**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility neglected to provide a breakfast tray for a dependent Resident (Resident #212) for 1 of 3 residents reviewed for neglect. Findings included: Resident #212 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) and aphasia (loss of ability to understand or express speech). Resident #212's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the Resident as cognitively impaired. She was coded as dependent with personal hygiene, toileting, oral hygiene and eating. Review of Resident #212's care plan revealed a care focus area initiated 3/11/24 that indicated that Resident #212 was at nutritional risk and interventions included staff to assist with feeding Resident at mealtimes. Facility investigation report dated 5/20/24 indicated Resident #212 was not provided with a breakfast tray on 5/15/24. The report indicated the Director of Nursing (DON) became aware of the incident at 11:20 AM when the Dining Assistant notified her that Resident #212's breakfast tray was still in the warmer in the kitchen. The DON went to inquire about the tray with Nursing Assistant #1 (NA #1) who was assigned to care for Resident #212 on 5/15/24 7:00 AM - 3:00 PM shift and NA #1 stated she forgot. During an interview on 11/13/24 at 11:40 AM with the Dining Assistant, she stated nursing assistants were responsible for obtaining trays from the food cart or kitchen for residents that ate meals in their rooms and required feeding assistance. The Dining Assistant stated she found Resident #212's tray in the warmer in the kitchen on 5/15/24 at around 11:20 AM and notified Nurse #1 that the tray was still in the kitchen. During an interview on 11/13/24 at 11:55 AM with Nurse #1, she stated she became aware that Resident #212 did not receive a breakfast tray on 5/15/24 when she was notified by the Dining Assistant at around 11:20 AM that Resident #212's tray was still in the kitchen. When she asked NA #1 about the tray, NA #1 stated she forgot about the tray. Nurse #1 explained that Resident #212 was dependent on staff for feeding and NA #1 should have obtained the tray from the kitchen to feed the Resident. She further stated that if NA #1 was busy she should have informed her that she needed assistance and she would have obtained the tray and fed Resident #212 herself. Attempts to interview NA #1 were unsuccessful. An Interview was conducted with the Director of Nursing (DON) on 11/13/24 at 12:06 PM. The DON stated that breakfast was normally served between 7:30 AM and 9:00 AM. She indicated that NA #1 stated she had forgotten to feed Resident #212 and when asked why she did not ask for assistance, NA #1 stated she was not running behind and that she got sidetracked and forgot about the tray. The DON verbalized Resident #212 ate her meals in her room with feeding assistance and NA #1 should have retrieved the breakfast tray from the kitchen and fed the Resident or asked for assistance from another staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse #2) took a Duragesic pain patch that was ordered for a Resident. The deficient practice was reviewed for 1 of 3 residents for misappropriation of residents' property (Resident #29). Finding included: Resident #29 was admitted to the facility on [DATE] with diagnosis including chronic back pain. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident#29 coded as cognitively intact. The care plan dated 11/07/2024 had focus of pain due to chronic back pain, osteoarthritis, and muscle spasms. The interventions included to please give me my pain medication as ordered. Monitor for narcotic overdose and follow protocol as ordered. The Initial Allegation Report dated 11/30/2023 completed by the Director of Nursing (DON) was reviewed. On 11/30/2023 staff notified the DON that Nurse #2 came into the facility during his off hours. Nurse #2 entered Resident #29's room to utilize a Duragesic patch. Later, Nurse #2 became pale, blood pressure 70/50, with low oxygenation. The Investigation Report dated 12/07/2023 completed by the DON was reviewed. On 11/30/2023 Nurse #2 provided enough information to substantiate allegation of deviating medication from Resident #29. The employee was terminated and support for professional assistance was provided. The North Carolina Board of Nursing (NCBON) and local police department were performing their own investigations. The employee was terminated. The staff had an in-service on communication, reporting, medication administration, and protecting your license. The Lumberton Police Department Incident Report dated 12/01/2023 by Officer #1 was reviewed. On 11/30/2023 the complainant (DON) reported Nurse #2 for larceny by employee of Fentanyl patch $1.00 value. The employee allegedly deviated Duragesic. Soon after, he became hypotensive with a low oxygen saturation. The emergency medical services (EMS) were notified but the employee refused transport. He later agreed to go to the emergency department (ED) with his parents. The allegation had been emailed to the NCBON. The November narcotic dosage form for Fentanyl 75mcg/hour for Resident #29 revealed all the medications for November were signed out as given and there were no patches missing. The November 2023 Medication Administration Record (MAR) for Resident #29 revealed an order for Duragesic (Fentanyl) 75 MCG/hour topical every other day for chronic pain syndrome was given as directed. Nurse #2 was not available for interview. An interview with Resident #29 was conducted on 11/12/2024 at 3:40 PM. The Resident stated he has been using pain patches for a while now and they are helping to control his pain. He has always received his patches and did not recall ever missing any doses. An interview with Officer #1 was conducted on 11/13/2024 at 10:16 AM. The officer stated he was the officer that responded to the report of larceny by an employee at the nursing home. Nurse #2 was accused of taking a Duragesic patch from the resident at the facility. The District Attorney (DA) did not press charges because the employee went to get treatment at a center for substance abuse. An interview with Nurse #3 was conducted on 11/13/2024 at 12:25 PM. The nurse stated she was the nurse working with Resident #29 on 11/30/2023. That morning, Nurse #2 was at the facility, and she thought he was still there from the prior shift. He came to her cart with Resident #29's old patch in a cup. The Nurse thought it had come off because she saw Nurse #2 go into Resident #29's room to check the resident because his light was on. She and Nurse #2 disposed of the old patch properly and signed out a new patch and she then gave the patch to Nurse #2 to place on Resident #29. She continued her medication pass and was told Nurse #2 was about to pass out. She thought about the patch he was supposed to change and went into the residents' room and did not see the replacement patch on the Resident. She reported it to the Assistant Director of Nursing (ADON). A telephone interview with Nurse #4 was conducted on 11/13/2024 at 2:04 PM. The nurse stated she worked 11/29/2023 third shift and Resident #29's patch was in place the last time she saw him at around 6:30 to 7:00 AM. An interview with ADON was conducted on 11/13/2024 at 3:04 PM. The ADON stated the morning of 11/30/2023 she was coming in to work around 7:30 AM and received a report that nurse #2 was going to the hosp. EMS was there but Nurse #2 would not allow them to perform a drug test. She was updated by Nurse #3 that Nurse #2 had gone into Resident #29's room to answer a call light and came out with a patch in a cup. The Nurse thought it had come off. The nurses discarded the old patch and Nurse #3 gave Nurse #2 a new patch to apply to the Resident and saw him go in Resident #29's room. The nurse did not think anything of it because Nurse #2 would work third shift regularly and answer call lights while charting. The ADON also stated she assisted in assessing residents that had patches and there were no complaints of pain from the residents. The Nurse Practitioner (NP) was in the facility and a one-time order for Resident #29 to have another patch was ordered and applied. An interview with the NP was conducted on 11/13/2024 at 3:20 PM. The NP was called to supply room because Nurse #2 was not acting right. He looked lethargic and 911 was called because his bp was low. She started an IV of normal saline and let it hang with gravity. She placed him in the Trendelenburg position, and he became more aware and coherent. When EMS arrived, he started walking and signed a waiver to not go to hospital. She thought he was tired at first and she did not know what was going on with him but was concerned about low bp. She then was updated on the missing Duragesic patch and ordered a one-time order for a new patch to be placed, and the nursing staff applied for the patch without any issues. The missing patch was long acting and there were no adverse reactions or pain while the patch was missing. An interview with the DON was conducted on 11/13/2024 at 3:37 PM. The morning of 11/30/2024 she received a call from her ADON stating Nurse #2 came in when he was not scheduled and helped Nurse#2 dispose of an old patch and was supposed to apply a new patch to Resident #29. The old patch that Nurse #2 brought to Nurse #3 was disposed of by the two nurses. Nurse #3 did not think anything of it when Nurse #2 was in the facility in the morning because he often would do double shifts. Nurse #2 became ill and found to have low blood pressure. He refused to go with the EMS to the hospital. He was escorted to the car at the back door, and she asked Nurse #2 if he remembers taking a patch from Resident #29, and Nurse #2 stated he did take the patch. After Nurse #2 left the facility, the police were called, and an investigation began. They assessed the three residents with pain patches and there were no complaints of pain. The police were called, and they also reported this incident to North Carolina Department of Health and Human Services (NCDHHS) and the NCBON. Nurse #2 was terminated, and staff were educated. An interview with the Administrator was conducted on 11/13/2024 at 4:08 PM. The Administrator stated it was an unfortunate incident with Nurse #2. He was loved by all staff and Residents. This was a shock that he had a problem. He had just gone through a bad break up with his significant other and they felt that was what sparked this incident. He had since gone to a rehab facility. They completed a Plan of Correction (POC) and there was no harm to any residents or pain voiced due to the removal of the patch. The Residents were assessed and there were no missing patches found during the count of narcotics and all patches were signed as administered as ordered. POC Problem: On 11/30/2023 Nurse #2 was supposed to replace a Duragesic (Fentanyl) 75 microgram (mcg) patch for Resident #29, but the patch was not replaced. o Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice include: Resident #29 was assessed, and the pain patch was missing. Resident #29 was interviewed and assessed and there were no reports of pain or any memory of him going without the patch in the past. A new Duragesic patch for Resident the resident was placed. It is the practice of [NAME] Pines to ensure that resident's pain medication patches are administered as ordered and residents are free from medication diversion. o Address how the facility will identify other residents having the potential to be affected by the same deficient practice include: All three of the Residents in the facility with Duragesic patches had the potential to be affected and all residents were assessed and assured the patches were placed as ordered. The Medication Administration Records (MAR) and narcotic medication sheets of the three Residents with Duragesic patches were checked for accuracy. o Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur include: The police were called 11/30/2023. A report was filed with NCDHHS on 11/30/2023. NCBON was made aware of the incident on 11/30/2023. The DON will in-service the nursing staff on 11/30/2023 and/or prior to working the next scheduled shift. Topics to include Communication, Reporting, Medication Administration, and Protecting Your license. Terminate Nurse #2. o Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The DON/Designee will monitor all MARs and controlled medication count sheets from 11/30/2023 to 12/30/2023 with audits to ensure all Duragesic patches are accounted for and in place. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the interdisciplinary team on December 1, 2023, concerning the drug diversion and this plan of correction that was developed and implemented. The facility's QAPI Committee will review this POC for the next 3 months. The Administrator stated she was responsible for this POC. Corrective action completion date: December 6, 2023 Validation On 11/15/2024 the facility's plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 11/30/2023 and was completed on 12/30/2023. No issues found. Reviewed all narcotic medications for the three residents that received a Duragesic patch in November and December to assure the count was equal. No issues noted. All residents on the Duragesic patch in November and November 2023 were checked to make sure they received their patches, and the residents received their doses as ordered. The Lumberton City Police Department report dated 11/30/2023 was reviewed and the police officer that conducted the investigation was interviewed on 11/13/2024 and stated the case was investigated and closed without prosecution. NCDHHS 24-hour report was submitted on 11/30/2023. 11/30/2023 to 12/06/2023 signed in-services were held for nursing staff by DON with topics including Communication, Reporting, Medication Administration, and Protecting Your license. Nursing staff voiced understanding of education. The training check-off sheets were noted to have DON's signature as the instructor. A review of the certified letter dated 12/01/2023 indicated Nurse #2s termination was sent out by the Human Resources Director. The DON stated she completed the auditing of the narcotic sheets and the MARs of the three Residents during the months of November and December 2023 and did not find any discrepancies. She completed the education for all nurses prior to their next shift. The Administrator stated she ensured the DON audited the MARs and narcotic controlled sheets and in-serviced all nursing staff including communication; to especially include knowing what staff that are on the schedule and not allowing any other nurse to administer any medications for them. They completed their monitoring of this medication deviation in March 2023. Reviewed NCBON complaint form dated 12/01/2023. The facility's plan of correction was validated to be completed as of 12/06/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to administer the antibiotic Doxycycline per the physician order which specified it was to be administered either 2 hours before or 2 hours after administering iron or a multivitamin for 1 of 5 residents review for unnecessary medications (Resident #42). Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses that included a non-pressure chronic ulcer of the left foot wound with the fat layer exposed. Review of an admission MDS (Minimum Data Set) assessment dated [DATE] documented Resident #42 had intact cognition. She had one venous/arterial ulcer on admission. Review of the Physician orders for 04/01/22 revealed: Doxycycline 100mg by mouth twice a day x 30 days-take 2 hours prior/after Iron or a multivitamin (MV) left foot wound; Ferrous sulfate 325 MG (Milligrams) (65 MG Iron) by mouth twice daily for anemia; and multivitamin with iron 8 MG tablet by mouth daily for a vitamin supplement. Review of Resident #42's April 2022 eMAR (electronic Medication Administration Record) revealed the following: Doxycycline 100 MG by mouth twice a day x 30 days-take 2 hours prior/after Iron or a multivitamin in the AM, Iron 325 MG by mouth at 8:00 AM and a multivitamin with iron 8 MG tablet by mouth daily at 8:00 AM. The AM dose of Doxycycline was administered with the Iron and the multivitamin with iron on 04/01/22, 04/02/22, 04/03/22, 04/04/22, 04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/09/22, 04/10/22, 04/11/22, 04/12/22, and 04/13/22 (a total of 13 doses). In an interview on 04/13/22 at 8:05 AM with the DON (Director of Nursing) she explained she was passing medications that morning because two nurses had called in sick. She stated she had administered medications to Resident #42 that morning. She indicated she had administered the Doxycycline, Iron and multivitamin with iron at the same time. She stated after she given Resident #42 her medication, she returned to the cart to sign them off as given and noticed the parameters documented for the Doxycycline. She knew at that point she had administered the Doxycycline incorrectly. In a second interview on 04/13/22 at 11:50 AM with the DON she reviewed the administration times for the Doxycycline from 04/01/22 through 04/13/22 and realized every morning dose had been documented as given at the same time as the Iron and multivitamin with iron. The evening doses had been given as ordered by the physician. She stated she would change the administration time for the Doxycycline to ensure it would not be given within 2 hours before or after the Iron or the multivitamin with iron. In an interview on 04/14/22 at 11:00 AM with Nurse #5 she stated she worked full time and was routinely assigned to care for Resident #42. She reported she had given the Doxycycline every morning at the same time as the Iron and the multivitamin with iron. She had not realized the Doxycycline was to be given either 2 hours before or 2 hours after the Iron and the multivitamin with iron. She explained she had received education that morning on how to give the medication. In a telephone interview on 04/14/22 at 11:13 AM with Nurse #6 she stated she realized there was supposed to be a 2- hour gap between the Doxycycline and the Iron and the multivitamin with iron. She explained she gave Resident #42 the Doxycycline at 8:00 AM each day, went down the hall giving medications, then gave the Iron and the multivitamin with iron to Resident #42 when she came back up the hall, but she documented all three at the same time. Record review revealed she documented she gave the Iron and multivitamin with iron on 04/09/22 at 8:27 and the Doxycycline at 8:28 AM; and on 04/10/22 she documented she gave all three at 8:56 AM not leaving a gap of two hours either day had she given the Doxycycline at 8:00 AM. When the sign off times were reviewed with Nurse #2 she had no response. In a telephone interview on 04/14/22 at 11:40 AM with Nurse #7 she stated she had administered medication to Resident #42 on 04/04/22 on day shift but had not had time to document that the medications were given because she had to leave to pick up her children and did not return to complete her charting. She did remember a resident who had to be given an antibiotic 30 minutes before other medications and two hours before eating but could not recall the resident. She was not aware the Doxycycline she had given was ordered to be given either 2 hours before or after the Iron and the multivitamin with iron. In an interview on 04/13/22 at 10:42 AM with the Physician she stated she would need to review the orders because she had just taken over beginning on 04/01/22 and was not very familiar yet with the residents. She explained, in general, Doxycycline should not be given with Iron or a multivitamin with iron because the Iron decreased the effectiveness of the antibiotic and the ability to manage the infection. She stated she may have recommended the facility hold the Iron and the multivitamin with iron during the 30 days the antibiotic was to be given or had the medication time altered to either 2 hours before or after the other medications. She commented because the resident was ordered to receive the antibiotic for 30 days and had the rest of the month remaining the medication would be effective if the rest of the remaining prescription was given as ordered and not given at the same time as the Iron or the multivitamin with iron. In an interview on 04/13/22 at 3:27 PM with the facility Pharmacy Consultant she stated when Doxycycline was given at the same time as Iron or a multivitamin with iron, the iron bound to the Doxycycline and could decrease the effectiveness of the medication. She stated the resident would not experience any negative outcome overall but concluded the best practice was to give the Doxycycline either 2 hours before or 2 hours after giving the Iron or the multivitamin with iron. She concluded she would contact the DON and discuss the correct time to administer the Doxycycline.

Based on record review and staff interview the facility failed to inform resident representatives (RP) and families by 5:00 PM the next calendar day following the occurrence of sixteen confirmed staff and eleven confirmed resident COVID-19 infections from 01/05/22 through 02/03/22 for thirteen instances the facility did not contact family/RP of sixteen staff and eleven residents reviewed for COVID-19 reporting. Findings included: Review of the facility COVID-19 testing log revealed 2-staff tested positive on 01/05/22 and 01/06/22. An interview with the Administrator on 04/11/22 at 11:00 AM revealed the 2-staff who tested positive for COVID-19 on 01/05/22 and 01/06/22 were notified of positive COVID-19 status via facility-rapid test the same day. The Administrator stated he did not think about notifying residents or residents' responsible parties of the 16-staff and 6-Residents who tested positive on 01/05/22 thru 02/03/22, because he was an interim Administrator and just forgot to send a letter out to all facility's resident families until 02/03/22. The Administrator confirmed he was aware the facility was required to report subsequent confirmed COVID-19 cases, so the facility did not contact families and/or responsible parties of 2-staff who were COVID-19 positive on 01/06/22.