, LPN #7, initiated in-services regarding use of the audit tool, proper storage of medication to maintain a safe environment for residents, and procedures for medications not available. 6. The SA validated through interview with random nursing staff that no staff was allowed to work until they were in-serviced. 7. The SA validated that all corrective actions to remove the Immediate Jeopardy were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].