**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services in that: The facility failed to follow physician orders for the fentanyl patch resulting in Resident #1 becoming unresponsive and suffering respiratory failure. An Immediate Jeopardy was identified on 7/25/24 at 3:15 PM. While the Immediate Jeopardy was removed on 7/26/24 at 4:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents and place them at risk for not receiving a therapeutic effect, could result in a decline in health, and overdose or death. The findings included: Record review of Resident #1 face sheet dated 7/24/24, Resident# 1 was a [AGE] year-old male admitted on [DATE] with diagnoses that included: COPD (chronic obstructive pulmonary disease), DM (diabetes), HTN (hypertension) , Bipolar disorder, quadriplegia non ambulatory. He discharged to hospital on 7/16/24. Record review of Resident #1's physician orders dated July 2024 revealed: Fentanyl patch 50 mcg change every 72 hours. Narcan PRN for opioid overdose [no order to monitor for opioid overdose] Record review of Resident #1's MAR July 2024 revealed: 7/13/24-removed from the abdomen's left upper quadrant (9:38 AM) and applied fentanyl path (09:38) by RN A to the abdomen's right lower quadrant. 7/16/24- removed from the abdomen's lower upper quadrant (9:58 AM) and applied to the lower upper quadrant (09:58) [by LVN B witnessed by LVN F]. Record review of EMS run sheet, dated 7/16/24 revealed: On 7/16/24 at 11:44 PM, EMS was dispatched to NF because Resident #1 was unresponsive and suffering respiratory failure. Resident #1, in the ambulance, was found with 2 fentanyl patches on body not reported by the facility. At the ER, resident was administered Narcan twice for a fentanyl overdose. Record review of EMS Run Sheet dated 7/16/24 revealed the following timeline: 7/16/24 at 11:44 PM EMS dispatched to NF. 7/16/24 at 11:59 arrived at patient. 7/17/24 at 00:29 AM arrived at ER. Also, The EMS narrative read: Medic 3 (Paramedic E) dispatched to nursing home for a 74 yo (year old) male that is unresponsive and difficulty breathing patient lethargic and with swallow breathing .Patient pupils presented pin point bilaterally .the patient was placed on a 12 lead ECG that revealed the patient in atrial flutter and RVR (rapid ventricular rhythm) .Upon further examination it was found that the patient presented with 2 Fentanyl patches that had not been reported to EMS crew by Nursing Home staff . Record review of Resident #1's hospital record MD C note dated 7/17/24 at 5:58 AM read: HPI (History of Present Illness .Chief Complaint: unresponsive .74 yo (year old) M (male) with hx (history) of quadriplegia, chronic pain, recently dx (diagnosed) HCC (liver cancer) with mets (metabolic equivalents) to the lumbar spine, DM (diabetes), HTN (hypertension), COPD, mood disordered .concern for narcotic overdose .Per report [patient] was brought in from SNF (skilled nursing facility) with concern for decreased responsiveness. Patient was found to have multiple fentanyl patches on him in the ER (emergency room) .He was noted to be hypoxic (lack of oxygen) in the ER and was placed on bi-pap (breathing mask) with improvement in [respiratory] status . Record review of Resident #1's hospital record MD H note dated 7/17/24 at 5:58 AM read: .At ER patient received a dose of Narcan and his fentanyl patch (unknown dose and quantity) was removed, then he rather quickly woke up and was conversant. After few hours patient once again became lethargic and required repeat dosing of Narcan, thus was started on Narcan drip .Diagnosis, Assessment & Plan .Impression .1. Fentanyl Overdose . Observation and interview on7/24/24 at 9:00 AM, Resident #1 was in bed on a ventilator in the ICU in a local hospital. Resident #1 had difficulties communicating because of the ventilator apparatus in his month. [Surveyor employed an thumbs up (meaning yes) and thumbs down (meaning no) interview technique. Resident #1 responded with thumbs up to the direct question whether he felt he received too much fentanyl and was overdose. [Resident #1 was too exhausted to continue the interview] During an interview on 7/23/24 at 12:45 PM, the DON stated: her internal investigation revealed there was no overdose of Resident #1. The DON stated that the facility could account for all the fentanyl patches given to the resident (Resident #1) for the past month (July 2024). The DON stated the resident was sent to the ER because of respiratory failure. The DON stated the facility had Narcan in the e-kit; and there were two other residents on fentanyl patches [Resident #2 and #3] During an interview on 7/24/24 at 9:05 AM, RN (ICU) stated: the resident was slightly sedated and was scheduled for a trach. The RN (ICU) stated that the hospital progress notes revealed that numerous fentanyl patches had been found on the resident in the ER. The RN (ICU) stated, the ER staff administered Narcan twice to counteract a drug overdose. During an interview on 7/24/24 at 10:50 AM, EMS Administrator, stated: EMS responded on 7/17/24 to an unresponsive resident at the nursing home. The EMS Administrator stated that the EMS staff was not told by nursing home staff that the resident had fentanyl patches. The EMS Administrator stated that in the ambulance the resident was found by the paramedics with two fentanyl patches. The EMS Administrator stated the treatment given to the resident in the ambulance was breathing treatment, heart medication and monitoring. During a telephone interview with Resident #1's primary physician on 7/24/2024 at 3:36 PM , she stated Fentanyl patch for pain should be removed every 72 hours and then a new one placed. If one were left on it would exceed the dose ordered by the physician, and respiratory and other overdose symptoms such as unresponsiveness could occur if overdosed was present. During a telephone interview with the facility RN A on 7/24/24 at 3:45 PM she stated she remembered Resident #1 having the Fentanyl patch ordered for pain. She stated she removed one and placed a new one the weekend before [7/13/24] before Resident #1 was sent to the hospital 7/17/24. She further stated she knew that only one patch should be placed on a resident at one time because an overdose could occur. During a telephone interview on 7/25/24 at 9:00 AM, witnessed by the Chief of EMS, Paramedic D [driver in the ambulance] stated that Paramedic E found two fentanyl patches on the resident's body in the ambulance. Paramedic D stated one patch was at the LLQ abdomen and the second patch was at the right upper shoulder. Paramedic D stated the LLQ patch was new and dated but the date was not recorded by EMS and the second patch on the upper right shoulder appeared to have reached the 7 day mark (date was not recorded by EMS); mcg were unknown on both patches. Paramedic D was present at the ER when the ER staff removed both patches and the physician stated they were fentanyl. Paramedic D stated once the 2 patches were removed the resident became responsive. During a telephone interview on 7/25/24 at 10:00 AM, LVN B stated: he removed and applied a fentanyl patch [on Resident #1] on 7/16/24 witnessed by LVN F. LVN B stated that he only lifted the resident's T-shirt chest high but did not strip the resident or search for other patches. LVN B stated he documented the removal and application of the fentanyl patch on the MAR July 2024. LVN B stated he could not recall the location of the patch removed and applied. LVN B stated he was familiar with fentanyl protocols. During an interview on 7/25/24 at 10:15 AM, LVN F stated she was present when LVN B removed and applied a fentanyl patch to Resident (#1's) abdomen. LVN F stated she could not recall where the location where the old patch removed and the location of the new patch. LVN F stated that the resident was not stripped or T-Shirt removed to check on the existence of any other fentanyl patch. LVN F stated that the removed patch was discarded in the sharps-container. LVN F stated he was familiar with fentanyl protocols. During a telephone interview on 7/25/24 at 10:30 AM, RN A stated, that she removed and applied a fentanyl patch to the RLQ (right left quadrant) . RN A stated that on 7/13/24 she did not strip down the resident or search for other fentanyl patches. RN A stated she gave the resident a bed bath on 7/14/24 and the resident only had one fentanyl patch present. During telephone interview on 7/25/24 at 11:55 AM, CNA G stated that: she gave Resident #1 a bed bath on 7/16/24 between 9:00 AM and 11:00 AM and noticed two patches on the resident's knees one on each knee and a patch on the floor. CNA G stated that there were no patches on the resident's abdomen and she did not see any other patches on the resident's body. CNA G stated she threw the patch on the floor in the trash can and did not know whether it was a fentanyl patch. CNA G stated that she informed LVN B that she threw the patch on the floor in the trash can. During a telephone interview on 7/25/24 at noon, LVN B stated that he was never told by CNA G that she found an unknown patch on the floor in Resident #1's room and threw it in the trash can. During an interview on 7/25/24 at 1:19 PM, the DON stated: she could not explain why the resident's hospital report stated, multiple fentanyl patches. The DON stated the resident sweated a lot and starting in July 2024 the location of the fentanyl patch was moved to the abdomen. The DON stated that when a resident was on an order for fentanyl patches the patch is removed and applied every 72 hours. The DON stated a fentanyl patch could be placed on the abdomen, back , shoulder and any fatty place; and should be dated. The DON stated if a medical patch was found on the floor, regardless as to whether it was fentanyl, the nurse should be informed and not thrown in a trash can; and disposed as medical waste. The DON stated the resident was sent to the ER on [DATE] because the resident had respiratory distress at 12:47 AM and altered mental status. The DON stated that Resident #1 was a quadriplegic, required total dependency for transfer and mobility. The DON stated the resident had usage of his arms and could remove a patch. The DON stated that best practice when removing a applying a fentanyl patch should be to do a full body search. The DON stated it was an unfortunate incident and LVN B and LVN F were competent and knowledgeable about the facility's fentanyl protocol. Record review of facility's investigation file, undated, revealed the following written statements: 7/23/24 LVN B: he only removed and applied one fentanyl patch. LVN B stated he did not see other patches Because he wears a T-shirt. 7/22/24; CNA H stated that she only saw one patch on the resident [present on 7/14/24 when bed bath was given by RN A] Record review of LVN B's Medication Pass Competency assessment dated [DATE] revealed LVN B was competent in Transdermal Patches which included: .old patch removed .Two nurses witnessed and signed for controlled substance wasting (fentanyl patch removal) .patch is dated and timed .Patches rotated to site as stated on MAR and placement documented. Record review of LVN F's Medication Pass Competency assessment dated [DATE] revealed LVN B was competent in Transdermal Patches which included: .old patch removed .Two nurses witnessed and signed for controlled substance wasting (fentanyl patch removal) .patch is dated and timed .Patches rotated to site as stated on MAR and placement documented. Record review of facility's Mediation Administration: Transdermal (Patch) Application dated revised 10/101/19 read: .Identify the location on the body for patch placement .Remove old path from body .Label path with date and nurse's initials .Document placement site on MAR .Fentanyl Patches require the path to be folded after removal, destroyed per policy and state regulations, dropped in the Sharps container and a witness be present to sign . The Administrator and the DON were notified of the Immediate Jeopardy on 7/25/24 at 3:15 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 7/26/24 at 10:53 AM and reflected the following: Nursing and Rehabilitation LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On 7/25/2024, the facility was notified by the surveyor that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F755 Pharmacy Services/Procedures/Pharmacist/Records For Residents Involved: Resident #1: Resident #1 is currently in the hospital. To Identify Any Other Residents to Have the Potential: The Director of Nursing and/ or designee has reviewed all current residents with fentanyl patch orders as of 7/22/24. The Director of Nursing and/ or designee has observed current residents for appropriate patch placement and documentation 7/22/24. The Director of Nursing and/ or designee will review new admissions to ensure that any new orders for fentanyl patch are complete and patch is placed appropriately. Education/ System Change: The Director of Nursing or designee began re-education on the following: Licensed nursing staff received re-education on appropriate order, placement and documentation of fentanyl patch, including identifying S/S of possible overdose. Licensed Nursing Staff re-educated on appropriate disposal of Fentanyl Patches Licensed Nursing Staff re-educated on validation of patch placement. Direct care staff re-educated on communication to supervisor of any displaced or dislodged patch, to ensure M.D. orders are followed. Re-education initiated on 7/22/24 with Licensed Staff and completed with Licensed staff and Direct care staff on 7/25/24. Those that are PRN, PTO/FMLA will complete prior to next schedule shift. Re-education will continue for any new hires and as part of the orientation process. Re-education will be validated using employee roster. Monitoring: The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that any new orders for fentanyl patch are documented and placed appropriately. This will begin 7/26/24 and will be an ongoing process. The Director of Nursing or designee will ensure new admissions have complete orders and correct placement for fentanyl patch. Placement of patches will be rotated on upper body. The facility does have Narcan available in the event of an overdose situation for residents who are prescribed Fentanyl. The Director of Nursing or designee will monitor compliance every shift x 4 weeks, then every shift 3 times per week x 4 weeks, then 1 x a week times 4 weeks. The results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. The DON or designee will utilize a validation log to document findings. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. An Ad-Hoc QAPI was conducted on July 25, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F755 and to develop the above-mentioned plan of care. We respectfully submit this action plan for removal of Immediate Jeopardy. Sincerely, Administrator Verification of Plan of Removal: Key Observations:. Observation on 7/26/24 at 1:20 PM revealed Resident #1 had not returned to the facility . Observation on 7/26/24 at 4:20 PM to 4:25 PM revealed that there were 3 injectable Narcan in the emergency kit locked in the medication room; and one Narcan spray in Nurse cart. Key Interviews: During an interview on 7/26/24 at 1:22 PM, the DON stated: she reviewed all current residents with fentanyl patch orders as of 7/22/24 and there were only two residents present in the facility; Resident #2 and Resident #3. The DON stated: there were no new admissions on 7/25-7/26/24. The DON stated for new admissions, she would ensure that any new orders for fentanyl patch were complete and patch is placed appropriately. The DON added: there were no new admissions on 7/25-7/26/24. The DON stated for new admissions she would ensure that any new orders for fentanyl patch are complete and patch is placed appropriately. In interviews on 07/26/24 from 1:45 PM to 3:15 PM with 4 day shift (6 a.m. to 6 p.m.) nursing staff ( 2 LVNs and 2 CNAs), 5 evening shift (2 p.m. to 10 p.m.) nursing staff (2 LVNs, 3 CNAs) and 3 night shift (10 p.m. to 6:00 a.m.) (2 RNs, 1 CNA) revealed they had been in-serviced on the S/S (signs and symptoms) of overdose, disposal of fentanyl patches, validation of placement, communications, and on the 5 rights in medication administration especially involving fentanyl patches. During an interview on 7/26/24 at 2:00 PM, the Administrator stated that the issue of new admissions and any concerns with the 2 residents on fentanyl patches was discussed at the 7/25 and 7/26/24 morning meetings. During an interview on 7/26/24 at 2:06 PM, the Regional Nurse stated that ad-hoc QAPI meeting on 7/25/24 discussed the fentanyl protocol and the need for nursing staff to adhere to the protocol. The Regional Nurse stated that the physician present at the meeting by telephone was requested to state in the physician's order the location of the fentanyl patch. Key Record Review Record review of the Resident Roster dated 7/26/24 revealed Resident #1 no longer resided in the facility. Record review of current residents with fentanyl patch orders as of 7/22/24 revealed only two residents on fentanyl patches; Resident #2 and Resident #3. Record review of facility's Fentanyl Audit F755 (form) dated July 26-27, 2024, revealed only 2 residents on fentanyl patches; Resident #2 and Resident #3. The audits were contained in the facility's POR binder. Record review of facility's Admissions/Discharge list dated 7/26/24 revealed non new admissions. Record review of the in-service from 7/25/24 to 7/26/24 revealed 100% completion of 49 nursing staff trained on fentanyl protocol, placement, proper disposal, location, dating, and signatures (see attached sheet). Form also present for non-license nursing staff on communications and patches found. Record review of facility's morning report dated 7/15/24-7/26/24 revealed the report was reviewed and signed by the DON and the Administrator. Record review of ad-hoc QAPI meeting held on 7/25/24 with the Medical Director present by telephone. On 7/26/24 at 4:50 PM the Administrator was informed the POR was validated and Immediacy was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 24 residents reviewed for medication storage. 1. The facility failed to store Resident #52's medications which were kept at her bedside which resulted in an incident on 11/22/2023, when she was hospitalized and diagnosed with overdose related to self-medication with Diphenhydramine (an antihistamines; used for relief from symptoms related to hay fever, upper respiratory allergy, or cold symptoms) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain). An Immediate Jeopardy (IJ) was identified on 03/29/2024. While the IJ was removed on 03/31/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for serious harm accidents. The findings included: Resident #52. A record review of Resident #52's admission record revealed an initial admission date of 09/20/2022 with diagnoses which included depression, cirrhosis of the liver (permanent scarring that damages your liver and interfere with its functioning), altered mental status, and need for assistance with personal care. A record review of Resident #52's annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 06 out of 15 indicating severe mental cognition impairment. A record review of Resident #52's care plan, undated, revealed the following: [Resident #52] is resistive to care at times. Refuses certain medications often . with an intervention Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care., initiated 05/30/2023. [Resident #52] has liver disease [related to] cirrhosis with an intervention Give medications as ordered, initiated 10/04/2022. [Resident #52] uses anti-anxiety medications [related to] Anxiety with an intervention Monitor the resident for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia ., initiated 10/04/2022. A record review of Resident #52's hospital documents, dated 02/19/24, revealed Resident #52 was admitted [DATE] with chief complaint of loss of consciousness. The hospital documents reflected EMS was called and on their arrival, there was note of a large bottle of Benadryl as well as Norco. There was some concern for polypharmacy. The toxicology report on 02/16/2024 at 05:47 PM revealed urine opiates screen was positive. The hospital documents further revealed likely altered mental status secondary to medication effect. A record review or Resident #52's Medication Administration Record for February, dated 03/28/24, revealed Resident #52 did not take Norco Tablet 7.5-325 MG (Give 1 tablet by mouth every 6 hours as needed for pain. Ensure resident drinks full glass of water after medication. Do not exceed 3 grams of acetaminophen in 24 hours) from 02/13/24 to 02/19/24. Acetaminophen-Codeine Tablet 300-30 MG (Give 1 tablet by mouth every 6 hours as needed for Pain. Do not exceed 3Gm of [acetaminophen] in 24-hour period) was last given on 02/15/24 at 06:00 AM and at 02:27 PM. During an interview on 03/27/24 at 05:30 PM, Resident #52 revealed she did not remember why she was in the hospital on [DATE]. Resident #52 did not remember if she had taken any medications before being hospitalized . Resident #52 revealed a family member brought in the medications but would not disclose who brought them in. She further revealed maybe she was taking Tylenol PM because she was self-medicating. She further revealed she did not know she had to let anyone know what she gets from outside of the facility. She further revealed no staff came in to inspect what she kept in her room. During an interview on 03/28/24 at 12:26 PM, the DON revealed she had asked Resident #52 where she got the medications that were at her bedside on 02/16/2024, but Resident #52 did not want to identify who brought the medications to her. The DON further revealed the facility educated Resident #52's RP to check with the nursing station before bringing anything to the resident. During an interview on 03/28/24 at 01:58 PM, Resident #52's RP revealed he was surprised by the 02/16/24 incident that led the hospitalization of Resident #52. He was told Resident #52 had bottle of Norco. The RP further revealed he did not know he could not bring in some OTC medications like TUMS. He did not know where Resident #52 was receiving the other OTC medications that were at her bedside. The RP was made aware to go through the nursing station when bringing anything to the resident. During an interview on 03/31/24 at 06:49 PM, MD AJ revealed she was aware Resident #52 had medications at her bed side last month. She revealed this would cause Resident #52 to be at risk of overdosing and she could have been given discharge orders due to this incident. She further revealed overdosing could cause hospitalizations. She added having OTC medications like Tylenol could cause liver problems if too much was taken. She further added there was a possibility of death if there was an over intake of opiates. During an interview on 03/28/24 at 12:26 PM the DON stated she and the department heads, including the Administrator, every weekday morning reviewed the previous days documents for all residents to include incident reports, grievance reports, 24-hour reports and all progress notes to include physician and nurse practitioner notes. During an interview on 03/28/24 at 12:38 PM the Administrator was asked if she was aware of resident #52's incident when she was discovered with AMS and pills at the bedside the Administrator stated she was. The administrator was asked if she could share some details about Resident #52; the Administrator stated she did not know much about Resident #52. During an interview on 03/28/2024 at 02:00 PM, the DON stated she had reported to the Administrator Resident #52's incident with altered mental status and need for hospitalization. A record review of an anonymous email to the corporate organization for this facility, provided by Confidential Staff member AF and dated 08/07/2023, revealed, The reason I am writing is because I no longer feel I or any of my other direct care coworkers can safely and confidently provide the care and services our special resident deserve . Our company has allowed agency but due to the cost they have begun cutting back on caregivers . the extent of cutting back is exceeding to the point of promoting unsafe and hazardous practices . I have expressed my concerns to management, I have written letters signed by other staff, I have reached as far as I can to try and resolve this issue with no results . Management is aware of this issue and I have personally witnessed them cover things up to try to consolidate the results of an unreported incident to an already open incident . We have reported unsupervised smoking and consumption of alcohol to management multiple times due to intoxication resulting in falls and cigarette burns to residents who fall asleep smoking. A plan was put into place and an alarm was placed on the doorway to alert staff if someone is going out, however the alarm is constantly disarmed therefore allowing incidents to continue happening. I cannot help but feel as though management does not care . Please help me. I want my residents to be safe, feel safe, and trust they are always being cared for by people who truly care. I don't know what else to do. I do want this complaint to remain anonymous due to fear of retaliation. A record review of the facility's Resident admission Agreement, revised 10/14/2021, revealed The resident has the right to retain and use personal possessions . unless doing so would infringe upon the rights, health, or safety of other residents. It further revealed prohibited items include smoking or tobacco products, lighters, other smoking paraphernalia or illegal substances. Additions and deletions to the inventory shall be brought to the attention of the facility's administration so that records remain current. The Facility may terminate this Agreement by discharging the Resident in accordance with state and federal law. A record review of the facility's Medication and Disposal policy dated 10/01/19, revealed, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate for the judgment of the facilities interdisciplinary resident assessment team. Procedure: a written order for the bedside storage of medication is present in the residence medical record. bedside storage of medications is indicated on the resident medication administration record and in the care plan for the appropriate medications. 4 residents who self-administer medications the following conditions are met for bedside storage to occur; the manner of storage prevents access by other residents. lockable drawers or cabinets are required only if unlock storage is deemed inappropriate. facility management should have a copy of the key in addition to the resident. the medications provided to the resident for bedside storage are kept in containers dispensed by the pharmacy or in the original container if a non-prescription medication. the bedside medication record is reviewed on each nursing shift, and the administration information is transferred to the medication administration record kept at the nurse's station. notation of each self-administered dose is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident. the resident is instructed in the proper use of bedside medications, including what the medication is for, how it is to be used, how often it is to be used . the completion of this instruction is documented in the residence medical record A record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . identification of abuse, neglect and exploitation . the facility will have written procedures to assist staff in identifying the different types of abuse- mental /verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. this includes staff to resident abuse and certain resident to resident altercations. possible indicators of abuse include, but are not limited to: . physical marks such as bruises or patterned appearances such as a handprint, built a ring mark on a resident body, physical injury of a resident, of unknown source . The administrator was given the IJ template and notified of the IJ(Immediate Jeopardy) on 3/29/24 and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 03/30/2024. plan of removal For Those Affected: On 3/29/24, the Licensed Nurse assessed residents # 15 related to consumption of alcohol and Tylenol with Codeine and Methadone. No ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. An order was received on 3/27/24, to call the physician if returns from on pass impaired. On 3/29/24, the Licensed Nurse assessed resident #50 related to alcohol consumption and administered Seroquel, Ambien, and Hydrocodone. Not ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. On 3/29124, the License Nurse assessed resident #52 related to Altered Mental Status with suspected overmedication. No ill effects were noted. Care plan updated 3/30/24 to reflect to note history of non-compliance re OTC medications. Interventions in place to daily monitoring compliance with not keeping medications at bedside. Interventions included: Resident #52 and RP were re-educated on importance of not having medications at bedside; RP will provide any medications he purchases for resident #52 to the licensed nurse. Staff to monitor daily to ensure no medications are found at bedside. Facility wide monitoring started 3-30-2024 to monitor for any non-compliance for any medications at bedside for all residents. Identify Others Affected: Those with orders allowing out on pass are identified. Those who smoke are identified. Those that have orders for alcohol consumption are identified. Those that self- medicate are identified. Those with Changes in Condition Actions Taken: The Director of Nursing or designee began reeducation for all staff on the following: o Abuse and Neglect o Recognition of Change of Condition including those who are impaired to call physician upon their return to include suspected alcohol consumption. This was completed 3-29- 24 & 3-30-24. o Self-Administration of Medications. No residents currently at facility self-administer medications. o Smoking Policy including Paraphernalia o Policy for Resident Personal Possessions Re-education initiated 3/29/24 and completed on 3/30/24 with all staff. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment. Beginning 3/29/24 and ongoing, newly hired and agency staff will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. On 3/29/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. Safe Smoking assessments were conducted By ADON'S on 3/30/2024 for all smokers. All paraphernalia must be surrendered by all smokers to the staff upon return from their smoking break and secured on designated cart. If resident assessed as impaired (inebriated), a change of condition will be done, and MD will be notified for further instructions on giving or holding medications. The physician on-call services are available 24/7 and/or Medical Director (or designee). All Licensed Nurses re-educated on resident with orders with alcohol consumption have revisions to reflect amount of alcohol consumed. This was conducted on 3/29/24. Order revision conducted on 3/29/24 to require additional documentation if alcohol is administered. Monitoring: Beginning 3/29/24 and going, The DON/designee will: Monitor that residents with intact cognition are allowed to sign in and out on pass. That residents who smoke do in a designated smoke area and time. Those with orders to go out on pass were re-education to check back with facility upon return and are asked by the Licensed Nurse that they return their smoking paraphernalia. Those that return from out on pass and determined to be impaired, have assessment completed and that the Physician is notified regarding their condition. Staff re-education completed on 3- 29-2024 & 3-30-2024. Required actions such as notifications to MD (or designee), RP, Administrator, DON. Those that Self Administer are doing as physician ordered. Monitoring will be completed per nurse managers Monday thru Friday and by Weekend Supervisor/Designee on weekends to ensure no medications at bed side. When staff administer medications, facility practice is that nurse will stay with resident to ensure medications are swallowed. Media alert sent 3/30/24 to families that all medications brought into facility must be turned into the nurse for proper storage and administration by licensed staff. Plan of Removal Verification For Those Affected: On 3/29/24, the Licensed Nurse assessed residents # 15 related to consumption of alcohol and Tylenol with Codeine and Methadone. No ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. Record review of Resident #15's progress note dated 3/29/2024 and written at 8:38 PM by ADON 1 reflected, Resident assessment completed: Resident is alert and oriented, BIMS=15. Resident propels self in w/c. Resident is frequently signing self out on pass and leaving from the facility alone. MD made aware and states resident is safe to go out on pass per self. Resident re-educated to sign RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE form prior to leaving facility and to check back in with facility staff upon return. Record review of Resident #15's progress note, dated 3/29/2024 and written at 9:33 PM by the DON reflected, Call placed to MD and verified order to remain in place for resident to be allowed to be administered (1) 12 oz beer during 2-10 shift, unless resident has gone out on pass or received alcohol beverages. Resident is aware of this order and aware when he goes out on pass, if he appears cognitively or physically impaired, the charge nurse will hold his medication per MD order and notify the MD, DON and administrator. Resident is aware the facility can assist resident with purchasing the alcoholic beverages and the facility will maintain control of these alcohol beverages and will administer them to the resident per MD order. Resident verbalized understanding and agrees with above plan of care. Record review of Resident #15's care plan, dated reflected, [Resident 15] has a behavior problem related to non-compliance with facility policies. [Resident 15] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times with date initiated of 3/30/2024 and interventions including, Administer medications as ordered. Monitor/document for side effects and effectiveness.; Anticipate and meet the resident's needs.; Educate [Resident 15] on importance of following facility policies.; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.; If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator.; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., all with a date initiated of 3/30/2024. Record review of Resident #15's care plan, dated reflected, [Resident 15] has a behavior problem related to non-compliance with facility policies. [Resident 15] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times. With intervention, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. With a care plan revision and interventions dated 3/30/2024. Interview on 3/31/2024 at 4:10, the DON stated that if a resident declines an assessment, they document, notify the Physician, RP, DON, and Administrator. An order was received on 3/27/24, to call the physician if returns from on pass impaired. Record review of Resident #15's orders revealed an order with a start date of 3/29/2024 reading, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. Ordered by the Medical Director. Record review of Resident #50's orders revealed an order with a start date of 3/29/2024 reading, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. Ordered by the MD. Interview on 3/31/2024 at 4:08 PM, the DON stated that the expectation is that the nursing staff will call the physician as soon as the impairment is recognized. On 3/29/24, the Licensed Nurse assessed resident #50 related to alcohol consumption and administered Seroquel, Ambien, and Hydrocodone. Not ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. Record review of Resident #50's progress note dated 3/29/2024 and written at 8:39 PM by ADON 1 reflected, Resident assessment completed: Resident is alert and oriented, BIMS=15. Resident is ambulatory with walker. Resident is frequently signing self out on pass and leaving from the facility alone. MD made aware and states resident is safe to go out on pass per self. Resident re-educated to sign RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE form prior to leaving facility and to check back in with facility staff upon return. Record review of Resident #50's progress note, dated 3/29/2024 and written at 9:33 PM by the DON reflected, Call placed to MD and verified order to remain in place for resident to be allowed to be administered (1) 12 oz beer during 2-10 shift, unless resident has gone out on pass or received alcohol beverages. Resident is aware of this order and aware when he goes out on pass, if he appears cognitively or physically impaired, the charge nurse will hold his medication per MD order and notify the MD, DON and administrator. Resident is aware the facility can assist resident with purchasing the alcoholic beverages and the facility will maintain control of these alcohol beverages and will administer them to the resident per MD order. Resident verbalized understanding and agrees with above plan of care. Record review of Resident #50's care plan reflected a problem dated 3/30/2024, [Resident #50] has a behavior problem related to non-compliance with facility policies. [Resident #50] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times., with interventions including, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. With a care plan revision and intervention date of 3/30/2024. On 3/29124, the License Nurse assessed resident #52 related to Altered Mental Status with suspected overmedication. No ill effects were noted. Care plan updated 3/30/24 to reflect to note history of non-compliance re OTC medications. Interventions in place to daily monitoring compliance with not keeping medications at bedside. Interventions included: Resident #52 and RP were re-educated on importance of not having medications at bedside; RP will provide any medications he purchases for resident #52 to the licensed nurse. Staff to monitor daily to ensure no medications are found at bedside. Record review of Resident #52's progress notes revealed a note written on 3/29/2024 and written at 7:29 PM by ADON 2 revealed, Resident assessment completed; Resident alert, able to voice needs/concerns to staff. VS- 121/77, 75, 17, 98.1, O2 98% RA. Resident denies any pain or discomfort at this time. Able to move all extremities without difficulty and follow commands. BIMS assessment completed, scored 10. This nurse asked resident if she remembered the recent care meeting regarding having OTC medications at bedside, resident stated yes and that she has been compliant and currently has no OTC medications at bedside. Resident laying in bed playing solitaire on cell phone prior to and after assessment. Call light within reach. Will continue with current POC. Record review of Resident #52's care plan revealed a problem of, [Resident #52] has a history of non-compliance regarding facility policies regarding OTC medications. [Resident #52] was found with OTC medication bottles in her room, putting [Resident #52] at risk for polypharmacy and medical complications related to excessive intake of OTC with interventions including, [Resident #52] and RP educated on importance of not having medications at bedside.; RP will provide any medications he purchases for [Resident #52] to the nurse; Staff to monitor to ensure no medications are found at bedside with care plan revision date and intervention dates of 3/30/2024. Interview 3/31/2024 at 4:11 PM, the DON stated that the nurses and nurse management team (DON, ADON, MDS Nurses, and Charge Nurses) will ensure with a form that is being filled out daily for each resident room that there are no prohibited items such as over-the-counter medication, cigarettes, lighters, or any paraphernalia that can be a danger to residents. Facility wide monitoring started 3-30-2024 to monitor for any non-compliance for any medications at bedside for all residents. Record review of document titled, Monitoring F689 revealed a checklist by room number with a requirement to check off and initial that no paraphernalia that could be a danger to residents was observed in the room. Interview on 3/31/2024 at 4:13 PM, the DON stated that the nurse management team to include the DON, ADON, MDS Nurse, and Charge Nurses will monitor by completing a daily form that includes each resident's room to ensure there are no prohibited items such as over-the-counter medication, cigarettes, lighters, or any paraphernalia that can be a danger to residents. The DON further stated that they will complete this monitoring form daily for 30 days, 4 times a week for the following 14 days, and 2 times a week for the 14 days following that. Observation on 3/31/2024 at 5:15 PM revealed the DON inspecting rooms [ROOM NUMBER] for unsafe items. Identify Others Affected: Those with orders allowing out on pass are identified. Interview on 3/31/2024 5:34 PM, the DON stated that the residents listed on the document provided were permitted to go out on pass as ordered. Record review revealed the following residents had orders to be able to be allowed to go out on pass: Resident #48 Resident #15 Resident #50 Resident #21 Resident #18 Resident #62 Resident #92 Those who smoke are identified. A record review of the POR revealed 15 residents were identified as residents who smoke; 1. Resident #50 2. Resident #15 3. Resident #2 4. Resident #62 5. Resident #12 a. During an interview on 03/29/2024 at 04:40 PM resident #12 stated she was educated on smoking safety with supervision and only during the designated smoking times six times a day. 6. Resident #41 7. Resident #49 8. Resident #92 9. Resident #7 10. Resident #31 11. Resident #45 12. Resident #66 13. Resident #13 14. Resident #150 15. Resident #11 Those that have orders for alcohol consumption are identified. Record review revealed Resident #15 and Resident #50 had orders for alcohol consumption. Those that self- medicate are identified. Record review revealed no resident self-medicate. Interview on 3/31/2024 at 4:56 PM, the DON stated that no residents self-administer medications. Those with Changes in Condition During an interview on 03/31/2024 at 04:25 the DON stated all the census had a potential for a change of condition for which all the staff had received in-services for nurses to recognize changes of condition, document, complete the sbar, notify the physician, and notify the don, the representative, the progress notes are auto to the 24-hr report which are reviewed the next morning during the department head meetings which in include the don and the administrator. Actions Taken: The Director of Nursing or designee began reeducation for all staff on the following: o Abuse and Neglect o Recognition of Change of Condition including those who are impaired to call physician upon their return to include suspected alcohol consumption. This was completed 3-29- 24 & 3-30-24. o Self-Administration of Medications. No residents currently at facility self-administer medications. o Smoking Policy including Paraphernalia o Policy for Resident Personal Possessions Re-education initiated 3/29/24 and completed on 3/30/24 with all staff. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment. A record review of the facility's employee roster dated, 03/31/2024 revealed 105 employees. 66% of employees, 69 of the 105, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/31/2024 revealed of the 105 employees, 34 were nurses. A sample of 23 nurses, 10 on the 6 am to 2 pm shift, 10 on the 2 pm to 10 pm shift, and 3 (of 3) on the 10 pm to 6 am shift, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/31/2024 revealed of the 105 employees 35 were CNAs. A sample of 24 CNAs, 11 on the 6 am to 2 pm shift, 7 on the 2 pm to 10 pm shift, and 6 on the 10 pm to 6 am shift, were interviewed to confirm receiving in-services for IJ F689. Record review of document titled In-service training report, dated 3/28/2024, with the topic Reportable Incidents, ANE Prevention, and Reporting revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/28/2024, with the topic Change in condition revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/2[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 24 Residents (Residents #15, #47 and #50) reviewed for safety, monitoring, and supervision. 1. The facility failed to monitor and supervise Resident #50's multiple incidents of drinking beer and receiving quetiapine (used to treat the symptoms of mental illness that caused disturbed or unusual thinking), Zolpidem (used to treat difficulty falling asleep or staying asleep; a class of medications called sedative-hypnotics) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain) with subsequent falls, possession of cigarettes and a personal lighter while assessed as a smoker who needed supervision. 2. The facility failed to monitor and supervise Resident #15's multiple incidents of drinking beer and receiving methadone with subsequent falls, possession of cigarettes and a personal lighter while assessed as an unsafe smoker who needed supervision. 3. The facility failed to monitor and supervise Resident #47's multiple incidents of Resident #47 allegedly drinking unprescribed alcohol and having extra Percocet's on hand. An Immediate Jeopardy (IJ) was identified on 03/29/2024. While the IJ was removed on 03/31/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for serious harm, accidents, or major injury. The findings included: 1. Resident #50 A record review on 03/30/2024 of the Texas Unified License Information Portal website for July 2023 to March 03/30/2024, accessed 03/30/2024, revealed no facility related report for Resident #50. A record review of Resident #50's admission record dated 03/27/2024 revealed an admission date of 04/22/2019 with diagnoses which included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), alcohol abuse, ataxia (Loss of coordination of voluntary muscle movements), nicotine dependence, dementia (A group of symptoms that affects memory, thinking and interferes with daily life) and malignant neoplasm of skin of nose (a cancer that can spread). A record review of Resident #50's admission MDS assessment, dated 01/17/2024, revealed Resident #50 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. Further review reveled resident #50 used a walker and needed set up or clean up assistance .supervision or touching assistance with ADL's. A record review of Resident #50's care plan dated 03/26/2024, revealed, (Resident #50) enjoys drinking beer and may have one 12 0z. beer as desired one time a day per MD order (Resident #50) is suspected of drinking while off facility premises when he signs himself out to go out on pass. Patent education unsuccessful Date Initiated: 02/09/2021 Revision on: 08/19/2023 .Administer beer as per MD orders Date Initiated: 02/09/2021; Beer to be kept in medication room refrigerator. Date Initiated: 02/09/2021; Resident must supply own beer Date Initiated: 02/09/2021 . further review revealed (Resident #50) is a smoker. (Resident #50) refused to sign the facility smoking policy. Educated resident of facility policy, still refused to sign (Resident #50) is non-compliant with facility policies, and smoking policies Date Initiated: 12/26/2018 Revision on: 05/10/2023 . The resident requires SUPERVISION while smoking. Date Initiated: 05/10/2023 .The resident's smoking supplies are stored in secure area behind the nurses station; Date Initiated: 12/26/2018; Revision on: 05/21/2021 . (Resident #50) has impaired cognitive function and impaired thought processes r/t Dementia Date Initiated: 03/21/2019 A record review of Resident #50's Nursing - Smoking Safety Screen dated 01/17/2024, signed by LVN R, revealed resident #50 needed supervision while smoking. A record review of Resident #50's physician's orders dated 03/27/2024 revealed resident #50 was prescribed quetiapine 500mg oral tablets by mouth at bedtime, 01:00 AM, for schizophrenia disorder; zolpidem 5mg by mouth at bedtime, 01:00 AM, for insomnia; and hydrocodone - acetaminophen 7.5mg/325mg by mouth 4 times a day (02:00 AM, 08:00 AM, 02:00 PM, and 08:00 PM, for pain in knees . Further review revealed resident #50 was also prescribed 1 12-ounce beer daily at 07:00 PM. A record review of resident #50's doctors progress note dated 08/15/2023 revealed Dr. S documented resident 50's HPI (History of Present Illness), [AGE] year-old white male at facility for long term care, seen today for regulatory physician visit, and follow up of multiple complex medical issues. He has a past medical history of EtOH (alcohol) dependence, weakness with falls, COPD, . tobacco use disorder . he has a history of surreptitious (secret) EtOH (alcohol) use .assessment and plan .EtOH abuse: ongoing chronic intermittent issue. Is allowed a small agreed upon amount of beer A record review of Resident #50's medical record revealed nursing progress notes and medication administration documentation as follows: 08/18/2023 at 05:38 AM LVN Z documented Resident (#50) pulled bathroom light, aids reported patient was on the floor, in between bathroom and bed, facing up. Patient had a strong odor of alcohol. Nurse asked Resident if he has been drinking alcohol, patient answers yes, free beer, when nurse question where he received it from he did not answer and only states it was free beer patient vitals were taken upon arrival blood pressure 98/67, 96.8 temp (temperature), R (respirations) 18, 02% 95, patient refused full assessment, nurse was able to do a quick assessment, no skin tear, no redness noted to head, back, arms or legs. Patient denies pain, patient denies hitting his head, patient denies range of motion assessment, patient denies help too bed, CNA moved his [NAME] to his side and he was able to get up on his own. Patient denies neuro checks and further assessment. Resident was given his 12 AM, 1:00 AM, and 2:00 AM meds; at that time nurse did not notice any alcohol odor on him. The patient was hanging out in the front of the building and the back patio area with other residents this evening. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's August 2023 Medication Administration Record revealed LVN Z documented on 08/18/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:18 AM. 08/20/2023 at 02:07 AM LVN Y documented, Resident (#50) was found on the floor by the CNA. Resident (#50) awake and responsive. He was on the floor close to the restroom with walker by his feet. Resident unable to state what happened or how he fell. He kept repeating I'm OK Resident did report he was drinking outside. He had been back for less than an hour when found on floor. Vital signs within normal limits. No injury noted. No complaints of pain voiced. Resident (#50) was assisted up to his feet and he was able to use walker but needed staff to hold him up. He made it to the bed where he immediately fell asleep and started snoring. [NAME] and call bell within reach. Door left open to keep a lookout for him. No other complaints at this time. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's August 2023 Medication Administration Record revealed LVN Y documented on 08/20/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:01 AM. 09/02/2023 at 02:30 AM LVN A documented, Resident finally in bed. Slurs words. Resident does not smell like alcohol but behaving the same on days he is inebriated. Resident already had night meds and is drowsy. Blood pressure earlier tonight around 12:00 AM was 140/92. Blood pressure lower at this time. Will sometimes get up from laying position and has blood pressure drop and will have fall where he sits down. Gets up by himself. Assisted tonight. Still no injury noted. neuros within normal limits for him. Has range of movement in all extremities. No complaint of pain. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's September 2023 Medication Administration Record revealed LVN A documented on 09/02/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 12:52 AM. 09/12/2023 at 02:39 PM the Activities Director T documented, Resident (#50) was sitting on the patio at 1:30 PM (staff) let resident know it was not smoke break time yet. Resident replied angrily 'I am allowed to sit out here.' I walked out to the patio at 1:45, Resident asked if (staff) had told me to come. I saw a lighter tightly held in his right hand and he had a cigar (unlit) hidden behind the ashtray. Resident did not move the cigar or lighter until (staff) came out at 2:00 PM for smoke break, he then hid them quickly and accepted two more cigars from her. Further review revealed the note was also posted to the facility's 24-hour report. 10/01/2023 at 12:56 AM LVN A documented, Resident (#50) had recent fall outside and hit face. Has not complained of pain so far tonight. Gets scheduled pain med at night. Able to move all extremities. Uses rollator, ambulates. Had X-ray done recently of right ankle. No fractures, injury. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's October 2023 Medication Administration Record revealed LVN A documented on 10/01/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:16 AM. 10/02/2023 at 01:54 AM LVN A documented Resident (#50) had recent fall outside. CMA witnessed incident. resident did not hit head, had no injuries noted. neuros have been within normal limits for him. has had no complaint of pain. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's October 2023 Medication Administration Record revealed LVN A documented on 10/02/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:19 AM. 02/18/2024 11:59 AM the Administrator documented, Witnessed (Resident #50) smoking in smoking patio during a non-smoking time. Approached (Resident #50) and he stated, 'you caught me.' Discussed the importance of smoking during supervised smoking times only to prevent any injuries. Discussed he is not allowed to keep smoking materials on his person and all smoking materials are to be turned in at the end of each smoke break. (Resident #50) voiced understanding and stated he does not have any other smoking materials on his person. Asked where he obtained cigarette and how he lit it, he again denied having any smoking materials on his person. He states it won't happen again. (Resident #50) does sign himself out on pass frequently. Explained to (Resident #50) if he purchases smoking materials when out on pass, two turn in smoking materials to charge nurse. he voiced understanding. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 03/05/2024 at 12:35 AM LVN A documented Resident (#50) seen lowering himself to one knee outside on West. nurse from [NAME] witness resident lowering himself. nurse helped him back up. resident came back over to east. CNA from [NAME] came over to inform east nurse who went over looking for him. nurse on [NAME] informed nurse on east what occurred. resident without injury resident in room at this time. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/05/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/05/2024 06:50 PM LVN C documented, Resident (#50) did not wait for nurse on [NAME] side to escort for smoking break even after he was told not to be outside smoking on own will continue to assess. Further review revealed the note was also posted to the facility's 24-hour report. 03/18/2024 at 01:20 AM LVN A documented Resident (#50) reported to have fall outside at front of building, reported by CNA on [NAME] and another Resident. Resident then came back over to east on rollator and explained several times until he stated what occurred. Stated he was sitting on rollator, leaned over to put in code to get in front lobby area under carport, and rollator slipped out from behind him, he went down on one knee and caught himself with right arm on planter pot, had episode of dizziness, took a few deep breaths, got himself up and back on rollator. No injury noted, had on shoes. Went on down hall. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/18/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/19/2024 at 02:49 AM LVN A documented (Resident #50) had recent fall outside of building. no injury noted. no complaint of pain. neuros within normal limits. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/19/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/20/2024 at 11:19 PM LVN C documented had an assisted fall while walking through the doorway from smoking no injuries. Reported to (the physician group). Further review revealed the note was also posted to the facility's 24-hour report. 03/25/2024 05:39 PM the Administrator documented, Administrator made aware resident may have smoking materials on his person. Administrator visited with Resident #50. States he does not have any cigarettes but did give Administrator his lighter. Re-educated Resident #50 on importance of safety, turning in all smoking materials to charge nurse or any manager, and not keeping smoking materials on his person or room while in facility. resident voiced understanding. Administrator LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 2. Resident #15 A record review on 03/30/2024 of the Texas Unified License Information Portal website for July 2023 to March 03/30/2024, accessed 03/30/2024, revealed no facility related report for Resident #15. A record review of Resident #15's admission record dated 03/26/2024 revealed an admission date of 05/24/2019 with diagnoses which included alcoholic cirrhosis of liver (a condition in which your liver is scarred and permanently damaged), viral Hepatitis C (a virus that attacks the liver and leads to inflammation), and alcohol abuse. A record review of Resident #15's admission MDS assessment, dated 02/02/2024, revealed Resident #15 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. Further review reveled resident #50 used a wheelchair and needed set up or clean up assistance .supervision or touching assistance with the wheelchair. A record review of Resident #15's care plan dated 03/26/2024, revealed, (Resident #15) enjoys drinking beer and may have one 12 0z. beer as desired one time a day per MD order .beer to be kept in medication room refrigerator .(Resident #15) must provide own beer .(Resident #15) is a smoker. (Resident #15) is at times non-compliant with facility policies and smoking policy. (Resident #15) refused to sign the facility smoking policy . instruct resident about the facility policy on smoking; locations, times, safety concerns . the resident requires supervision while smoking . the resident smoking supplies are stored at the nurses station A record review of Resident #15's Nursing - Smoking Safety Screen dated 01/30/2024, signed by the MDS Nurse, revealed resident #15 could not safely use a lighter and needed supervision while smoking. A record review of Resident #15's physician's orders dated 03/27/2024 revealed resident #15 was prescribed cyclobenzaprine 10mg (a muscle relaxer) give every 8 hours, 12:00 AM, 08:00 AM, and 04:00 PM; methadone 5mg (a narcotic used to treat opioid use) give 1 tablet .every 8 hours, 07:00 AM, 3:00 PM, and 11:00 PM; Tylenol with codeine#3 (used to relieve mild to moderate pain. Codeine belongs to a class of medications called opiate (narcotic) analgesics), and 1 12-ounce beer at 07:00 PM. A record review of resident #15's Nurse Practitioner notes revealed NP B documented on 03/02/2024 at 06:09 PM, . patient (Resident #15) is a chronic methadone user. Staff reports that the patient checks himself out a few times a week and wheels himself to the bar down the street or to the convenience store and buys beer and sits outside and drinks beer. Staff reports administration is aware Further review revealed the note was also posted to the facility's 24-hour report. A record review of resident #15's medical record revealed nursing progress notes as follows: On 12/21/2023 at 12:15 AM RN U documented, Resident on cement sidewalk proximal to employee after hours door near the bushes. he is left side lying in front of his wheelchair. It is drizzling rain. Per another male resident, it began to rain and resident rounding the corner too fast and slid out of the wheelchair. The witness stated that he did not hit his head on the sidewalk. Resident was out on pass at the time. Further review revealed the note was also posted to the facility's 24-hour report. On 12/23/2023 at 10:57 PM RN U documented, Resident had slipped out of wheelchair outside while out on pass Further review revealed the note was also posted to the facility's 24-hour report. On 12/24/2023 at 11:20 PM LVN A documented, Resident (#15) had slipped out of wheelchair outside while out on pass. No injuries, neuros within normal limits for him. Alert and verbal. Has no complaint of any pain from falling out of wheelchair. Further review revealed the note was also posted to the facility's 24-hour report. 02/18/2024 at 12:05 PM the Administrator documented, Witnessed (Resident #15) smoking during a non-smoking time in patio. Upon approaching (Resident #15), he immediately put out the cigarette in ashtray. Discussed the importance of following smoking policy and supervised smoking to prevent any injuries. (Resident #15) frequently attempting to change the subject / topic; redirected conversation and he voiced understanding. (Resident #15) frequently goes out on pass and discussed turning in all smoking materials to charge nurse should he purchase any smoking materials while out on pass. He voiced understanding. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 03/05/2024 at 06:42 PM LVN C documented, Resident (#15) ask to have door unlocked so he could go outside I'll hit him know everyone is waiting on [NAME] nurse to take him that she will be here in a minute and he said no I can go outside whenever I want I said yes but not to smoke on your own he left and is smoking outside even after being told to wait for nurse from [NAME] side. Further review revealed the note was also posted to the facility's 24-hour report. 03/25/2024 at 06:28 PM the Administrator documented, Administrator made aware that (Resident #15) may have smoking materials on his person. Administrator, senior administrator, and RCS visited (Resident #15) in room. (Resident #15) initially denied having smoking materials. discussed concern for his safety and the safety of other residents. he was asked again if he had smoking materials at which time he produced 2 packs of cigarettes. he was asked if he had a lighter and he produced a lighter as well. read educated importance of turning in all smoking materials to the charge nurse or any manager. (Resident #15) does go out on pass and he was educated on turning in smoking material if he purchases and brings back smoking materials to the facility. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 1. and 2. Residents #50 and #15 During an observation on 03/25/2024 at 02:24 PM revealed Resident #50 and resident #15 seated outside in the designated smoking patio. The facility's Activities Assistant was in control of a large yellow metal cabinet on wheels which contained the facility Residents smoking materials, for example, cigarettes, and lighters. Resident #50 and Resident #15 were observed seated at a patio table. Resident #50 and Resident #15 were observed to each reach into their pockets and produce cigarettes and personal lighters. Resident #50 proceeded to light and begin to smoke a cigarette. Resident #15 was observed to place a cigarette in his mouth but held his lighter in his hand. The Activities Assistant presented resident #50 with an additional 2 cigarettes and did not offer to light Resident #50's cigarette because it was already lit. The Activities Assistant presented Resident #15 with an additional 2 cigarettes and used her lighter to ignite resident #15's cigarette. During an interview on 03/25/2024 at 02:40 PM the Activities Assistant V stated Resident #50 had his lighter and cigarettes in his possession and did not light Resident #50's cigarette because it was already lit. The Activities Assistant stated she did light Resident #15's cigarette and gave him an additional 2 cigarettes. The Activities Assistant V stated resident #50 and Resident #15 did have their cigarettes and lighters on their person and have a history of going out and purchasing their cigarettes and lighters. The Activities Assistant V stated the practice of keeping cigarettes and lighters was against facility policy and would report the incident to the Activities Director. During an interview on 03/26/2024 at 04:55 PM LVN C stated Residents #50 and #15 were often smoking unsupervised. LVN C stated Residents #15 and #50 had a history of signing themselves out every evening around 6 to 7 PM and would return around 11PM to midnight. LVN C stated Residents #15 and #50 had a history of smelling like beer because they had an order for beer. LVN C stated she had often signed resident #50's and resident #15's medication administration record for the order to administer the beer even though the facility kept no beer for the residents, we don't have beer here .they sign themselves out and maybe buy beer .I don't know what they do when they sign themselves out. LVN C stated she had verbally told the leadership of the resident's routine but could not elaborate details of the reports. LVN C stated she had not documented any incident reports or reports to the physicians. During an interview on 03/28/2024 at 03:00 PM LVN C stated for Residents #15 and #50 she often signed the medication administration record for the order to administer the beer without administering the beer. LVN C she did not report Residents #15 and #50 might be drinking off the premises and if they smell like beer it is because they have an order for beer. During an interview on 03/31/2024 at 02:43 PM LVN A stated she worked the 10PM to 6AM shift on the hall for Residents #50 and #15. LVN A stated Residents #50 and #15 had a history of signing themselves out and leaving the facility on the shift before she arrived. LVN A stated Residents #50 and #15 would return back to the facility usually around 11PM to midnight. LVN A stated Residents #50 and #15 would sometimes return to the facility smelling like alcohol and then would be administered their scheduled quetiapine; zolpidem; and hydrocodone. LVN A stated Residents #50 and #15 had a history of falling around these times, from midnight to 2AM. LVN A stated she had documented the episodes of falls with the suspicion of Residents #50 and #15 drinking alcohol while away from the facility. Interviews by leadership for residents #15, and #50: During an interview on 03/28/2024 at 10:48 AM, NP B stated she worked for the Medical Director and had been calling upon the facility since August 2023. NP B stated Residents #15 and #50 had a history of signing out at 6:00 PM and returning at midnight and falling. NP B stated, prior to February 2024, she had not received report that residents had returned from being out on pass and had fallen while smelling like beer. NP B stated she spoke to the Administrator and the Medical Director and said the Administrator and the DON knew of the allegation of alcohol abuse off property as evidenced by the progress notes and care plans. During an interview on 03/28/24 at 11:14 PM the DON stated the incidents for Residents #15 and #50 were documented as falls and not connected to the use of alcohol while out on pass and the few incidents where nurses documented alcohol were in August and September 2023 when she first started and did not understand Resident #15 and #50's routines. The DON stated she was unaware the facility had no beer to administer to residents #15 and #50. The DON stated she was unaware Nurses were signing the MAR as if they were administering the beer without administering the Beer. The DON stated she interviewed the Nurses who had documented as such, and they reported to her they believed they were documenting the residents were receiving beer while out on pass. The DON stated she was not informed by NP B or any of her nursing staff the suspicion Residents were drinking alcohol. The DON stated the notes regarding unsupervised smoking and possession of lighters were reviewed by the Administrator and herself. The DON stated the Administrator wrote some of those progress notes. The DON stated she had expectations the Administrator would have reported those incidents to the state agency and investigated those incidents for safety reasons. 3. Resident #47 A record review of Resident #47's admission record revealed an initial admission date of 06/28/2018 with diagnoses which included cirrhosis of the liver (degenerative disease of the liver resulting in scarring and liver failure), major depressive disorder, cognitive communication deficit (difficulty with communication that has an underly cause in a cognitive deficit), unsteadiness of feet, anxiety disorder, and age-related physical debility (physical weakness). A record review of Resident #47's annual MDS assessment dated [DATE] revealed Resident #47 had a BIMS of 15 out of 15 indicating intact cognition. A record review of Resident #47's care plan, undated, revealed the following: [Resident #47] has liver disease r/t cirrhosis with interventions that included Give medications as ordered, date initiated 12/18/2018. A record review of Resident #47's Order Summary report revealed no orders for alcohol consumption and Percocet Tablet 10-325 MG (oxycodone-acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain **Administer medication with a full glass of water**. A record review of TULIP on 03/27/2024 revealed an intake on 01/11/2024, reported by an anonymous complainant, revealed My second concern is a situation where a resident #47 is reported for having empty liquor bottles in her room and is known. To be pocketing her Percocet and trading them with a visitor for the liquor. There were no intakes in TULIP reported by the facility from December 2023 to present day involving Resident #47. A record review of Resident #47's nursing note, dated 02/03/2024 at 09:50 PM and authored by LVN AI, revealed, Dayshift CNA notified nurses resident was on the floor after falling. Oncoming nurse entered room to find resident lying on her back sideways across bed. CNA notified nurse patient was assisted back into bed. Resident was assisted with proper repositioning on bed. Appears groggy and eyes with glossy appearance. Disoriented. Laughing when asked what happened and how she fell. CNA answered she slipped on her shoes. Resident stated, yeah I sure did slip on my shoes. Speech slurred. Strong smell of alcohol. Off going nurse in room for verification of this. Bed low, call light in reach. Resident educated on fall precautions and importance of not getting OOB by herself. Encouraged her to call for any assistance needed. Also encouraged use of RW with ambulation. [DON] was notified of unwitnessed fall and patient current symptoms/condition. Attempted to call on call NP/MD for [MD AH] but not able to reach on call. 72-hour neuro checks initiated. A record review of Resident #47's Doctor's Progress Note, dated 02/08/2024 and signed by MD AH, revealed, [Resident #47 had a fall secondary to being inebriated. They state that the family member of another resident is trading gin and alcohol for her percocets. They have tried to stop this. They are aware of the situation and are looking into it . They have searched her room and are trying to get rid of her alcohol. She is allowed to have some wine at night but not to have gin being the hard alcohol and get inebriated. A record review of Resident #47's nursing note, dated 03/20/2024 at 01:15 PM and authored by LVN D, revealed, Several pills found under and next to residents wheelchair, some pills wrapped in Kleenex appearing slightly dissolved. Pills with identifying numbers verified with pills in card of Percocet. [Doctor's group] called and message left requesting a return call. All supervisors notified. During an interview on 03/28/24 at 09:39 AM, Confidential Staff Member AF revealed Resident #47 had an incident where she dropped percocets in a public area. This was reported to her supervisors. She further revealed she made Resident #47 take her medications nurse's desk so the medications dissolve by the time she goes to her room. During an interview on 03/28/24 at 10:48 AM, NP B revealed she was unaware of what family is providing gin to Resident #47. NP B further revealed this incident could have potential for death due to polypharmacy and possible consequences could include sedation, falls, and injuries. During an interview on 03/28/24 at 12:26 PM the DON stated she and the department heads, including the Administrator, every weekday morning reviewed the previous days documents for all residents to include incident reports, grievance reports, 24-hour reports and all progress notes to include physician and nurse practitioner notes. During an interview on 03/28/24 at 12:38 PM The administrator was asked if she could share some details about Residents #15, #50, and #57; the Administrator stated she did not know much about them. The Administrator was asked how the facility supported Resident's #15 and#50 in purchasing and storing the beer ordered by the physician, the Administrator replied she was not aware how the support occurred or if nursing staff were signing the be[TRUNCATED]