**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, State Medical Doctor Consultant review, and interview, the facility failed to ensure 1 of 9 (Resident #2) sampled residents reviewed for medication administration was free of any significant medication errors. Resident #2's orders for Fentanyl were erroneously changed from being administered every 3 days to being administered daily. Resident #2 was administered Fentanyl patches daily on [DATE], [DATE], and [DATE] when the prescribed order was for the patch to be applied every 72 hours. The failure to apply Resident #2's Fentanyl patches as ordered had the potential to cause serious adverse outcomes, overdose, and/or death, which placed Resident #2 in Immediate Jeopardy. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, harm, serious injury, impairment, or death to a resident). The Interim Administrator, the Director of Nursing, and the Regional Significant Care Coordinator were notified of the Immediate Jeopardy for F-760 on [DATE] at 1:08 PM in the Conference Room. F-760 was cited at a scope and severity of J which is Substandard Quality of Care. A partial extended survey was conducted from [DATE] through [DATE]. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-760 was received on [DATE]. The corrective actions were validated onsite by the surveyor on [DATE] through observation, review of records, audit review, education review, and staff interviews. Noncompliance continues at F-760 at a scope and severity of D. The facility is required to submit a Plan of Correction. The findings include: 1.Review of the facility's policy titled Medication Administration dated [DATE], revealed .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration [MAR] Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule .Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age or condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate .Verify medication is correct three (3) times before administering the medication. a. When pulling medication from the med cart b. When dose is prepared c. Before dose is administered . 2. Review of the medical record revealed Resident #2 was admitted on [DATE], with diagnoses of Rheumatoid Arthritis, Pain Unspecified, History of Chronic Viral Hepatitis C, Atrial Fibrillation, Coronary Bypass Graft, Atherosclerotic Heart Disease, and Type 2 Diabetes. Resident #2 was scheduled to be discharged home on [DATE], but expired in the facility on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment. Review of a Physician's order for Resident #2 with a start date of [DATE], revealed an order for Fentanyl Schedule II 50 microgram (mcg) transdermal patch apply once daily every 72 hours (3 days). Review of a Physician's order for Resident #2 with a start date of [DATE], revealed Fentanyl Schedule II 75 mcg transdermal patch apply once daily every 72 hours (3 days). The 50 mcg patch was to be discontinued when the Fentanyl 75 mcg patch arrived. Review of the Medication Administration Record (MAR) dated [DATE] - [DATE], revealed a Fentanyl 50 mcg patch was applied to Resident #2 on [DATE]. The MAR documented a Fentanyl 75 mcg patch was applied to Resident #2 on [DATE] and [DATE]. Resident #2 had a Fentanyl patch applied daily for 3 days ([DATE], [DATE], and [DATE]). Review of a Nurse Practitioner (NP) Progress Note dated [DATE], revealed Rheumatoid Arthritis and Pain .Discontinue Fentanyl 50mcg and start Fentanyl 75 mcg Q [symbol for every] 72 hours . The State Medical Doctor Consultant Review of Resident #2's medical records dated [DATE], revealed .[Resident #2] was started on Fentanyl 25mcg/hr [hour] q72hrs on 11/25 [[DATE]], changed to Fentanyl 50 mcg/hr q 72hrs on 12/27 [[DATE]] (during this time there is some discrepancy in documentation seemingly indicating [Named Resident #2's initials] may have had his patches changed more frequently than q 72hrs) .The Progress Notes indicate that on 2/23 [[DATE]] Fentanyl 75 mcg/hr q72hrs was ordered by [Named Nurse Practitioner]. The DC [discontinued] order for the 50 mcg/ hr patch was written on 2/26 [[DATE]] which could lead to confusion regarding which strength the patient was to receive-50, 75, or 125 (combination of the two) between 2/23 ad 2/26 [2024]. There is a note from [Named LPN A] indicating that the 50mcg patch was dc'd [discontinued] on 2/25 [2024] .There is a note on 2/27 [[DATE]] (page 8) indicating no complications are noted with increase in Fentanyl patch dosing. Finally, notes written on 2/29 [2024] (less than 48 hours later) indicate that the patient was scheduled to be discharged after having been seen by the physician the previous day. After showering in the morning of 2/29 (the note is timed for midnight so it is not clear what time this occurred) [Named Resident #2's initials] was found unresponsive at 0942 [9:42 AM], [Named Nurse Practitioner] was contacted, there was an order to remove the Fentanyl patch at 1046 [10:46 AM] and dispose of it then an order for the patch to be replaced at 1456 [2:56 PM] prior to being pronounced dead at 1520 [3:20 PM]. [Progress notes page 8, 6, 3, 1] MD orders indicate that between 2/23-26 [2024] Fentanyl patch 75mcg/ hr QD [every day] was ordered (dc 50mcg when 75 arrives). On 2/27-29 [2024] the order was then changed to Fentanyl 75mcg/hr q 72hrs (dc 50 when 75 arrives). [Medical Doctor (MD) Orders Vaccines 11, 4, 6, 14] Per the MAR [Medication Administration Record] which is a bit difficult to follow due to many late entries, [Named Resident #2's initials] received (on a page with the following order)-Fentanyl 75mcg/hr q72hrs-a new patch each day on 2/23 and 2/24 [2024], no patch administered on 2/25 and 2/26 then given again on 2/27. There is a note regarding late administration of the patch on 2/29 [2024] though it refers to the patient [Resident #2] passing after the patch was opened.[MARS page 20, 29-31, 32] Death certificate indicates cause of death as CVA [Cerebral Vascular Accident], PAD [Peripheral Arterial Disease], HTN [Hypertension]. No autopsy means unable to confirm death by Fentanyl intoxication. Based on an NIH [National Institutes of Health] article regarding Fentanyl Transdermal use, within 1-2 hours after administration the drug can be detected in the blood stream and within 12-16 hours can reach therapeutic levels. Generally it takes 12-24 hours after patch placement for drug levels to stabilize whenever starting or changing dose. Transdermal use increased bioavailability [the ability of a drug or other substance to be absorbed and used by the body] of the drug by 90% [percent] making it possible to lower the dose necessary to achieve an adequate patient response. Elimination 1/2 [half] life [the length of time required for the concentration of a drug to decrease to one-half of it's starting dose] after patch removal is 13-22 hours due to slow release of Fentanyl from the skin depot. Fully used patches contain up to 84% of the original dose within the adhesive gel. [ncbi.nlm.nih.gov] Conclusions: [Initials of Resident #2's name] died after receiving Fentanyl patches daily rather than q72 hrs as ordered. This inappropriate administration could have caused drug overdose by increasing the available drug in the bloodstream and inhibiting the elimination of that drug in the manner expected by using the patch appropriately. The notations made do however make interpretation of the actions of the staff difficult. Finally, the death certificate indicates that the patient died from CVA [Cerebral Vascular Accident] whose signs can mimic that of opioid intoxication. There was no toxicology information provided with this case so it is impossible to know the exact cause of death . During an interview with the Director of Nursing (DON) on [DATE] at 2:10 PM, when asked about the Fentanyl patch being removed and reapplied on Resident #2 on [DATE], the DON stated, .The NP gave order to remove Fentanyl patch due to his [Resident #2] decline. We wanted him comfortable, so the NP gave order to reapply at same dosage [75 mcg]. Before the nurse had gotten to him he had passed . During an interview with the NP on [DATE] at 10:20 AM, the NP was asked about Resident #2 on [DATE] when he was found unresponsive. The NP stated, .They [facility staff] found him not responding. They told me and I got up from my office and went. When I saw him I knew he was initially dying. He had transitioned. I had not seen him that morning before that. I had planned to go see him before he discharged home that day .I didn't leave the room .I was assessing him. He was placid, they got vital signs. When I first walked in the room I asked does he only have one patch on? I wanted to make sure they had not left one on in error. I told them to take the patch off. [Named LPN H] took it off. After it was off I realized it wasn't the patch. He didn't come around, nothing improved. So after [that] we got a hold of the family and they were on their way. His daughter had come up and was in the room. I was talking with the daughter and because he did take pain med and had pain daily I told her we can give him oxycodone and crush it and put it in his cheek. They did that and they told me he had vomited. I then said they could put the patch back on. That's what they did .From what I've read the medicine starts immediately but doesn't reach full dose till sometime within 24 hrs. Some release at first but not full until the 24 hours time frame. The NP was asked if there were any concerns regarding the daily administration of the fentanyl patches. The NP stated, My first concern as a nurse I would have been like daily. Isn't this an every 3 day. I would think the nurse that verifies the order in matrix would have questioned a daily order. But as I've looked into the use of the patches from what I've read I would think he wasn't getting enough because of the timeframe of release. I would have been more concerned if he had 2 patches, multiple patches on. During an interview with the DON on [DATE] at 12:04 PM, when asked what a nurse should do before administering a medication, the DON stated, Have the MAR, verify the rights, verify the med [medication] is correct . During an interview on [DATE] at 10:20 AM, when the NP was asked if she had ordered a Fentanyl patch to be applied daily for Resident #2, the NP stated, .The intention was to increase the Fentanyl to 75 mcg. I put the order in Matrix [software system used for documentation in medical record], as once a day is how it turned out. I'm not sure why it came through on Matrix that way. I know I wrote it for every 3 days. The intention was for it to be every 3 days. It showed up to pharmacy as every 3 days. If it had not, they would have caught it and not accepted .I put it in my company's electronic health record to send to pharmacy. So the actual script was for every 3 days .I would think the nurse that verifies the order in Matrix would have questioned a daily order .On the box the label would have said every 3 days. Should be checking the label as well . My order to pharmacy was correct . During an interview on [DATE] at 1:45 PM, when asked if she questioned the Fentanyl 75 mcg patch to apply daily order for Resident #2, LPN J stated, I did. It crossed my mind because I knew it was every 3 days. I went ahead and verified in the computer. I should have clarified the order . During an interview on [DATE] at 11:23 AM, when asked if he applied the daily Fentanyl 75 mcg patch on Resident #2, LPN I stated, I saw the order. I thought that was strange. I had the thought that is weird. In my error I didn't call the NP or the DON to clarify. I saw that it might be wrong. I failed to look at the label. I just looked at the MAR . An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE], and was validated onsite by the surveyor on [DATE] through review of staff education and sign-in sheets, observations, interviews with staff and Administration, and review of the audits conducted as follows: Identification of other residents having the potential to be affected was accomplished by: On [DATE] a Medical Record review was conducted by the Director of Nursing to identify residents who have active orders for Fentanyl Transdermal patches to ensure the order was transcribed correctly. One other resident has an order for a Fentanyl Transdermal Patch. The order was correct. There were 2 residents in the facility with orders for Fentanyl Transdermal Patches and both resided on Hall #3. Findings were reported to the legal and regulatory authorities: Health Facilities Commission, [NAME] Tennessee (TN) Regional Office; Ombudsman and Adult protective Services (APS). On [DATE] an audit of medications in the medication carts was conducted by the Clinical Interdisciplinary Team (IDT) to ensure the labels on the medication cards match the order in Matrix Care. A label was placed on the cards that did not match informing to nurse there was a change in the order and to check the order in Matrix Care. This audit was completed on [DATE]. Measures/Systematic changes that will be put into place to ensure that the deficiency does not recur: A root cause analysis was conducted by the Clinical Interdisciplinary Team on [DATE]. It was determined the order had been entered for Fentanyl Transdermal Patches into MatrixCare to be applied daily instead of every 3 days. The NP entered the electronic script (e-script), which goes to the pharmacy, to be applied every 3 days. The Unit manager (UM) verified the order in MatrixCare without clarification of the order. Root cause is the need of more education regarding order entry. On [DATE] the Nurse Practitioner was educated by the Signature State Care Consultant and the Director of Nursing on Order Entry in Matrix Care. A power point and screen shots were provided. On [DATE] the Nurse Practitioner attended an on-line Matrix Care Provider Training. On [DATE] the Director of Nursing educated the Unit Manager #2 to ensure the order is transcribed accurately and clarify any discrepancies with the provider before verifying the order. On [DATE] Unit Managers #1, #2, and #3 and licensed nurses were educated to verify orders for accuracy before activating them and to clarify any discrepancies with the providers. Beginning [DATE] all licensed staff were educated by the Director of Nursing to ensure the label on the medication card matches the medication order in MatrixCare and to call the provider to clarify any discrepancies. This education was completed on [DATE]. Any staff/agency staff not educated will be prior to working their next shift. Quality Assurance & Process Improvement Program (QAPI) An Ad Hoc [meeting held for a particular purpose] QAPI was held on [DATE] and [DATE] with the Leadership Team and Medical Director to discuss the incident, the investigation outcome and discuss the Plan of Correction. Beginning [DATE] the DON or Unit Manager will verify the medication card labels match the order in Matrix Care for 5 days per week for 1 week then, 3 times per week for 3 weeks then, 1 time per week for 1 month. Beginning the week of [DATE] a pharmacy nurse consultant will audit all medication carts to ensure the labels on the medication cards match the order in MatrixCare until the QAPI team determines compliance. Findings of audits will be reported to the QAPI Committee which consists of the Administrator, Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director. The Quality Assurance Committee will review staff education and audit logs for completion and accuracy. QAPI meetings will be held weekly beginning [DATE] for 4 weeks, then 2 times per month for the next 30 days, then monthly thereafter until the QAPI Committee determines substantial compliance. Regional oversite has been in place daily since [DATE], the date Misappropriation of Resident Property was reported to Health Facilities Commission regarding Transdermal Fentanyl Patches. The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, audits, education, process changes, attending QAPI meetings, and oversight of compliance with process changes. Regional oversite has occurred onsite or by phone from the Sr. State Signature Care Consultant, the Regional [NAME] President of Clinical Operations, or the Regional [NAME] President of Operations. The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility document review, and interview, the facility failed to ensure residents' rights to be free from misappropriation of controlled narcotics for 7 of 9 (Resident #1, #2, #5, #6, #7, #8, and #9) sampled residents reviewed with orders for controlled narcotics. Resident #1 had a total of 48 tablets of Oxycodone 10 milligram (mg) missing. Resident #2 had a total of 61 tablets of Oxycodone 5 mg missing. Resident #5 had a total of 78 Hydrocodone 7.5 mg tablets missing. Resident #6 had a total of 28 tablets of Oxycodone 5 mg missing. Resident #7 had a total of 94 tablets of Oxycodone 10 mg missing. Resident #8 had a total of 144 tablets of Hydrocodone 5 mg missing. Resident #9 had a total of 56 tablets of Hydrocodone 5 mg missing. On [DATE] the facility discovered Resident #2's Controlled Drug Record sheet (a form for documentation of the ongoing number of narcotic medications in the medication cart) had been removed from the Controlled Substance Count sheet (a form for documentation of the number of Controlled Drug Record sheets) and could not be located. The facility's failure to ensure all residents were free of misappropriation abuse of resident property resulted in Immediate Jeopardy (IJ) for Residents #1, #2, #5, #6, #7, #8, and #9. The facility's failure to ensure the residents' rights to be free from misappropriation abuse of resident property (narcotic medications) resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, a serious injury, harm, impairment or death to a resident). The Interim Administrator, the Director of Nursing (DON), and the Regional Signature Care Coordinator (SCC) were notified of the Immediate Jeopardy for F-602 on [DATE] at 1:08 PM in the Conference Room. F-602 was cited at a scope and severity of K which is Substandard Quality of Care. A partial extended survey was conducted from [DATE] through [DATE]. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-602 was received on [DATE]. The corrective actions were validated onsite by the surveyor on [DATE] through observation, review of records, audit review, education review, and staff interviews. Noncompliance continues for F-602 at a scope and severity of E. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Misappropriation of Property dated [DATE], and revised [DATE], revealed .It is the organization's intentions to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin, and misappropriation are investigated and reported immediately .Definitions: .Misappropriation of resident property Is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of the facility's policy titled Controlled Medications dated [DATE], revealed .The facility will ensure Controlled Medications are handled, stored, disposed of, and recordkeeping is in place in accordance with federal, state, and other applicable laws and regulations . 1. A controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV, or V medications. The following information is compiled in the report: a. Name of resident. b. Prescription number. c. Name, strength, and dosage form of medication. d. Date received. e. Quantity received. f. Name of person receiving medication supply. 2. At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either licensed nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled medications accountability record .Once the medications count is completed, both licensed nurses or medication technicians will also count the number of individual narcotic control sheets, together and will sign the controlled medication accountability record .If a new medication is added or a medication is discontinued/removed, the controlled medication accountability record must reflect the above by completing the controlled medication accountability record by two licensed nurses or medication technicians .3.Current controlled medication accountability records are kept in the narcotic book. When completed the accountability records are submitted to the director of nursing and maintained on file at the facility .6. Any controlled medications that have been competed including empty medication cards, discontinued, or are from a resident being discharged will be left on the medication cart and continued to be counted, as detailed in #2 above, until 2 nurse leaders remove the completed, discontinued, or discharged medications together . 2. Review of the medical record revealed Resident #1 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses of Pain in Joints of Right Hand, Dysarthria (slurred speech) and Anarthria (complete loss of speech), Neuropathy, Type 2 Diabetes, Cerebrovascular Disease, Migraine, Seizures, Chronic Respiratory Failure, and Right Bundle Branch Block (a problem with the heart's electrical signal). Review of a Physician's Order for Resident #1 with a start date of [DATE], and no end date revealed an order for Oxycodone/Acetaminophen Schedule II 10/325 milligrams (mg) tablet give 1 tablet by mouth three times daily. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 263 tablets of Oxycodone 10 mg to the facility for Resident #1 on [DATE], [DATE], and [DATE]. Resident #1 had a total of 48 Oxycodone 10 mg tablets missing from those deliveries during the time of [DATE] through [DATE]. Review of the Controlled Substance Count sheet dated February 2024, revealed Resident #1 had Oxycodone 10 mg 1 card removed and 1 sheet removed from the controlled count. The Inventory Shift Count column was dated [DATE] (on the sheet for February) 6 PM and the columns for total number of cards had the number 28 written over another number and words in writing stated Twenty 8ish + [plus] 2. During an interview with the DON on [DATE] at 2:23 PM, when asked if there should be a witness when a Controlled Substance Count sheet and/or a Controlled Record Count sheet was added and/or removed from the count, the DON stated, A 2nd nurse should sign, but sometimes they don't. When asked what the Twenty 8ish + 2 meant on the Controlled Substance Count sheet, the DON stated, I can't answer that. 3. Review of the medical record revealed Resident #2 was admitted on [DATE], with diagnoses of Rheumatoid Arthritis, Pain Unspecified, History of Chronic Viral Hepatitis C, Atrial Fibrillation, Coronary Bypass Graft, Atherosclerotic Heart Disease, and Type 2 Diabetes. Resident #2 was scheduled to be discharged home on [DATE], but expired in the facility on [DATE]. Review of the admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Review of a Physician's order for Resident #2 with a start date of [DATE], and end date of [DATE], revealed an order for Oxycodone Schedule II 5 mg tablet give 1 tablet by mouth every 6 hours for pain. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered a total of 402 tablets of Oxycodone 5 mg for Resident #2 on [DATE], [DATE], and [DATE]. Resident #2 had a total of 61 Oxycodone 5 mg tablets missing. During an interview on [DATE] at 8:47 AM, LPN E was asked if there had been any concerns with controlled narcotic counts on [DATE] when she had counted at shift change. LPN E stated, .The card of Oxycodone [for Resident #2] was gone. I can't remember the count. I feel comfortable saying the first line of tablets was empty and the rest of card I'm unsure [LPN E] could not recall the exact number of tablets], but I know he [Resident #2] had enough for several days. When I came back [returned to work on [DATE] after scheduled off days] there was no sheet [Narcotic sheet]. There was none. There was no sheets [Count sheets or Narcotic sheets] . During an interview with the DON on [DATE] at 3:10 PM, when asked when the facility identified Resident #2 had missing Oxycodone tablets, the DON stated, .The next morning [[DATE]] [Named LPN E] was here at 6:00 AM. She called me and asked where was the Fentanyl and oxy [Oxycodone] [was]. She thought there should have been a full box of Fentanyl and some oxy on a card. I asked her to look and see if the count of cards [for Resident #2] had been removed and she said yes by [Named LPN A]. There was no Fentanyl missing, only oxy missing. There should have been 51 tablets of the 86 received left on the card in the cart. This got me started looking at recently discharged or expired residents and then all residents with controlled medications. During an interview with Registered Nurse (RN) A on [DATE] at 5:49 PM, when asked if she witnessed the removal of any of Resident #2's medication cards from the Drug Record Count sheet on [DATE], RN A stated, .I was inside the room giving meds. She [LPN A] said she had some empty cards to sign out. She didn't bring them initially with her. I said what am I signing out. 2 nurses had to sign that a card [ medication card] and a sheet [Narcotic sheet] was coming out of the book. She went back and got it .She handed me an empty card. I saw there were no tablets left in the card. I would have been the witness to the removal. When asked if she verified the medication and the count on the Controlled Drug Record sheet, RN A stated, No, I did not. RN A confirmed she did not verify the Narcotic sheet was accurate. 4. Review of the medical record revealed Resident #5 was admitted on [DATE], with diagnoses of Dementia, History of Traumatic Brain Injury, Fracture Upper End of Left Humerus, Chronic Obstructive Pulmonary Disease, History of Falling, Type 2 Diabetes, Vertigo, and Hypertension. Review of a Physician's order for Resident #5 with a start date of [DATE], revealed an order for Hydrocodone Schedule II 7.5mg tablet, give 1 tablet by mouth three times a day. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 5, which indicated severe cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 351 tablets of Hydrocodone 7.5 mg to the facility for Resident #5 from [DATE] through [DATE]. Resident #5 had a total of 78 Hydrocodone 7.5 mg tablets missing and unaccounted for. 5. Review of the medical record revealed Resident #6 was admitted on [DATE], with diagnoses of Cirrhosis of Liver, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Morbid Obesity, Obstructive Sleep Apnea, Congestive Heart Failure, and History of Myocardial Infarction. Review of a Physician's order for Resident #6 with a start date of [DATE] revealed an order for Oxycodone Schedule II 5 mg tablet give every 6 hours as needed for pain. Review of the admission MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 14, which indicated no cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 118 tablets of Oxycodone 5 mg to the facility for Resident #6 on [DATE]. Resident #6 had 28 tablets of Oxycodone 5 mg missing and unaccounted for. 6. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses of Malignant Neoplasm of Supraglottis [the upper part of the voice box], Malignant Neoplasm of Lymph Nodes, Cirrhosis of Liver, Tracheostomy Status, Cerebral Infarction, Viral Hepatitis C, and Acute Respiratory Failure. Review of a Physician's order for Resident #7 with a start date of [DATE], revealed an order for Oxycodone Schedule II 10 mg tablet give every 6 hours as needed for pain. Review of the admission MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated no cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 356 tablets of Oxycodone 10 mg to the facility for Resident #7 on [DATE] through [DATE]. Resident #7 had 94 tablets of Oxycodone 10 mg missing and unaccounted for. 7. Review of the medical record revealed Resident #8 was initially admitted on [DATE] with diagnoses of Congestive Heart Failure, Diabetic Neuropathy, Type 2 Diabetes, Bipolar Disorder, Peripheral Vascular Disease, Chronic Venous Ulcer Bilateral Lower Extremities, and Chronic Obstructive Pulmonary Disease. Review of a Physician's order for Resident #8, with a start date of [DATE], revealed an order for Hydrocodone/Acetaminophen Schedule II 5/325 mg tablet give every 6 hours as needed for pain. Review of the admission MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 15, which indicated no cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 348 tablets of Hydrocodone 5 mg to the facility for Resident #8 on [DATE] and [DATE]. Resident #8 had 144 tablets of Hydrocodone 5 mg missing and unaccounted for. 8. Review of the medical record revealed Resident #9 was admitted on [DATE], with diagnoses of Dementia, Peripheral Vascular Disease, Major Depression, Pain Unspecified, Restless Leg Syndrome, Repeated Falls, and Type 2 Diabetes. Review of a Physician's order for Resident #9 dated [DATE], revealed an order for Hydrocodone/Acetaminophen Schedule II 5/325 mg tablet give every 12 hours as needed for pain to right hip. Review of the quarterly MDS assessment dated 10/102023, revealed Resident #9 had a BIMS score of 15, which indicated no cognitive impairment. Review of the Pharmacy Manifest delivery records, the Controlled Substance Count sheets and the Controlled Drug Record sheets revealed the pharmacy delivered 116 tablets of Hydrocodone 5 mg to the facility for Resident #9 on [DATE]. Resident #9 had 56 Hydrocodone 5 mg tablets missing and unaccounted for. During an interview with the DON on [DATE] at 11:46 AM, the DON confirmed the Oxycodone and Hydrocodone tablets for Resident #1, #2, #5, #6, #7, #8, and #9 could not be accounted for due to missing Narcotic sheets and missing medication cards that were removed from the medication cart and were not completed. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE], and was validated onsite by the surveyor on [DATE] through review of staff education and sign-in sheets, observations, interviews with staff and Administration, and review of the audits conducted as follows: Corrective actions for identified residents affected by the deficient practice. 1.Residents #2 and #7 are deceased . 2.Resident #6 discharged from the facility on [DATE]. Charges to his insurance was reversed and charged to the facility. 3.On [DATE] Resident #1 was assessed for pain, no pain was noted and on [DATE], current residents #1, #5, #8 and #9 were assessed for pain by the DON. No pain was noted. 4.On [DATE] and [DATE] controlled medications were reconciled on every medication cart by the DON. This was completed on [DATE] and [DATE]. 5.On [DATE] the pharmacy was informed of the missing medications for residents #1, #5, #8, and #9. The charges to their insurance for their medications were reversed and charged to the facility. Identification of other elders who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. 1.Beginning [DATE] the DON and SCC conducted interviews with licensed staff to inquire if they had knowledge of controlled medication unaccounted for or if they had suspicion of anyone working while impaired. The interviews were completed on [DATE]. 2.On [DATE], the DON and SCC began auditing the Controlled Medication delivery logs for Resident #1 to ensure all deliveries were added to carts #1 and #2 on Hall #3. 3.On [DATE], the DON and SCC began auditing the Controlled Drug Records for residents that were recently discharged or deceased from Hall #3. Beginning [DATE] an audit of controlled medication logs from [DATE] to [DATE] was conducted for every resident in the facility with an order for a controlled medication to determine if other nurses/residents were involved. This was performed by the DON and SCC. The audit was completed on [DATE]. Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings were reported to the legal and regulatory authorities: Health Facilities Commission, [NAME] TN Regional Office; TN Bureau of Investigation; [NAME] Police Department, Ombudsman and APS. 4.On [DATE], the affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied pain. 5.On [DATE], the affected resident with a BIMS less than 8 was assessed for pain by the DON, there was no complaint or signs of pain. 6.On [DATE], pain assessments were completed for all residents on Hall #3 by the nurse managers to determine if any had uncontrolled pain. There were no residents experiencing uncontrolled pain. 7.On [DATE], the nurse managers interviewed residents on Hall #3 with a BIMS equal or greater than 8 to determine if their pain is controlled and as needed (PRN) medications had been administered when requested. All stated their pain is controlled and they receive their PRN medications when requested. 8.On [DATE], the DON reviewed documented pain levels for uncontrolled pain. No one had uncontrolled pain levels. 9.One nurse was suspended on [DATE] due to reasonable suspicion and remains suspended. This nurse was reported to the Tennessee (TN) Board of Nursing on [DATE]. The TN Bureau of Investigation is continuing the investigation. Measures put in place and systemic changes you will make to ensure that the deficient practice does not reoccur: 1.a. A root cause analysis was conducted on [DATE]. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. The process was changed to prevent the nurses/medication aides from removing completed medication cards or discontinued medication cards. The DON or Unit Managers will remove controlled medications from the medication cart; completed medication cards/sheets and discontinued medication cards/sheets. b. A root cause analysis was conducted on [DATE]. It was determined the excess controlled medication cards/sheets did not need to be on the medication cart. A cabinet with 2 locks was secured in the medication room for overflow-controlled medications and a new form was developed, Controlled Substance Overflow Sheet, to record the addition and removal of controlled medication to that cabinet. 2.Beginning [DATE], education was conducted by the Director of Nursing (DON) and Staff Development Coordinator (SDC) with all staff on the Abuse and Misappropriation Policy. This was completed on [DATE]. Any staff/agency staff who were not educated will be before working their next shift. 3.Beginning [DATE], education was conducted by the DON and SDC with all licensed staff and Medication Aides on the Controlled Medication Policy and process changes for counting/receiving/removing controlled medication. This was completed on [DATE]. Any staff/agency staff who were not educated will be educated prior to working their next shift. 4.Two nurses will verify the pharmacy delivery manifests for controlled medications in the presence of the driver. Once the quantity has been verified, they will sign the pharmacy delivery manifest. Two nurses will sign the Controlled Drug Record sheet and indicate the total quantity for the prescription (RX) number and the number of medication units, i.e. tablets, on the Controlled Drug Record sheet. Once the quantities are verified the two nurses will add the controlled medications to the medication cart and sign them into the Controlled Substance Record sheet. 5.Beginning [DATE] the Unit Managers will audit the pharmacy delivery manifests, daily, to verify controlled medications and Controlled Drug Record Sheets were added to the Controlled Substance Count Sheet and for count accuracy. 6.Beginning [DATE], the DON/UM will remove all controlled medications with a witness (empty and discontinued) from the medication cart, reconcile the Controlled Substance Count Sheets and compare the Controlled Substance Count Sheets to the Controlled Drug Records as they are removed from the cart to be secured for destruction. No one will remove controlled medication card/sheets without the DON/UM witnessing. This process, along with the process in #5 above, will prevent the ability to remove a count sheet and medication card without being discovered. 7.On [DATE] a secured cabinet with 2 locks was placed in the Four Seasons (hall #2) medication storage room. Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses (the DON and SDC). The DON and SDC will access the controlled medication cabinet as needed: when multiple cards/sheets are delivered and as the nurses need medications due to running out on the cart. The carts will be checked at the end of the day and before the weekend to ensure the residents will not miss a dose of their controlled medication. The transaction will be recorded on the Controlled Substance Overflow sheet. There will not be a key to this cabinet on any other key ring. In the event the DON or SDC are not in the facility, the DON will designate a Clinical Manager to hold one key. 8.Beginning [DATE], the licensed nurses/medication aides were educated by the DON, SDC or UM. This was completed on [DATE]. Any licensed staff including agency nurses that were not educated will be before their next shift. Describe the Quality Assurance and Process Improvement Program (QAPI) put into place. 1.An Ad Hoc QAPI was held on [DATE], via phone, with Corporate Leadership, SCC, Pharmacy [NAME] President (VP) Strategic Accounts, and the Medical Director to discuss new findings and ongoing investigation. 2.An Ad Hoc QAPI was held on [DATE] with Corporate Leaders to discuss audit findings, via phone. 3.An Ad HOC QAPI was held on [DATE] with the Medical Director to discuss the event and plan of correction. 4.An Ad HOC QAPI was held on [DATE] with the Medical Director, to discuss implementation of a secured overflow cabinet for controlled medications, the process for accessing the cabinet and the recording of adding/removing controlled medications. This new process will be discussed in QAPI meetings to ensure compliance and determine any changes that may be warranted. 5.Beginning [DATE], the Clinical Interdisciplinary Team (IDT) will audit every scheduled nurse at shift change for accuracy of the count process daily for two weeks then, weekly times (x) 2 weeks, then monthly x 2 months, then quarterly thereafter. 6.Beginning [DATE] the DON/Unit Manager (UM) will audit the medication carts to ensure discontinued/completed controlled medications have been removed from the cart and the Controlled Medication Count Sheet accurately records the removal 5 times per week x 2 weeks then, 3 times per week x 2 weeks then, 2 times monthly x 2 months. 7.Beginning [DATE] the DON will conduct random audits of the Pharmacy Delivery Report to ensure the delivered controlled medications were accurately added to the medication carts and Controlled Substance Count Sheets; 5 deliveries per week x 2 weeks then, 3 deliveries per week x 2 weeks then, 3 deliveries per month x 2 months. 8.The Quality Assurance (QA) Team will review staff education and QA audits for completion and accuracy. Findings of audits will be reported to the QAPI Committee which includes the Administrator, DON, Unit Managers, SDC, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director. The QAPI meetings will be held weekly beginning [DATE] for 4 weeks then, 2 times per month for the next 30 days then, monthly thereafter or until the QAPI Committee determines substantial compliance has been achieved. The QAPI Committee reserves the right to modify or extend monitoring times according to outcomes. Regional oversite has been in place daily since [DATE]. The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, education, audits, process changes, attending Ad Hoc QAPI meetings and oversight of compliance with process changes. Regional oversite has occurred onsite or by phone from the Sr. Signature State Care Consultant, the Regional VP of Clinical Operations, or the Regional VP of Operations. The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Pharmacy Services agreement, facility investigation review, review of facility medication reconciliation documents, and interview, the facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medications, failed to promptly identify loss or potential diversion of controlled medications, and failed to timely determine the extent of loss or potential diversion of controlled medications for 7 of 9 (Resident #1, #2, #5, #6, #7, #8, and #9) sampled residents reviewed with orders for controlled narcotics. On [DATE] the medication nurse (LPN E) discovered that Resident #2's Fentanyl transdermal patch had been tampered with, no actions were taken at that time on [DATE]. On [DATE] the facility discovered Resident #1 and #2's Fentanyl transdermal patches had been tampered with (cut open and resealed), which possibly diverted the prescribed controlled medication for pain control for Resident #1 and #2. The facility failed to test or seek expert identification for the Fentanyl medication patch in the resealed package. On [DATE] it was discovered the Oxycodone and Hydrocodone narcotic count reconciliations were not accurate. Review of the facility's narcotic reconciliation documents from [DATE] through February 2024 revealed Residents #1, #2, #5, #6, #7, #8, and #9 had a combined total of 509 Oxycodone and Hydrocodone narcotic tablets missing, the facility was unable to account for the missing 509 narcotic tablets. The facility's failure to ensure a system was in place for records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate and timely reconciliation and accounting for all controlled drugs was maintained and prompt identification of loss or potential diversion resulted in Immediate Jeopardy for Residents #1, #2, #5, #6, #7, #8, and #9. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator, the Director of Nursing (DON), and the Regional Significant Care Coordinator were notified of the Immediate Jeopardy for F-755 on [DATE] at 1:08 PM in the Conference Room. F-755 was cited at a scope and severity of K. A partial extended survey was conducted from [DATE] through [DATE]. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-755 was received on [DATE]. The corrective actions were validated onsite by the surveyor on [DATE] through observation, review of records, audit review, education review, and staff interviews. Noncompliance continues at F-755 at a scope and severity of E. The facility is required to submit a Plan of Correction. The findings include: 1.Review of the facility's policy titled Controlled Medications dated [DATE], revealed .The facility will ensure Controlled Medications are handled, stored, disposed of, and recordkeeping is in place in accordance with federal, state, and other applicable laws and regulations .1. A controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV, or V medications. The following information is compiled in the report: a. Name of resident. b. Prescription number. c. Name, strength, and dosage form of medication. d. Date received. e. Quantity received. f. Name of person receiving medication supply. 2. At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either licensed nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled medications accountability record .Once the medications count is completed, both licensed nurses or medication technicians will also count the number of individual narcotic control sheets, together and will sign the controlled medication accountability record .If a new medication is added or a medication is discontinued/removed, the controlled medication accountability record must reflect the above by completing the controlled medication accountability record by two licensed nurses or medication technicians .3. Current controlled medication accountability records are kept in the narcotic book. When completed the accountability records are submitted to the director of nursing and maintained on file at the facility .6. Any controlled medications that have been completed including empty medication cards, discontinued, or are from a resident being discharged will be left on the medication cart and continued to be counted, as detailed in #2 above, until 2 nurse leaders remove the completed, discontinued, or discharged medications together .7. Controlled medications remaining in the facility after the order has been discontinued or due to residents being discharged are retained in the facility in a securely locked area with restricted access until destroyed by 2 nurse leaders and/or 1 nurse leader and a consultant pharmacist; or otherwise by state law . 2. Review of the Pharmacy Services Agreement dated [DATE], revealed .Consulting Services .Pharmacy shall appoint a Pharmacy representative to serve on the Customer's Quality Assurance (QA) Committee and/or Pharmaceutical services committee .Additional Services. Upon client's request, Pharmacy shall provide the following and any other additional consulting services .b) Consult with the Client's staff as to its compliance with Applicable Law with respect to the destruction of unused Medications, including, but not limited to, controlled substances. Pharmacy shall assist in the accounting, destruction, and reconciliation of unused Medications .d) Perform random quarterly audits of medication carts or audit medication storage areas for controlled and non-controlled medications. E) Perform on-site audits of Medical Records, contents of medication carts and/or Resident treatment charts, if provided by Pharmacy .Nurse Consulting Services .Perform a Narcotics Review with documentation review for the protection of facility staff and residents .Perform a Root Cause Analysis to determine process gaps and provide written solutions for both Pharmacy and Client issues . 3. Review of a facility's investigation and survey investigation findings revealed on [DATE], Licensed Practical Nurse (LPN) E discovered Resident #2's Fentanyl pack had been tampered with, there were no actions taken by the facility on [DATE]. On [DATE], LPN B discovered Resident #2's Fentanyl patches had been tampered with, and then checked Resident #1's Fentanyl patches and discovered that both Resident #2's and Resident #1's Fentanyl patches had been tampered with resulting in a diversion of the medication. a. Review of the medical record revealed Resident #1 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses of Pain in Joints of Right Hand, Dysarthria and Anarthria, Neuropathy, Type 2 Diabetes, Cerebrovascular Disease, Migraine, Seizures, Chronic Respiratory Failure, and Right Bundle Branch Block. Review of a Physician's order dated [DATE] for Resident #1, with no end date, revealed an order for Fentanyl transdermal patch 25 micrograms (mcg) apply once a day every 3 days for pain. Review of a Pharmacy manifest sheet dated [DATE] and [DATE], revealed 10 Fentanyl transdermal patches [2 boxes of 5] were delivered for Resident #1 on each date. There was no signature of verification of receipt for either delivery. b. Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses of Rheumatoid Arthritis, Pain Unspecified, History of Chronic Viral Hepatitis C, Atrial Fibrillation, Coronary Bypass Graft, Atherosclerotic Heart Disease, and Type 2 Diabetes. Resident #2 was schedule to be discharged home on [DATE], but expired in the facility on [DATE]. Review of a Physician's order for Resident #2 dated [DATE], revealed an order for Fentanyl transdermal patch 50 mcg apply once a day every 3 days for pain. Review of a Physician's order for Resident #2 dated [DATE], revealed an order for Fentanyl transdermal patch 75 mcg apply once a day every 3 days for pain. Review of the Pharmacy manifest sheets for Resident #2 dated [DATE] for 1 box totaling 5 Fentanyl patches, [DATE] for 2 boxes totaling 10 Fentanyl patches, [DATE] for 2 boxes totaling 10 Fentanyl patches, and [DATE] for 2 boxes containing 10 Fentanyl patches, revealed there was no facility nurses' signature of verification of receipt for all 3 deliveries. Review of the Narcotic sheet for Fentanyl 50 mcg patch, belonging to Resident #2, with a start date of [DATE], revealed there were 5 patches in the box in use. Documentation on the Narcotic sheet revealed 1 patch was removed from the count on [DATE] at 2:00 PM, 1 patch was removed from the count on [DATE] at 9:45 AM, and 1 patch was removed on [DATE] at 10:00 AM but no administered to Resident #2. Review of the Narcotic sheet for Fentanyl 75 mcg patch, belonging to Resident #2, with a start date of [DATE], revealed there were 5 patches in the box in use. Documentation on the Narcotic sheet revealed 1 patch was removed from the count on [DATE] at 10:00 PM, 1 patch was removed from the count on [DATE] at 6:00 PM, 1 patch was removed from the count on [DATE] at 6:30 PM, 1 patch was removed from the count on [DATE] at 7:00 PM, and 1 patch was removed from the count on [DATE] at 3:00 PM. c. Review of a facility investigation dated [DATE], revealed Licensed Practical Nurse (LPN) B discovered Resident #1 and #2's Fentanyl transdermal patches had been opened, resealed, and placed back in the packaging boxes causing a diversion of the medication. Resident #2's Fentanyl patches were first discovered to have been tampered with, afterwards, Resident #1's Fentanyl patches were discovered to have also been tampered with. Review of a written witness statement dated [DATE] from the facility investigation file and signed by LPN B, revealed .Date Incident Occurred: [DATE] .When attempting to place a fentanyl patch on an elder [Resident #2] I was unable to remove the patch from the plastic. I went to get another patch and the patch appeared the same as the other patch. I noticed the pack [individual package containing the Fentanyl patch] was torn so I compared his pack to another elder's [Resident #1] and found two of her four patch [patches] appeared to have been opened and resealed as well. I then contacted the DON . Review of a written witness statement dated [DATE] from the facility investigation file and signed by LPN F, revealed .Date Incident Occurred: [DATE] .Named LPN [LPN B] called me to come over to Brandywood [Hall 300]. When I arrived Named LPN [LPN B] had the boxes of fentanyl patches on the top of the cart and showed me the patches/packaging. The packaging was cut and resealed. Some of the fentanyl patches were bubbled and off in color d. During an interview with the DON on [DATE] at 2:00 PM, when asked about the Fentanyl patches that had been tampered, the DON stated, .She [LPN B] tried to remove 1 patch from the covering [on [DATE] for Resident #2] and it was difficult and stretched. She then went to get another one and it was the same. Then noticed what looked like a substance dried like school glue . The DON stated she opened an unused box of 5 Fentanyl patches belonging to Resident #1 and the same substance that looked like glue was there. The DON stated, Named Resident [Resident #1] had 4 patches in the opened box. Each package had a cut on the back of the pkg. When I opened the patch cover the [Fentanyl] patch looked used [looked like it had already been used]. There was air bubble-like spots [on the patch] . During an interview with LPN G on [DATE] at 3:20 PM, when asked if the Pharmacy manifest sheet was signed by a nurse to verify the delivery of medications, LPN G stated, We have to count with Pharmacy now when delivered. We didn't sign on the Pharmacy sheet before this [discovery of missing narcotics and Fentanyl tampering]. During an interview with LPN E on [DATE] at 8:47 AM, when asked if the Pharmacy manifest sheet was signed by a nurse to verify the delivery of mediations, LPN E stated, .Before all this [discovery of missing narcotics and Fentanyl tampering] started happening, we didn't have 2 nurses sign on this sheet [Count sheet]. Now we have to sign both. When asked to clarify both, LPN E stated, We have to sign the Pharmacy sheet [and the Controlled Count sheet]. During an interview of [DATE] at 9:21 AM, LPN D stated, .The only time I had noticed anything was on Friday [DATE]. [Named LPN E] brought me a patch that still had the backing on it. She asked me if it looked odd. She had taken it out of the white sealed pack. It still had the clear backing. When I looked at it to me it looked like the edges may have been loosened, but they still appeared to be sealed. It was not clear around the edges. The center itself, the patch, was still attached The Unit Manager told her [LPN E] if package had been sealed it should be ok. This was on [Named Resident #2] . During an interview on [DATE] at 2:15 PM, LPN H/Unit Manager stated, .Someone had tampered with the packages of Fentanyl a few days before this time [[DATE]]. LPN E brought me a patch [on [DATE]] and asked me if it looked odd or used. It was flat on the paper, but there was a few bubbles. It wasn't crooked on the paper or wrinkled. I looked at the package and it looked fine. I didn't turn the package over it was laying on the cart and I just looked at it. I said if it's from a fresh package it should be fine. I did say it could be used. When asked if the DON was notified of the patch appearance LPN H/Unit Manager stated, No, I didn't . During an interview with the DON on [DATE] at 3:13 PM, when asked if the Pharmacy manifest [delivery] sheets should be signed by a nurse to verify the medications were delivered, the DON stated, .On the 19th [[DATE]] our process was changed. Whenever they receive the controlled narcotics from pharmacy they have to verify what is in the delivery box, matched the delivery sheet. 4. Review of a facility investigation dated [DATE], revealed audits conducted beginning on [DATE], related to the Fentanyl transdermal patch tampering, led to a discovery on [DATE], that a Controlled Drug Record (Narcotic sheet, a sheet for documentation of removal of a tablet from the medication card) for Resident #2 had been removed from the Controlled Substance Count sheet (Count sheet- a form for documentation of the number of Narcotic Sheets and medication cards). When the DON went to obtain the Narcotic sheet from the folder of completed records, the Narcotic sheet for Resident #2 could not be located. There were 11 Narcotic sheets and 11 medication cards containing Oxycodone and Hydrocodone unaccounted for from [DATE] - [DATE]. From [DATE] - February 2024, Residents #1, #2, #5, #6, #7, #8, and #9 had Hydrocodone and Oxycodone missing and unaccounted for. 5. Review of a Physician's Order for Resident #1, with a start date of [DATE] and no end date, revealed an order for Oxycodone/Acetaminophen Schedule II 10mg/325 milligrams (mg) tablet give 1 tablet by mouth three times daily. Review of the Pharmacy manifest sheet dated [DATE], revealed 88 Oxycodone 10 mg tablets were delivered for Resident #1 on 1 card with 60 tablets and 1 card with 28 tablets. The Narcotic sheet and the card of 28 tablets belonging to Resident #1 were missing. Review of the Pharmacy manifest sheet dated [DATE], revealed 88 Oxycodone 10 mg tablets were delivered for Resident #1 on 1 card with 60 tablets and 1 card with 28 tablets. The Narcotic sheet for the card with the remaining 12 tablets from the card of 28 belonging to Resident #1 were missing. Review of the Pharmacy manifest sheet dated [DATE], revealed 87 Oxycodone 10 mg tablets were delivered for Resident #1 on 1 card of 27 tablets and 1 card of 60 tablets. The Narcotic sheet for the card of 27 tablets was started on [DATE] and would have been completed on [DATE]. This Narcotic sheet and medication card with the remaining 8 tablets belonging to Resident #1 were missing. Resident #1 had a total of 48 tablets of Oxycodone 10 mg tablets missing and unaccounted for between [DATE] - [DATE]. Review of the Count sheets for [DATE], revealed there was no documentation of the Pharmacy delivery of the 2 cards of Oxycodone 10 mg tablets for Resident #1. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the Count sheet dated [DATE] revealed initials that were marked through multiple times with no other initials entered from an oncoming shift change nurse to witness the narcotic count. Review of the Controlled Substance Count sheet dated February 2024, revealed Resident #1 had Oxycodone 10 mg 1 card removed and 1 sheet removed from the controlled count. The Inventory Shift Count column was incorrectly dated [DATE] for the sheet for February 2024. The column for total number of cards had the number 28 written over another number and words in writing stated Twenty 8ish + [plus] 2. During an interview with the DON on [DATE] at 2:23 PM, when asked if there should be a witness when a Controlled Substance Count sheet and/or a Controlled Record Count sheet was added and/or removed from the count, the DON stated, A 2nd nurse should sign, but sometimes they don't. When asked what the Twenty 8ish + 2 meant on Resident #1's Controlled Substance Count sheet, the DON stated, I can't answer that. The facility failed to ensure a second nurse always signed as a witness for added/removed medication card and sheets. 6. Review of the admission MDS assessment for Resident #2 dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Review of a Physician's order for Resident #2 with a start date of [DATE], and end date of [DATE], revealed an order for Oxycodone Schedule II 5 mg tablet give 1 tablet by mouth every 6 hours for pain. Review of the Pharmacy manifest sheet for Resident #2 dated [DATE], revealed 176 Oxycodone 5mg tablets were delivered for Resident #2 on 1 card with 86 tablets and 1 card with 90 tablets. The Narcotic sheet and remaining 10 tablets belonging to Resident #2 were missing. A new Narcotic count sheet for the card of 86 tablets was started on [DATE]. The Narcotic sheet and remaining 51 tablets belonging to Resident #2 were missing and unaccounted for. Resident #2 had a total of 61 Oxycodone 5 mg tablets missing and unaccounted for. Review of the Count sheet dated [DATE], revealed there was no 2nd nurse signature to verify the 176 Oxycodone 5 mg tablets were added to the count. 7. Review of the medical record revealed Resident #5 was admitted on [DATE], with diagnoses of Dementia, History of Traumatic Brain Injury, Fracture Upper End of Left Humerus, Chronic Obstructive Pulmonary Disease, History of Falling, Type 2 Diabetes, Vertigo, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 3, which indicated severe cognitive impairment. Review of a Physician's order for Resident #5 with a start date of [DATE], revealed an order for Hydrocodone/Acetaminophen 7.5/325 mg, give 1 tablet three times a day. Review of the Pharmacy manifest sheet dated [DATE], revealed 90 Hydrocodone 7.5 mg tablets were delivered for Resident #5 on 1 card of 30 and 1 card of 60 tablets. On [DATE] there were 30 tablets were missing belonging to Resident #5. Review of a Physician's order for Resident #5 with a start date of [DATE], revealed an order for Hydrocodone Schedule II 7.5 mg tablet, give 1 tablet by mouth every 6 hours as needed for pain. Review of the Pharmacy manifest sheet dated [DATE], revealed 87 Hydrocodone 7.5 mg tablets were delivered for Resident #5 on 1 card of 27 tablets and 1 card of 60 tablets. Review of the Pharmacy manifest sheet for Resident #5 revealed on [DATE] the pharmacy delivered 87 Hydrocodone 7.5 mg tablets. On [DATE] there were 30 tablets missing belonging to Resident #5. Review of the Pharmacy manifest sheet dated [DATE], revealed 87 Hydrocodone 7.5 mg tablets were delivered for Resident #5 on 1 card of 27 tablets and 1 card of 60 tablets. On [DATE] there were 18 tablets missing belonging to Resident #5. Resident #5 had a total of 78 Hydrocodone tablets missing and unaccounted for. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 5, which indicated severe cognitive impairment. 8. Review of the medical record revealed Resident #6 was admitted on [DATE], with diagnoses of Cirrhosis of Liver, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Morbid Obesity, Obstructive Sleep Apnea, Congestive Heart Failure, and History of Myocardial Infarction. Review of a Physician's order for Resident #6 with a start date of [DATE], revealed an order for Oxycodone Schedule II 5 mg tablet give every 6 hours as needed for pain. Review of the admission MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 14, which indicated no cognitive impairment. Review of a Pharmacy manifest sheet dated [DATE], revealed 118 Oxycodone 5mg tablets were delivered to Resident #6 on 1 card of 28 tablets and 1 card of 90 tablets. On [DATE], there were 28 tablets belonging to Resident #6 missing. Resident #6 had a total of 28 Oxycodone 5mg tablets missing and unaccounted for. 9. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses of Malignant Neoplasm of Supraglottis [upper part of the voice box], Malignant Neoplasm of Lymph Nodes, Cirrhosis of Liver, Tracheostomy Status, Cerebral Infarction, Viral Hepatitis C, and Acute Respiratory Failure. Review of a Physician's order for Resident #7 with a start date of [DATE], revealed an order for Oxycodone Schedule II 10 mg tablet give every 6 hours as needed for pain. Review of the admission MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated no cognitive impairment. Review of a Pharmacy manifest sheet dated [DATE], revealed 118 Oxycodone 10 mg tablets were delivered to Resident #7 on 1 card of 58 tablets and 1 card of 60 tablets. There were 37 of Resident #7's Oxycodone missing on [DATE]. Review of a Pharmacy manifest sheets dated [DATE], revealed 119 Oxycodone 10 mg tablets were delivered to Resident #7 on 1 card of 29 tablets and 3 cards of 30 tablets. On [DATE] there were 27 Oxycodone tablets missing, and on [DATE] there were 30 Oxycodone tablets missing. Review of the Pharmacy manifest sheet dated [DATE], revealed 119 Oxycodone 10 mg tablets were delivered to Resident #7. Resident #7 had a total of 94 Oxycodone 10 mg tablets missing and unaccounted for. 10. Review of the medical record revealed Resident #8 was admitted on [DATE], with diagnoses of Congestive Heart Failure, Diabetic Neuropathy, Type 2 Diabetes, Bipolar Disorder, Peripheral Vascular Disease, Chronic Venous Ulcer Bilateral Lower Extremities, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 13 which indicated no cognitive impairment. Review of a Physician's order for Resident #8 with a start date of [DATE], revealed an order for Hydrocodone/Acetaminophen Schedule II 5/325 mg tablet give every 6 hours as needed for pain. Review of a Pharmacy manifest sheet dated [DATE], revealed 174 Hydrocodone 5mg tablets were delivered for Resident #8 on 2 cards of 60 tablets and 1 card of 54 tablets. Review of a Pharmacy manifest sheet dated [DATE], revealed 174 Hydrocodone 5 mg tablets were delivered for Resident #9 on 1 card of 24 tablets and 5 cards of 30 tablets. On [DATE] 30 tablets belonging to Resident #9 were missing. On [DATE] 114 tablets were belonging to Resident #9 were missing. Resident #8 had a total of 144 Hydrocodone 5 mg tablet missingand unaccounted for. Review of the admission MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 15 which indicated no cognitive impairment. 11. Review of the medical record revealed Resident #9 was admitted on [DATE], with diagnoses of Dementia, Peripheral Vascular Disease, Major Depression, Pain Unspecified, Restless Leg Syndrome, Repeated Falls, and Type 2 Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 had a BIMS score of 15 which indicated no cognitive impairment. Review of a Physician's order for Resident #9 dated [DATE], revealed an order for Hydrocodone/Acetaminophen Schedule II 5/325 mg tablet give every 12 hours as needed for pain to right hip. Review of a Pharmacy manifest sheet dated [DATE], revealed 116 Hydrocodone 5mg tablets were delivered for Resident #8 on 1 card of 56 tablets and 1 card of 60 tablets. On [DATE] there were 56 tablets belonging to Resident #9 missing. Resident #9 had a total of 56 tablets of Hydrocodone 5 mg missing and unaccounted for. 12. During an interview on [DATE] at 10:52 AM, when asked if 2 nurses signed the Count sheet when a controlled narcotic was added or removed from the count, LPN I stated, If I use the last sheet [Narcotic sheet] I would sign out the sheet and take it out and the card .No, not always two nurses sign [when a controlled narcotic or count sheet was added or removed]. I guess that [2 nurses signatures] would be best . During an interview on [DATE] at 10:34 AM, when asked the process for reconciling the Narcotic sheets, LPN H/Unit Manager stated, I would get the narc [narcotic] sheets and file them [the narcotic and count sheets when the nurse removed them form the count]. I would look at sheet [narcotic sheet] to see if it looked right .I glanced down it and looked, not in detail at that time. I just filed away until someone asked for them. When asked how often the sheets were reconciled, LPN H/Unit Manager stated, Sometimes it would be a while. I guess other things came before that. During an interview on [DATE] at 11:30 AM, when the Pharmacy Consultant was asked if a resident had 180 tablets of a controlled narcotic in the medication cart, would that amount of overflow be checked for accuracy compared to the date of delivery, the Pharmacy Consultant stated, I look at the charting and see what they are working from, which sheet [Narcotic sheet] they are charting on. I wouldn't do a follow through of all the overflow. I look at the sheet they are working from. During an interview with the DON on [DATE] at 12:39 PM, when asked the process for reconciling controlled Narcotic sheets when removed from the count, the DON stated, .I have a folder and the nurses would put the sheet in the folder when completed. Some of them [nurses] would turn in the whole card [medication card] in the shred box. Some would tear off the label from the top of the card [medication card] and just put it in the box. When asked when the Narcotic sheets that were removed were compared to the medications administered, the DON stated, The Unit Managers were to get the sheets from the folder . During an interview on [DATE] at 5:15 PM, when asked how the overflow of controlled narcotics delivered by the Pharmacy were reconciled, the DON stated, .I'm not sure what you are asking. All the delivery is kept in the medication cart for the elder [resident] it is ordered for. It's entered on the Substance Count Record sheet. When asked if the Substance Count Record sheet included the amount of tablets delivered and placed in the medication cart, the DON stated, No, the number of cards is tracked [not the number of tablets] from the time added until removed . During an interview with the DON on [DATE] at 11:46 AM, the DON confirmed the Oxycodone and Hydrocodone tablets for Resident #1, #2, #5, #6, #7, #8, and #9 could not be accounted for due to missing Narcotic sheets and missing medication cards that were removed from the medication cart and were not completed. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE], and was validated onsite by the surveyor on [DATE] through review of staff education and sign-in sheets, observations, interviews with staff and Administration, and review of the audits conducted as follows: Identification of other elders who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. On [DATE] a reconciliation of controlled medications from [DATE] to [DATE] was initiated for every resident with an order for a controlled medication verifying the disposition of the controlled medications. This was performed by the DON and Regional Signature Care Consultant (SCC) and completed on [DATE]. Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities: Health Facilities Commission, [NAME] Tennessee (TN) Regional Office; TN Bureau of Investigations; [NAME] Police Department, Ombudsman and Adult Protective Services (APS). The DON and SCC reviewed all delivery manifests to ensure all narcotics delivered and signed in by the alleged nurse were added to the narcotic count and narcotic box on the medication cart. This audit was completed on [DATE]. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities. On [DATE], the affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied increased pain. On [DATE], the affected resident with a BIMS of less than 8 was assessed for pain by the DON, there were no complaints or signs of increased pain. On [DATE] all residents on hall #3 were assessed for pain by the Unit Managers. No one complained of pain. Hall #3 was the only hall identified with controlled medications unaccounted for. On [DATE] a secured cabinet with 2 locks was placed in the Four Seasons Medication storage room. Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses. The DON and a witness will access the controlled medications and record transactions on a medication reconciliation record. Measures put in place and systemic changes you will make to ensure that the deficient practice does not reoccur: A root cause analysis was conducted on [DATE]. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. This process was changed to prevent the nurses/medication technicians from removing completed medication cards or discontinued medication cards. The DON or Unit Managers (UM) will remove controlled medications from the medication cart; completed medication cards/sheets and[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview the facility failed to provide supervision to ensure a safe environment for a resident with known substance abuse for 1 of 1 (Resident #4) and for a drug seeking resident for 1 of 1 (Resident #7) reviewed. On 1/28/2023, Resident #4 gave his roommate, Resident #7, what was reported to be Tylenol that was not provided by the facility, on 2/15/2023 Resident #4 became lethargic, pupils were pinpoint, and not responding normally, an unlabeled bottle of pills was found in his sock, on 3/10/2023 Resident #4 became lethargic, gray in color, 69% (percent) oxygen saturation (amount of oxygen in the blood) and two doses of Narcan was administered the resident became alert, which resulted in Immediate Jeopardy (IJ) for Resident #4. The facility failed to identify, assess, investigate, develop a plan of care, and provide supervision to ensure a safe environment for Resident #4. A partial extended survey was conducted on 4/27/2023 through 4/28/2023. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide a safe environment for a resident with a history of substance abuse. The facility's failure placed Resident #4 in Immediate Jeopardy. The Administrator, Regional Nurse Care Consultant, and the Director of Nursing were notified of the Immediate Jeopardy at F689 on 4/26/2023 at 6:30 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F689. The facility was cited Immediate Jeopardy F689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy started on 2/15/2023 through 4/27/2023. The facility's corrective actions were validated onsite by the surveyors 4/28/2023 through 5/1/2023. An acceptable IJ Removal plan, which removed the immediacy of the jeopardy, was validated onsite by the surveyors on 4/28/2023 through 5/1/2023, by review of the in-service training records, observations and interviews. The findings include: 1. Review of the facility's policy titled, Accidents and Incidents Investigating and Reporting, dated 11/6/2019, revealed .Accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident .shall be included in Electronic Medical Record (EMR) .date and time of the accident or incident took place .nature of the injury/illness .the circumstances surrounding the accident or incident .name(s) of witnesses and their accounts of the accident or incident person's account of the accident or incident .the time the Attending Physician was notified, as well as the time the physician responded and his or her instructions .date/time .person's family was notified and by whom .The condition .including his/her vital signs .The disposition .Any corrective actions taken .Follow-up information .The name and title of the person completing the report .The incident will be reported to Administrator and/or Director of Nursing . Review of the facility's policy titled, Elder Justice Act policy and Procedure, dated last reviewed 10/24/2023, revealed it is the intent of the facility to uphold The Elder Justice Act as established under the Social Security Act .which requires covered individuals to report reasonable suspicion of a crime to their state regulatory agency and to local law enforcement within specific time frames .If a covered individual has reasonable suspicion that a crime has occurred involving a resident or person receiving care at this facility, the individual has the responsibility to report suspicion directly to both local law enforcement and the state survey agency .If the event that causes the reasonable suspicion result in a serious bodily injury to a resident, to covered individual shall report the suspicion immediately, but no later than two hours after forming the suspicion .Serious bodily injury is defined as an injury .involving substantial risk of death . Review of the facility's policy titled, Behavioral Health Policy, dated 4/14/2022, last revised 10/18/2022, revealed It is the organization's intent to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment plan of care .Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual Substance use disorder is defined as recurrent use of .drugs that causes clinically and functionally significant impairment .Potential signs and symptoms may include, unexplained drowsiness, slurred speech, lack of coordination .particularly after interaction with visitors .GUIDELINES .Stakeholders will be alert to the effectiveness of interventions and the care plan will be reviewed and revised as necessary . Review of the facility's policy titled, Standing Order for Emergency Use of Naloxone, signed and dated by the Medical Director on 11/2/2022, revealed .This standing order has been created to reduce the risk of fatal opioid overdose. Naloxone is a pure opioid antagonist indicated for the reversal of opioid overdose induced by natural or synthetic opioids in the setting of respiratory depression or unresponsiveness. Rapid administration of naloxone can prevent death and reduce disability or injury from opioid overdose .When an individual is suspected of an opioid overdose the staff member will promptly conduct an initial assessment to evaluate the need for naloxone .Difficult to arouse .Unresponsive .Inability to communicate or follow commands .Decreased respiratory status .Pinpoint pupils .Cold, clammy or pale skin .Documentation, including a description or summary of the event must be completed and maintained at the facility. It shall include .Patient presentation .Date and time of event .Dose, route, and number of administrations .Patient response . Review of the facility's policy titled, Comprehensive Care Plans, reviewed 4/14/2021, revealed, .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument .Each resident's Comprehensive Care Plan is designed to .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Reflect currently recognized standards of practice for problem areas and conditions .Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving resident goals .Care plans are ongoing and revised as information about the resident's condition change .The care plan should reflect the current status of the resident and be updated with changes in the residents [resident's] status . Review of the facility's policy titled, Hospice Program, effective date 6/1/2015, and last reviewed 12/5/2022, .When a resident participates in the hospice program, a coordinated plan of care will be developed .The care plan shall be revised and updated as necessary to reflect the resident's current status .The DON .clinical designee will coordinate provision of care by the facility staff and the hospice staff . 2. Review of the hospital's History and Physical dated 2/10/2022, and filed in the facility medical record, revealed .Pt [Resident #4] came to [Named hospital] complaining of weakness .Patient is lethargic on exam likely related to large dose of Ativan [relieves anxiety] .Does endorse cocaine [illegal stimulant medication] use daily .cocaine use . Review of the Pre-admission Screening and Resident Review [PASARR] dated 3/27/2022, and filed in the facility's medical record, revealed .Does the individual have a substance related disorder [abuse or dependency] .Yes .Opioids . Resident #4's admission to the facility on 4/28/2022, revealed diagnoses that included Chronic Obstructive Pulmonary Disease, Use of Opiate Analgesic, Anxiety, Depression, Insomnia, Severe Protein-Calorie Malnutrition, and Malignant Neoplasm of Large Intestine. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4's Brief Interview of Mental Status (BIMS) score was 14, which indicated Resident #4 had intact cognition for daily decision making. Continued review revealed Resident #4 had an unsteady gait and could stabilize without staff assistance. Active Diagnoses revealed no diagnosis related to substance abuse. Review further showed the resident received hospice care. Review of Resident #4's Home Health and Hospice Physician's Note signed and dated 5/18/2022, and filed in Resident #4's medical record revealed .was a patient at [Named Facility] from 3/8/2022-4/28/2022 at which time he was transferred to [Named Facility where resident is residing at this time] had been witnessed pocketing his oxycodone [a potent opioid for severe pain]10mg [milligrams]and witnessed crushing and snorting the oxycodone 10 mg .Reported to the physician and NP [Nurse Practitioner] .medication was changed to methadone .did not complain about it until he was moved to [Named Facility he currently resides in] .[Named Hospice Medical Doctor] does not think he needs the oxycodone increased d/t [due to] his drug abuse history and his actions with the oxycodone before . Review of Resident #4's Medication Administration Record (MARs) dated January 5, 2023 through March 11, 2023, revealed .Hydrocodone-acetaminophen [a combination of medications to relieve pain] .tablet .Every 6 Hours .Special Instructions .Medications is to be crushed . 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Malignant Neoplasm of Prostate, Dementia with Behavioral Disturbance, Diabetes, Depression, Anxiety, Hypertension, and History of Benign Neoplasm of the Brain. Review of the admission MDS dated [DATE], revealed Resident #7 had a BIMS score of 04, which indicated he had severe cognitive impairment, and no behaviors were identified. Review of the comprehensive Care Plan dated 1/24/2023, revealed, Resident #7 .I have inappropriate behaviors at times .can be verbally aggressive with staff .I sometimes ask for medication from other elders [residents] . Review of Resident #7's Resident Progress Note dated 1/28/2023 at 11:06 AM, revealed, elder [Resident #7] handed nurse a Tylenol ER [extended release - used to treat minor pain] that he got from his room mate [roommate - Resident #4]. educated elder that he should not take any medications from his room mate, he should let us know if he needs Tylenol and we will give him some for his pain . Review of Resident #4's Resident Progress Notes dated 1/28/2023 at 11:17 AM, revealed .roommate [Resident #7] stated that he was receiving Tylenol ER from this elder [Resident #4] and showed the pill. found Tylenol ER bottle and laxatives in elder's drawer. put in cart with name on them. educated elder that he is not allowed to have medicine in his room. he should only take medication from nursing . There was no documentation Resident #4's Comprehensive Care Plan to include interventions such as increased monitoring or education. When asked, the facility was unable to provide a completed investigation related to the 1/28/2023 findings. Review of the Home Health and Hospice Medical Social Worker Visit Note dated 2/2/2023 at 2:30 PM, revealed Resident #4 .Emotional and Behavioral Needs .Still struggling and med [medication] seeking .Behavior .Manipulative .Facility staff have reported to hospice that patient meds have been switched to crushed and putting or applesauce, due to patient behaviors with meds. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 scored a 15 on the BIMS assessment which indicated intact cognition. The resident required supervision for his Activities of daily living. Resident #4 had an unsteady gait and could stabilize without staff assistance. No active diagnoses of substance abuse was included in the assessment. Review of Resident #4's Resident Progress Notes dated 2/15/2023 at 6:50 PM, revealed, .Respiratory Therapy [RT] came to this nurse and stated that the elder was lethargic. This nurse arrived at the bedside and noted that the elder [Resident #4] was sitting on the side of bed. This nurse asked the elder if they were feeling ok. The elder did not respond the elder was pulling at the sheet on their bed. This nurse told the elder that this nurse was going to obtain their vitals. The elder did not respond . The hospice nurse went .with this nurse to observe the elder. The elder's pupils were pinpoint and reactive to light. The elder's Heart Rate [HR] was 98 bpm, all other vitals were Within Normal Limits [WNL]. The hospice nurse then noticed that the elder had something inside their sock. The hospice nurse removed the object and found it to be a prescription bottle with no name or type of medication .The elder stated it was trazadone [medication to treat depression] .This nurse placed the bottle in the med room .On call and Director of Nursing [DON] notified. The hospice nurse told this nurse to just continue to monitor the elder. Will continue to monitor. Review of the Vitals Report for Resident #4 dated 2/15/2023-2/16/2023, revealed vitals were documented on 2/15/2023 at 6:17 PM, and not again until 2/26/2023 at 10:28 AM. Continued review showed no additional monitoring of Resident #4 after 2/15/2023 at 6:50 PM. The next progress note was dated 2/16/2023 at 4:28 PM, with elder educated on the importance of calling staff for assistance with needs. Review of Resident #4's hospice Miscellaneous Communication dated 2/15/2023 at 7:05 PM, showed, .the respiratory therapist came and got her because she thought something was wrong .[Resident #4] is lethargic, slurred speech, pale color .Arrived to patients room to find patient sitting slumped on the side of the bed, partially in the floor and assisted patient to lie down in the bed. Patient speech .slurred his pupils are pinhole size .heart rate is elevated 136 and irregular, respiratory rate is 16 .Skin color is pale .went and got .the facility nurse .something was in his sock, this nurse removed a bottle that had no label on it full of pills .Patient stated it was trazodone and he had them for a long time Bottle was removed from the patient's room and given to the facility nurse .[verified] that the medication in the bottle was trazodone 100 mg and there was 14 tablets in the bottle .Contacted my supervisor and notified of the medications that were found in patient's sock. Nurse also contacted her supervisor who states that we are not allowed to search the patient's rooms or perform drug test .Facility nurse educated that she may hold .trazodone if patient is lethargic . Review of Resident #4's Hospice Skilled Nursing Visit Note dated 2/16/2023 at 1:45 PM, revealed, .Plan of Care Meeting .with [Named Facility] admin [Administration] team. Patient had an incident last evening involving him taking medication unknown that had been brought into the facility by someone visiting [Resident #4]. He became minimally responsive and very difficult to arouse while hospice nurse in the building .found a bottle of trazodone .in patients sock .After meeting with the admin about this they informed hospice that this was a facility issue they would have to handle that it was not a hospice issue to handle . Review of the facility's Medication Disposal documentation dated 2/16/2023, revealed that two staff members had signed that they had counted and disposed of Resident #4's Trazodone 50mg equaling 15 pills. Review of Resident #4's Physician Progress Note dated 2/17/2023 at 2:01 PM, revealed, Seen and examined after resident was lethargic and is believed to have ingested medication that was identified as Trazodone. Resident currently back at baseline and wanting more narcotics .Medication confiscated . The facility provided no documentation on an investigation to determine how the resident obtained the pills. Review of the Home Health and Hospice Nurse Practitioners Visit Note for Resident #4 dated 2/22/2023 at 12:20 PM, revealed, .2-15-2023 A bottle of unlabeled medication found in his sock after a change in his status was noted. Medication was determined to not be what he is prescribed nor administered by the facility .Spoke with the medication nurse for his hall. She states that he admits that he has a 'drug problem' .Spoke with [Named Master Social Worker] who reports that [Named Hospice MD], the hospice staff, and company legal services are working on a contract addressing his use of medication not prescribed for him while receiving hospice services . Review of the Home Health and Hospice Skilled Nursing Visit Note dated 3/2/2023 at 5:55 PM, revealed .Medication Profile Review .Issues Identified .Pt is somehow getting meds brought to him . Review of Resident #4's Progress Note dated 03/10/2023 at 10:25 AM, revealed, .This RT started treatment patient bilateral breath sounds diminished, sat [oxygen saturation - the amount of oxygen carried in the blood] 97% [percent] on 3 lpm [liters per minute-oxygen], HR [Heart Rate] 50 [beats per minute], RR [Respiratory Rate]15, during treatment patient became lethargic, color in face changed to gray, sat 69% 3 lpm, HR 45, called for nurse and placed elder on non-rebreather sat 69-81%, HR 61-114. Nurse called Hospice will continue to monitor . Review of the Home Health and Hospice Skilled Nursing Visit Note dated 3/10/2023 at 10:29 AM, revealed, .Was called to [Named Facility] .as patient was found unresponsive .O2 [Oxygen] Sat were 35% with non rebreather mask, pt is unresponsive in respiratory distress. Color is dark gray and moist feeling .[Named Responsible Party] arrives and desires to change Do Not Resuscitate [DNR] to resuscitate and send to the hospital. [Named Medical Doctor] is present and orders narcan to be given .[Named Responsible Party] signs revocation from hospice form . Medical record review revealed on 3/10/2023 at 11:00 AM, and again at 11:15 AM, Resident #4 was ordered and received Naxolone 0.4 mg injections. Review of a Physician's Order dated 3/10/2023, (not timed) revealed, Send to ER [Emergency Room] for eval . Review of the Standing Order for Emergency Use of Naloxone dated 3/10/2023 at 11:15 AM, revealed Resident #4 was, .lethargic breathing approx. 1-2 times a min. not responsive to verbal or painful stimuli .Naloxone .0.4/ml .Injection (IM) [Intramuscular] .Number of Administrations: two .first dose pt [patent] RR [Respiration Rate] increased and become more baseline. Second dose pt become almost completely back to baseline .MD present at bedside during both verbal orders . Review of the Physician Progress Note dated 3/10/2023 at 1:39 PM, .[Recorded as Late Entry on 04/20/2023 13:48 during the survey] Created Date: 04/20/2023 13:48 . revealed Resident #4 .was seen and examined after nursing found resident to be unresponsive and apneic. Nursing noted that the resident had a visitor in his room approximately 10-15 minutes prior to becoming unresponsive. On arrival to room, resident found to have agonal respirations and was unresponsive to verbal or physical stimuli. During examination, resident's POA [Power of Attorney] entered the room and was informed of the situation. She stated that the resident would want to be sent to the hospital for life-saving measures and had signed up for hospice so he could be here. POA was asked if she wanted staff to attempt to resuscitate resident and send him to the hospital and she replied in the affirmative. One dose of Narcan was administered while Emergency Medical Services [EMS] was called. Resident's respirations improved but he remained unresponsive. A second dose of Narcan was administered and resident awoke and was responsive to questioning. EMS arrived around that time and resident was transported to the emergency room for further evaluation and management. Review of the Incident Report from the local Police Department dated 3/10/2023, revealed at 5:21 PM, the police made contact with the facility Director who stated that roughly 3 minutes after Resident #4's visitor had left, Resident #4 began to turn gray and went unresponsive. The medical staff administered 2 doses of Narcan at which time the Resident became responsive. The facility believes the visitor may have delivered some narcotics to Resident #4. Review of the Ambulance Service report dated 3/10/2023 at 11:17 AM, revealed Resident #4 .FOUND LYING IN BED ALERT AND ORIENTED .[Named MD] ON SCENE STATED PATIENT WAS GIVEN .08MG OF NARCAN AND MENTAL STATUS IMPROVED TO NORMAL. HE STATES THAT PATIENT HAD A VISITOR WITH HIM [NAME] HOSPICE THERE AS WELL, AND PATIENT WENT UNRESPONSIVE WITH FAMILY THERE . Review of the Hospital] Emergency Note dated 3/10/2023 at 12:53 PM, revealed Resident #4 .presents to the emergency department complaining of altered mental status .found at scene with decreased respirations and somnolent [sleepy] after a friend stopped by for a visit. Initial report was patient was breathing 1 time per minute .was given a dose of narcan and aroused .complains of 'all over body pain' .made better by Narcan .It is associated with possible OD [Overdose] . The facility was unable to provide a complete investigation of the above incident or evidence that interventions had been developed and implemented to protect Resident #4 and other residents residing in the facility. Review of the PSYCHOTHERAPY PROGRESS NOTE dated 3/14/2023, revealed .Today's session was held at the request of the NH [Nursing Home] social worker, who reported that twice they couldn't arouse the pt, but that he quickly awakened when given Narcan. Staff believe that a cousin who visits him brought him some narcotics .pt. again denied haven taken any pills brought by anyone, saying that he did take extra trazodone from a supply he had with him when he first came to the NH . Review of the PSYCHOTHERAPY PROGRESS NOTE dated 4/27/2023, revealed .Today [Resident #4] says that the pill he took was in his mail that a visitor brought him and said that he has had no more pills in his room at all. He has not been entirely honest about his drug use in the past . During an observation and interview on 4/19/2023 at 12:15 PM, Resident #4 was sitting up in bed, alert and confirmed he was receiving hospice services twice a week. During an interview on 4/19/2023 at 3:09 PM, the DON confirmed Resident #4 was receiving hospice. The DON stated, .we had issues with the narcotics .we did change his medication to liquid. During his stay here he has been noted to have altered mental status, we did take the medications from the resident. The pill bottle did not have a label . The DON confirmed the family revoked the hospice, we administered Narcan to him, and then EMS to the resident to the hospital. During an interview on 4/20/2023 at 10:02 AM, the DON confirmed the doctor was in the Resident #4's room on 3/10/2023 when the RT was giving the breathing treatment and was assessing him. The DON stated, The MD was here doing his rounds and gave an order for Narcan. The DON confirmed Resident #4 slowly became more alert. Continued interview confirmed at 11:15 AM, Resident #4 had a second dose of Narcan and Emergency Medical Services (EMS) arrived and transported Resident #4 to the hospital. The DON confirmed Resident #4 arrived at the ER at 11:54 AM. The DON confirmed there was no drug screen test, no discharge medications, no medications were given while in the ER, and Resident #4 was discharged back to Nursing Home. During an interview on 4/20/2023 at 10:40 AM, RT #1 confirmed while performing a breathing treatment on the morning of 3/10/2023, Resident #4, seemed a little off, not as talkative, and drowsy, he was responsive, and I put the mask on him. Approximately 12 minutes had passed since I put the breathing treatment on [Resident #4]. When I turned around [Resident #4] was on the side of the bed, lethargic and not responding at all. My pulse ox showed 70's, I could not get Resident #4 back on the bed, I called for the med tech, and they came we got Resident #4 up in the bed. I placed a Nonrebreather (NRB) on and still could not get his oxygen out of the 80's. I called for the nurse, and she came and said [Resident #4] had only got his regular medications. I kept working with [Resident #4], MD came in and suggested [Resident #4] get Narcan, and that brought [Resident #4] out of what was going on. The RT confirmed she put a note in his chart. The RT stated, I was not asked to write a statement. I talked to the hospice nurse before we sent [Resident #4] out. Once they gave the Narcan [Resident #4] oxygen level started coming up and he became more alert. During an interview on 4/20/2023 at 12:13 PM, the DON confirmed the facility does not have standing orders for Narcan. The DON stated that the MD was in the facility and gave the verbal orders for Narcan. The MD wanted us to notify him if we have any resident that has a change in status. During an interview on 4/20/2023 at 12:26 PM, with Resident #4, in his room, Resident #4 was asked what happened when he went out to the hospital. Resident #4 stated They gave me Narcan .a buddy of mine sent me something in mail .something to help me sleep .It was cocaine or heroin [an illegal medication used for recreational use] .I told him not to write or call again. Resident #4 was asked what happened to him after he took the medication he had received in the mail. Resident #4 stated, I can't remember, it put me out .I went to the hospital to be on the safe side. Resident #4 stated, .the pill was crushed in a letter .got in mail .it was white powder, it may have been cut with some fentanyl [strong narcotic used to treat pain - used as a recreational drug illegally]. I never want any more. Resident #4 was asked how he took it. Resident #4 stated, .poured the powder in his mouth .wanted to go to sleep .my friend had sent me some 2-3 times before .after I took it, I went out, I could see myself above my body, looking down at myself . Resident #4 was asked, if staff had found medication in his room. Resident #4 confirmed they had found some medication in his clothes that was brought to him by his cousin. Resident #4 stated .the pills had been here since he came in, they were in my clothes . Resident #4 stated, I put the pill bottle in my sock. I was going to give them away .I take the same med at night to help me sleep. I don't know how they got here, they had to be in my clothes from home, or a coat pocket. Resident #4 confirmed staff found the pills and took them. During an interview on 4/20/2023 at 12:40 PM, the DON confirmed an incident report was not completed, when medications not ordered by the physician, were found in an unlabeled bottled in Resident #4's socks. No psych notes were found to address the incidents. During a telephone interview on 4/20/2023 at 3:01 PM, RT #2 confirmed she was in the facility on 2/15/2023. RT #2 stated, [Resident #4] was lethargic, labored [difficulty breathing] .I told the hospice nurse that he has OD [Overdosed] .I'm telling you I have seen OD .I left, the hospice nurse was in the room .I told hospice they needed to send [Resident #4] out .[Resident #4] was on 2 liters he was 60% .I bumped him up to 3 litters .I waited until [Resident #4] oxygen came up in the 92% .a couple days later, I asked about [Resident #4] and was told they had to send him out again for an OD .It was hearsay [Resident #4] had family bringing in med crushed up. I had heard nurses saying [Resident #4] was holding medication and crushing his medication and snorting . RT#2 confirmed she did make a progress note in [Resident #4] chart when this incident occurred. The surveyor was unable to locate RT #2's note and facility communicated there was no progress note from RT#2. During an interview on 4/24/2023 at 12:14 PM, RN #2 confirmed Resident #4 was on hospice. RN #2 confirmed, it was hearsay that Resident #4 was a drug seeker. RN #2 stated, [Resident #4] is on scheduled morphine, he had too much medication and was lethargic and received Narcan. During an interview on 4/24/2023 at 12:58 PM, the DON confirmed the police were called and stated it was, to cover our bases and the police had completed a report on 3/10/2023. The DON stated, That was the administrator's decision. The DON confirmed nothing happened, the administrator just called. The DON stated, I did not ask him his reason or rational. The DON confirmed on 3/10/2023 she didn't recall Resident #4 having a visitor. The DON confirmed on 1/28/2023 that Resident #7 had reported that Resident #4 tried to give him medication. The DON was asked if an investigation done. The DON stated, No. and confirmed no statements from staff were obtained. The DON was asked if the Administrator was aware of this incident. The DON stated, Yes . The DON was asked about 2/15/2023 incident and what medications were found on Resident #4. The DON confirmed, I recall Hospice saw him. Hospice found the medication, in his sock, and he was able tell her the medication was trazadone, and the amount he said was in the bottle. The DON confirmed the Administrator asked if the resident would allow us to search his room or do a drug screen, he would not allow us. The DON was asked if the facility had an investigation for the 3/10/2023 incident when Resident #4 went out to the hospital. The DON stated, No. During an interview on 4/24/2023 at 1:29 PM, with a second surveyor present, Resident #4 confirmed that he did receive a pill crushed up in mail. Resident #4 stated, .it was white powder mashed up in a plastic bag. I should have smelled a rat .took the .powder on my tongue .it did not take long, then everything started getting blurred .like going to sleep .struggling to breathe .into a deep sleep and I was looking down on myself. Resident #4 confirmed, the police came out. Resident #4 was asked what did you tell the police. Resident #4 stated, Yes .it was Fentanyl or something mixed with something .never felt that way before. Resident #4 was asked about having medication in his sock. Resident #4 stated, .did not know it was there . Resident #4 confirmed he had[TRUNCATED]