Every finding on record at Roman Eagle Rehabilitation and Health Care Center

Based on observations, interviews, and document review, the facility staff failed to ensure two (2) common bathrooms were equipped with a call system. These two (2) bathrooms were located near the lobby area of the facility; one had a sign reading MEN and the other had a sign reading WOMEN. The findings include: On 3/6/23 at 3:10 p.m., it was observed that a common bathroom with a sign reading MEN was not equipped with a call system. This bathroom was unlocked and accessible to residents, staff, and visitors. This bathroom was able to be locked from the inside. On 3/6/23 at 4:19 p.m., it was observed that a common bathroom with a sign reading WOMEN was not equipped with a call system. This bathroom was unlocked and accessible to residents, staff, and visitors. This bathroom was able to be locked from the inside. On 3/7/23 at 4:49 p.m., the survey team met with the facility's Administrator, Assistant Administrator, DON, and Quality Assurance Coordinator (QAC). The two (2) common bathrooms, which were not equipped with a call system, was discussed. The two (2) bathrooms had been locked and closed, by facility staff members, while the facility staff decided how to address the issue with no call system. On 3/8/23 at 8:02 a.m., the Director of Nursing (DON) provided a policy which addressed responding to resident call system/lights; the DON reported the facility did not have a policy that addressed the location of call system/lights.

Based on observation, staff interview, clinical record review, facility document review and during a medication pass and pour the facility staff failed to ensure 1 of 38 residents was free from significant medication errors, Resident #140. The findings included: For Resident #140 the facility staff crushed and administered the non-crushable medication potassium chloride (KCl). Resident #140's face sheet listed diagnoses including but not limited to hypokalemia, hypertension, and anxiety. Resident #140's most recent minimum data set with an assessment reference date of 01/25/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Surveyor observed licensed practical nurse (LPN) #2 administer medications to Resident #140 during a medication pass and pour on 03/07/23 at 8:20 am. LPN #2 prepared Resident #140's medications, including a 20 mEq (milliequivalent) KCl tablet, crushing all medications together, placing them all together in ice cream and then administering them to Resident #140. Resident #140's medications were reconciled with the clinical record on 03/07/23 at 9:15 am. Resident #140's clinical record contained a physician's order summary for the month of March 2023 which read in part Potassium CL (chloride) ER (extended release) 20 MEQ (milliequivalent)-One tablet PO (by mouth) daily for supplement. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part Time-release and enteric coated medications should not be crushed. Contact Pharmacist to determine if alternative available. Specific order from physician for alternative or crush medications must be obtained. Surveyor spoke with the staff development coordinator (SCD) and director of nursing (DON) on 03/07/23 at 10:30 am. Surveyor asked SDC and DON if the medication KCl should have been crushed, and DON stated the facility has a list of non-crushable medications, and they would check with pharmacy for clarification. SDC provided surveyor with a copy of a list of Meds That Should Not Be Crushed on 03/07/23 at 10:45 am and stated to surveyor that the KCl should not have been crushed per the list and facility pharmacy. Surveyor reviewed the list, and it contained the medication KCl. The concern of the facility staff crushing a non-crushable medication was discussed with the administrator, assistant administrator DON, and quality assurance nurse on 03/07/23 at 4:45 pm. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and during a medication pass and pour the facility staff failed to follow established infection control guidelines. The findings included: For one of 9 medication carts, the facility staff left ice cream and ginger ale open/uncovered on top of medication cart. Medication cart was soiled. On 03/07/23, during a medication pass and pour observation, surveyor observed an opened, uncovered cup of ice cream on top of the medication cart. Surveyor also observed an opened bottle of ginger ale, used pill crusher cups, and a white powder-like substance on top of the medication cart. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part,2. Technique I. CART PROPERLY CLEANED-Cart surfaces and medication containers kept clean. Spills wiped immediately and the cart cleaned before and after the med pass. 4. Other E. Infection Control/Aseptic Technique-Juice/applesauce covered? The concern of facility staff not following infection control guidelines was discussed with the administrator, assistant administrator DON, and quality assurance nurse on 03/07/23 at 4:45 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 38 residents, Resident #389 and #110. The findings included: 1. For Resident #389, the facility nursing staff failed to accurately document in the clinical record for the medication Xanax. Resident #389's diagnoses included, but were not limited to, generalized anxiety disorder and major depressive disorder. There was no completed minimum data set (MDS) assessment for this resident. Resident #389's clinical record included an order for Xanax 0.5 mg by mouth three times a day for generalized anxiety disorder. The administration times on the medication administration record were documented as 8:00 a.m., 2:00 p.m., and 8:00 p.m. On 03/03/23 5:28 p.m., Registered Nurse (RN) #2 documented Xanax scheduled for 03/03/23 at 2:00 p.m. not available. 03/07/23 11:37 a.m., RN #2 stated they took over the hall this resident resided on at 2:45 p.m. and did not give any Xanax to this resident as the medication was scheduled at 2:00 p.m. After reviewing their documentation RN #2 stated they began administering medications at 4:00 p.m. and they had documented the Xanax was not available in error. 03/07/23 12:06 p.m., RN #3 stated we moved all the patients to another hall, a family member was in the room, Resident #389 was becoming frustrated stated don't even worry about it and they had forgot to document that the resident refused. 03/07/23 3:00 p.m., the facility staff provided the surveyor with a copy of their policy titled, DOCUMENTATION OF NURSING CARE. This policy read in part, It is the policy of this facility to keep an accurate record of each resident's care .Documentation must be pertinent, concise, reflect the resident's status and include nursing interventions and resident responses . 03/07/23 4:45 p.m., the Administrator, Director of Nursing, Assistant Administrator, and Quality Assurance Nurse were made aware of the issue regarding the documentation of Resident #389's Xanax on 03/03/23. No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 2. For Resident #110 the facility staff failed to document medication refusals. Resident #110's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, chronic kidney disease and depression. Resident #110's most recent minimum data set with an assessment reference date of 01/14/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part Novolog 100 unit/ml vial-Give 8 units sq (subcutaneously) with meals for DM (diabetes mellitus) Resident #110's electronic medication administration record (eMAR) for the month of March 2023 was reviewed and contained an entry as above. This entry was coded N on 03/02/23 at 12:00 pm. Per the eMAR, chart code N equates not administered. The administration notes section of the eMAR contained an entry which read in part, 11:22AM, 3/02/23 (Scheduled: 12:00PM, 3/02/23; Novolog 100 unit/ml vial) Novolog 100 unit/ml vial-give 8 units S . scheduled for 03/02/2023 12:00PM.accuchec 113 // 03/02/2023 11:22 AM. This entry was electronically signed by licensed practical nurse (LPN) #3. Surveyor spoke with LPN #3 on 03/07/23 at 1:35 pm. Surveyor asked LPN #3 why they had not administered Resident #110's insulin on 03/02/23 at 12:00 pm, and LPN #3 stated that resident's blood sugar was outside of parameters for sliding scale insulin administration. Surveyor then had LPN #3 read resident's insulin order and pointed out that resident is not on sliding scale insulin. LPN #3 then stated that resident refused insulin, and they had just forgotten to chart the refusal. During review of Resident #110's clinical record, several instances of medication refusals were documented. The concern of the facility staff failing to document a medication refusal was discussed with the administrator, assistant administrator DON, and quality assurance nurse on 03/07/23 at 4:45 pm. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and during a medication pass and pour the facility staff failed to ensure medications were stored in a secure manner for 1 of 9 medication carts. The findings included: Facility staff failed to secure medications during a medication pass and pour. Surveyor observed licensed practical nurse (LPN) #2 on 03/07/23 during a medication pass and pour. LPN #2 removed a medication bin from the medication cart, placed it on top of the medication cart and prepared resident's medication. After preparing medication, LPN #2 entered resident's room, leaving the medication bin on top of the medication cart, and leaving cart unlocked. Upon returning to the cart, LPN #2 replaced the bin in the cart. Surveyor asked LPN #2 if they normally left the bin on top of the cart, and LPN #2 stated they did not and Can you tell I'm a little nervous? Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, 4. Other A. Security of cart and med room/privacy-Medicine refrigerator, cabinets, and med cart locked when the nurse's back is turned or leaved the cart. The concern of failing to secure medications was discussed with the administrator, assistant administrator DON, and quality assurance nurse on 03/07/23 at 4:45 pm. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and during a medication pass and pour the facility staff failed to follow professional standards of practice for the administration of medications. The findings included: During a medication pass and pour observation, the facility staff crushed medications and administered together for 2 of 6 Residents, Resident #140, and Resident #77 Surveyor observed licensed practical nurse (LPN) #2 on 03/07/23 during a medication pass and pour at 8:20 am. LPN #2 prepared medications (4 medications) for Resident #140, crushing all medications together, placing in ice cream and administering together. LPN #2 them prepared medications (7 medications) for Resident #7, crushing all medications together, placing in ice cream and administering together. Surveyor requested and was provided with a facility policy entitled Medication Administration, which read in part C.Crushed medications must be given one at a time, oral or via peg tube. Surveyor spoke with staff development coordinator (SDC) and director of nursing (DON) on 03/07/23 regarding the combined crushing/administering of the medications on 03/07/23 at 10:30 am. The concern of not following professional standards of practice was discussed with the administrator, assistant administrator, DON, and quality assurance nurse on 03/07/23 at 4:45 pm. No further information was provided prior to exit.

Based on staff interviews, clinical record review, facility document review, and during a medication pass and pour observation, it was determined the facility staff failed to provide services to meet professional standards of practice for one (1) of four (4) residents observed during the Medication Administration Facility Task, (Resident #119). The findings included: A facility staff member, LPN (licensed practical nurse) #21, documented they had provided Resident #119 with two (2) medications that had not been administered. Resident #119's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/18/21, was documented as completed on 11/1/21. Resident #119 was coded as being able to make them self understood and as able to understand others. Resident #119's Brief Interview for Mental Status (BIMS) summary score was coded as 12 out of 15 (this indicated intact/borderline cognition). Resident #119 was coded as requiring limited assistance with bed mobility, transfers, eating, and personal hygiene. Resident #119's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/1/21 at 7:49 a.m., LPN #21 was observed to prepare and administer medications to Resident #119. During the observation LPN #21 was not observed administering Resident #119's nasal spray and topical pain medication. Both the nasal spray and the topical pain medication were scheduled to be administered at 8:00 a.m. Resident #119's clinical record included the following current medical provider orders: - An order dated 10/8/19 for [MEDICATION(S)] 1% GEL; APPLY 2GMS TOPICALLY TO RIGHT SHOULDER (four times a day) FOR PAIN and - An order dated 4/16/19 for SALINE 0.65% NASAL SPRAY, ADMINISTER 2 SPRAYS EACH NOSTRIL (twice a day) FOR ALLERGIES Resident #119's medication administration records (MARs) were reviewed on 12/1/21 at approximately 9:30 a.m. It was noted that LPN #21 had documented they had administered Resident #119's 8:00 a.m. doses of saline nasal spray and [MEDICATION(S)] topical pain medication. On 12/1/21 at 9:36 a.m., LPN #21 was interviewed about the documentation indicating they had administered Resident #119's saline nasal spray and [MEDICATION(S)] topical gel. LPN #21 confirmed they had not administered either medication to Resident #119. LPN #21 reviewed Resident #119's MARs and reported both the saline nasal spray and [MEDICATION(S)] gel had been documented as being administered. LPN #21 reported they should not have documented those medications had been administered. LPN #21 obtained Resident #119's nasal spray from the medication cart and reported they would administer the nasal spray now. LPN #21 stated they had planned to wait until after the resident was bathed to administer the topical pain medication. The following information was found in Pharmacology for Nurses: A Pathophysiologic Approach 3rd Edition (2011, page 21): Once medications are administered, the nurse must correctly document that they have been given to the patient and this documentation is completed only after the medications have been given, not when they are prepared. The following information was found in a facility policy/procedure titled MEDICATION ADMINISTRATION (this document did not contain a date): PREPARATION AND CHARTING . E. RECORD IMMEDIATELY. On 12/1/21 at 4:08 p.m., the Assistant Administrator reported the facility did not have a policy/procedure that specifically addressed medications not being documented as administered prior to actually being administered to the resident. The following information was found in a facility policy/procedure titled DOCUMENTATION OF NURSING CARE (this document did not contain a date): It is the policy of this facility to keep an accurate record of each resident's care, his/her condition and progress in the EMR (electronic medical record) . the MAR (medication administration record) must be signed electronically by the nurse giving medications or treatments. If not given, document the reason not given on the MAR. On 12/1/21 at 3:32 p.m., the Director of Nursing (DON) and Infection Preventionist (IP) was interviewed about the aforementioned MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported that medications should not be signed as given prior to the medications being administered to the residents.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinica record for one of 37 residents in the survey sample, Residents #77. A [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Section 2 had been left blank. The findings included: Resident #77's clinical record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of Resident #77's admission MDS (minimum data set) assessment with an (ARD) assessment reference date of [DATE] was coded [DATE] to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Resident #77's clinical record included a physicians order dated [DATE] that read, NO CPR. Resident #77's clinical record included a DDNR order form dated [DATE] from the Virginia Department of Health. This form read in part: Under section 1 I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Box 2 had been checked Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. [DATE] RN (registered nurse) supervisor #1 reviewed the clinical record with the surveyor and acknowledged section 2 of the residents DDNR was not complete. [DATE] 4:50 p.m., the DON (director of nursing) and QA (quality assurance) coordinator were notified of the incomplete DDNR form. No further information was provided to the survey team regarding the incomplete DDNR prior to the exit conference.

Based on observation and staff interview, the facility staff failed to ensure a narcotic medication (Lorazepam/[MEDICATION(S)]) was stored in a locked permanently affixed compartment on one of 7 units, East unit. The findings included: The medication refrigerator on the East unit included a narcotic box that was not permanently affixed. This narcotic box included 3 vials of the narcotic Lorazepam ([MEDICATION(S)]). Per the website https://www.dea.gov/drug-information/drug-scheduling .Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are .[MEDICATION(S)] . 11/30/21 12:30 p.m., the surveyor and RN (registered nurse) #2 checked the refrigerator on the East unit. RN #2 unlocked the refrigerator, pulled a locked brown metal tackle box from the refrigerator, and placed it on the counter in the medication room. RN #2 identified this box as containing the narcotic Lorazepam. The label attached to this box read, Lorazepam 2mg/ml. 12/01/21 9:52 a.m., in an interview with pharmacist #1, they stated they were just inspected by the pharmacy board and was not aware the box needed to be permanently affixed. Pharmacist #1 stated they would have maintenance attach the box to the refrigerator immediately. 12/01/21 9:58 a.m., pharmacist #1 stated the narcotic box contained 3-2mg/ml vials of Lorazepam. 12/01/21 1:05 p.m., the surveyor requested from the DON (director of nursing) a copy of their policy in regards to storage of narcotics. The facility did not provide any documentation in regards to securing the narcotic box. 12/01/21 4:50 p.m., the DON (director of nursing) and QA (quality assurance) coordinator were made aware of the issue regarding the unsecured narcotic box on the East unit. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interviews, clinical record review, facility document review, and during a medication pass and pour observation, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) errors in 27 opportunities for a medication error rate of 7.41%. These medication errors affected Resident #119. The findings included: LPN (licensed practical nurse) #21 failed to administer Resident #119's ordered SALINE 0.65% NASAL SPRAY (this nasal spray was ordered by a medical provider due to allergies). LPN #21 attempted to administer an incorrect dose of [MEDICATION(S)] injection to Resident #119. ([MEDICATION(S)] is a medication used to treat [CONDITION(S)] (MS).) Resident #119's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/18/21, was documented as completed on 11/1/21. Resident #119 was assessed as being able to make themself understood and as able to understand others. Resident #119's Brief Interview for Mental Status (BIMS) summary score was a 12 out of 15 (this indicated intact/borderline cognition). Resident #119 was assessed as requiring limited assistance with bed mobility, transfers, eating, and personal hygiene. Resident #119's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #119's clinical record included the following current orders: - An order dated 4/16/19 for SALINE 0.65% NASAL SPRAY, ADMINISTER 2 SPRAYS EACH NOSTRIL (twice a day) FOR ALLERGIES and - An order dated 12/14/19 for [MEDICATION(S)] 0.3 MG KIT: 0.25 MG (subcutaneous injection) ONE TIME A DAY EVERY MON, WED, AND FRI FOR MS (RECONSTITUTE MED WITH 1.2 ML OF 0.54 [MEDICATION(S)], INJECT 1 ML). On 12/1/21 at 7:49 a.m., LPN #21 was observed to prepare and administer medications to Resident #119. LPN #21 did not administer a nasal spray to Resident #119. Resident #119's medication administration records (MARs) were reviewed on 12/1/21 at approximately 9:30 a.m. It was noted that LPN #21 had documented they had administered Resident #119's nasal spray. On 12/1/21 at 9:36 a.m., LPN #21 was interviewed about the documentation indicating they had administered Resident #119's nasal spray. LPN #21 confirmed they had not administered nasal spray to Resident #119. LPN #21 reviewed Resident #119's MARs and confirmed the nasal spray had been documented as being administered. LPN #21 reported they should not have documented the nasal spray had been administered. LPN #21 obtained Resident #119's nasal spray from the medication cart and reported they would administer the nasal spray now. On 12/1/21 at 7:49 a.m., LPN #21 was observed to prepare Resident #119's [MEDICATION(S)] injection. LPN #21 reported they had withdrawn all the liquid from the [MEDICATION(S)] vial; LPN #21 stated all the liquid would be administered to the resident. Greater than 1 ml of liquid was noted in the syringe. This injectable medication was transported to Resident #119's bedside. The injection site was exposed and LPN #21 opened an alcohol prep to cleanse the site. LPN #21 was asked to step back into the hallway. LPN #21 was asked about the correct dose of the [MEDICATION(S)]. After reviewing Resident #119's medication orders, LPN #21 confirmed an incorrect dose the [MEDICATION(S)] had been drawn up. LPN #21 adjusted the amount of medication in the syringe prior to reentering Resident #119's room and administering the [MEDICATION(S)] injection. LPN #21 administered the [MEDICATION(S)] injection without removing the vial and the vial adapter from the syringe. On 12/1/21 at 9:45 a.m., a facility pharmacist (Pharmacist #1) was interviewed about the correct administration process for the [MEDICATION(S)] Injection; the facility's Director of Nursing (DON) and Infection Preventionist (IP) was present during this interview. Pharmacist #1 reported, when administering this dose of [MEDICATION(S)], the syringe should contain 1 ml of the medication to give the ordered 0.25 mg dose. Pharmacist #1 also reported that the vial should be removed from the syringe prior to administering the [MEDICATION(S)] to decrease the chance of the medication going back into the vial instead of being administered to the resident. The following information was found the [MEDICATION(S)] Full Prescribing Information and Medication Guide (this document had a copyright date of 1993): - Step 3: Preparing the Injection . Remove any air bubbles by tapping the outside of the syringe with your fingers. Slowly push the plunger to the 1 mL mark on the syringe or to the mark that matches the amount of [MEDICATION(S)] prescribed . Remove the vial adapter and the vial from the syringe by twisting the vial adapter. This will remove the vial adapter and the vial from the syringe, but will leave the needle on the syringe. - Step 5: Injecting [MEDICATION(S)] . Step 5 detailed the cleaning of the injection site and the administration of the [MEDICATION(S)]. The following information was found in a facility policy/procedure titled MEDICATION ADMINISTRATION (this document was not dated): TYPE OF MEDICATION ERRORS . B. OMITTED DOSE - scheduled dose not given within the proper time limit or not at all without documentation of legitimate reason . F. INCORRECT STRENGTH OF DOSE - mg, gram, gr., Units, ml, given p.o. or injected. [sic] The aforementioned medication errors, resulting in a medication error rate of 7.41%, was discussed with the facility's DON and IP on 12/1/21 at 4:52 p.m.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection control program designed to help prevent the development and transmission of communicable diseases and infections. The facility staff failed to follow the manufacturer's guidelines when obtaining rapid COVID-19 tests for two of two employees (Employee #1 and #2). The findings included: The facility staff failed to obtain COVID-19 rapid test samples per the manufactures instructions. The facility staff only sampled one nare when the instructions stated to use the same swab for both nares. The facility was using the BinaxNOW COVID-19 Ag Card test system. During the entrance conference on 10/14/2020 with RN (registered nurse) #1 and #2, these staff verbalized to the surveyor that they were doing the rapid COVID-19 testing. On 10/14/2020 at approximately 11:05 a.m., the surveyor observed RN #3 obtain a nasal swab sample from employee #1. After obtaining this sample and while it was processing the surveyor, RN #1, and RN #3 reviewed the manufacturer's instructions. Page 2 of these instructions read in part, .Nasal Swab Only the swab provided in the kit is to be used for nasal swab collection .carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible .Using the same swab, repeat sample collection in the other nostril . Page 1 included information to indicate what was provided with the test kits (40) nasal swabs were included for use with the BinaxNOW COVID-19 Ag Card test. RN #3 verbalized to the surveyor that they had only obtained a sample from employee #1's right nare and stated their facility policy stated to only use one nare. After reading the manufacturer's instructions RN #3 began the process of obtaining a nasal swab sample from employee #2. RN #3 was observed to obtain a sample from employee #2's right nare only. RN #1 asked RN #3 if they had obtained the nasal sample from employee #2 from both nares. RN #1 verbalized that they had not. The facility provided the surveyor with a copy of their policy titled, COVID-19 Infectious Disease. This document read in part, COVID-19 Testing for Staff and Residents .Steps for collecting a COVID-19 nasopharyngeal Specimen .It is not necessary to collect specimen from other nare if the tip of the swab is fully saturated from first nare. Place swab into [MEDICAL CONDITION] transport medium .send to lab . This document did not include a date. The surveyor observed RN #3 obtain two rapid test samples that were processed onsite and not sent to the lab. The facility also provided the surveyor with a copy of document from the CDC (centers for disease control and prevention). The facility staff had highlighted the following statement for a NP (nasopharyngeal) sample.Specimens can be collected from both sides using the same swab, but it is not necessary to collect specimens from both sides if the minitip is saturated with fluid from the first collection . This document also included the following information that had not be highlighted by the facility staff, .Anterior nares specimen .insert the swab at least 1 cm (0.5 inch) inside the nostril .Sample both nostrils with same swab . On 10/15/2020 at 4:00 p.m., during an interview with RN #1 and #2. RN #1 verbalized to the surveyor that they had spoken with RN #3 yesterday and instructed them to swab both nares when obtaining the COVID-19 samples. During an interview with RN #3 on 10/16/2020 at 12:40 p.m., RN #3 was asked the difference between a nasal swab and a nasopharyngeal swab. RN #3 verbalized that the nasal swab was thinner. RN #3 verbalized to the surveyor that they had used the swabs that were packaged with the rapid test kit when obtaining the samples and they had been obtaining samples from both nares until last Monday. RN #3 then added if they did not obtain an adequate amount of mucus, they would swab the other nare unless the person had a medical reason such as a deviated septum. RN #3 stated they were obtaining samples from both nares now. The surveyor accessed the website https://www.fda.gov/media/ 8/download on 10/16/2020. This website included information regarding the BinaxNOW COVID-19 Ag Card. The document was dated August 26, 2020 and was titled, FACT SHEET FOR HEALTHCARE PROVIDERS.This test is to be performed only using nasal swab specimens collected from individuals who are suspected of COVID-19 by their healthcare provider within the first seven days of the onset of symptoms .The BinaxNOW COVID-19 Ag Card can be used to test nasal swab samples directly using a dual nares collection (swab inserted in both nares) . Both IPs (infection preventionists) were out during the time of the survey and were not interviewed. No further information regarding this issue was provided to the surveyor prior to the exit conference on 10/16/20.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. The findings included: The facility staff failed to ensure that 4 male facility staff members hair was secured while working in the facility kitchen. On 10/31/18 at 11:25 am, the surveyor observed a facility maintenance employee working on electrical outlet in the facility kitchen. The surveyor observed that the maintenance employee's hair and facial hair was not secured with a hair net or beard guard. The surveyor also observed Dietary Staff # 1 and Dietary Staff # 2 wearing beard guards, however, their mustaches were uncovered. Dietary Staff # 3 was observed to have a mustache and was not wearing a beard guard to keep facial hair contained. On 10/31/18 at 11:50 am, the surveyor spoke with the dietary services manager about the males in the kitchen hair not being properly secured. The dietary services manager agreed that the facility maintenance employee and dietary staff # 1. # 2, and # 3's hair was not secured properly and advised each person to correct the issues at that time. The facility policy on Personnel Standards contained documentation that included but was not limited to: .2. The following standards have been adopted by the dietary department: a. Hair nets, covering all of the hair, must be worn at all times while on duty. On 10/31/18 at 2:50 pm, the director of nursing and quality assurance coordinator was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/2/18.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to store and date medications when opened on 5 of the 7 units. The findings included: 1. The facility staff failed to date medications when opened and failed to remove expired medications from the medication refrigerators on South Terrace and Garden Terrace for 4 residents (Resident #106, Resident #18, Resident #280, and Resident #136). (a) The surveyor observed the medication refrigerator on South Terrace with licensed practical nurse #2 on 10/30/18 at 4:09 p.m. In the refrigerator was [MEDICATION NAME]flex pen for Resident #106. The [MEDICATION NAME] flex pen had been opened 9/27/18 and the expiration date was 10/25/18. The surveyor asked L.P.N. #2 what the protocol was for insulins that had expired. L.P.N. #2 stated the pharmacy needed to be called so a new flex pen could be used. Resident #106's clinical record was reviewed 10/30/18 through 11/2/18. Resident #106 was admitted to the facility 9/6/14 with [DIAGNOSES REDACTED]. Resident #106's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/27/18 assessed the resident with a brief interview for mental status (BIMS) as 00. Resident #106's current comprehensive care plan identified a care plan description dated 11/3/16 that read in part Resident #106 needs enteral nutrition with a therapeutic TF (tube feeding) formula d/t (due to) dysphagia, [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]), NPO (nothing by mouth), [MEDICAL CONDITIONS],[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease),[MEDICAL CONDITION](hypertension), DM II (diabetes mellitus type 2), [MEDICAL CONDITION]. Care plan goal: Will maintain blood glucose levels < (less than) 250 mg/dl (milligrams/deciliter) consistently. Interventions: Monitor for s/s (signs/symptoms) of hypo/[MEDICAL CONDITION]. Checks blood glucose levels as ordered. Administer nutrition related medications as ordered. Resident #106's (MONTH) (YEAR) physician orders [REDACTED].=No med, 251-300=6 units, 301-350=10 units, 351-400=15 units, 401 and over=20 units and notify MD (medical doctor). Start Date: 1/15/17. A review of the (MONTH) (YEAR) electronic medication administration records indicated Resident #106 received [MEDICATION NAME] sliding scale insulin three (3) times on 10/26/18, three times on 10/27/18, three times on 10/28/18, three times on 10/29/18, and one time on 10/30/18. (b) The facility staff failed to date insulin flex pens for Resident #18 when opened. The surveyor reviewed the refrigerator on South Terrace with licensed practical nurse #2 on 10/30/18 at 4:09 p.m. In the refrigerator, the surveyor observed two (2) Tresiba flex touch pens for Resident #18. The flex touch pens did not have a date when opened and were dispensed 10/23/18. Resident #18 also had a flex pen for Trulicity 0.75 mcg (micrograms). The pen had been dispensed 10/30/18. There was not a date when the pen had been opened. L.P.N. #2 stated Resident #18 had received Trulicity 0.75 mcg on 10/30/18. Resident #18 was admitted to the facility 11/12/14 with diagnoses, that included but not limited to [MEDICAL CONDITIONS], chronic venous hypertension with ulcer of left lower extremity, major [MEDICAL CONDITION], obesity, type 2 diabetes mellitus, hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #18's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/16/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #18's current comprehensive care plan identified the care plan description for Diabetes Mellitus start date 5/8/17. Interventions: Obtain blood sugars as ordered. Administer insulin as ordered. Administer Trulicity as ordered. The (MONTH) (YEAR) physician's orders [REDACTED].#18's orders read Tresiba Flex touch 100 units/ml-give 55 units-sq (subcutaneous) bid (twice a day) for DM and Trulicity 1.5 mg/0.5 ml pen-Give sq q (every) week d/t (due to) DM. (c) The facility staff failed to date an opened [MEDICATION NAME]pen for Resident #280. The surveyor checked the medication carts and refrigerator on Garden Terrace with licensed practical nurse #3 on 10/30/18 at 4:41 p.m. The medication refrigerator had [MEDICATION NAME] sliding scale insulin belonging to Resident #280. The [MEDICATION NAME]did not have a date when opened. The [MEDICATION NAME] flex pen had been dispensed 10/11/8. L.P.N. #3 stated, Supposed to date when opened when it comes from the pharmacy. Will have to get rid of them and pharmacy will have to replace them. Resident #280 was admitted to the facility 4/4/18 with diagnoses, that included but not limited to Type 2 diabetes mellitus, [MEDICAL CONDITION] reflux disease, hearing loss, and visual loss. Resident #280's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/10/18 assessed the resident with a brief interview for mental status as 3 out of 15. Current comprehensive care plan titled Routine Maintenance Care included the intervention for accuchecks as ordered- and administer insulin as ordered-started 4/5/18. Resident #280's (MONTH) (YEAR) physician's orders [REDACTED]. Novalog (sic) 100 unit/ml vial per SS (sliding scale); 0-60 Notify MD 61-250=adm (administer) no med (medication), 251-300-6 units, 301-350-10 units, 351-400-15 units, 401-500-20 units, > (greater than) 500 notify MD. [MEDICATION NAME] sliding scale had been administered twenty seven times from 10/11/18 through 10/30/18 to Resident #280. (d) The facility staff failed to date insulin when opened for Resident #136. The surveyor checked the medication refrigerator on Garden Terrace on 10/30/18 at 4:41 p.m. with licensed practical nurse #3. In the refrigerator was a [MEDICATION NAME] SSI (sliding scale insulin) pen labeled for Resident #136. The [MEDICATION NAME]pen did not have a date when opened and had been dispensed on 10/11/8. L.P.N. #3 stated, Supposed to date when opened when it comes from the pharmacy. Will have to get rid of them and pharmacy will have to replace them. Resident #136 was admitted to the facility 3/27/15 and readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #136's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/6/18 assessed the resident with a brief interview for mental status (BIMS) of 14/15. Resident #136's current comprehensive care plan identified that the resident needs a therapeutic diet with DM II (diabetes mellitus) type 2. Care plan goal: Blood glucose levels will remain below 250 mg/dl (milligrams/deciliter) consistently. Interventions: Treat elevated blood sugar levels with sliding scale insulin, as ordered. Resident #136's (MONTH) (YEAR) physicians orders read Accucheck ac meal (before meal) & HS (and at bedtime), [MEDICATION NAME] 100 unit/ml vial per SS (sliding scale): 0-60 Notify MD 61-250=Adm (administer) No med (medication), 251-300=6 u, 301-350=10 u, 351-400=15 u, 401-500=20 u, > (greater than) 500 Notify MD (medical doctor). The surveyor reviewed the (MONTH) (YEAR) electronic medication administration records. Resident #136 received [MEDICATION NAME] sliding scale insulin nineteen (19) times from 10/11/18 through 10/30/18. The surveyor informed the director of nursing and the quality assurance registered nurse of the above concerns during a meeting with the administrative staff on 10/31/18 at 2:40 p.m. The surveyor requested the facility policy on storage of medications, a list of when insulins expire and the policy for dating medications when opened. The DON stated the facility does not have a policy on dating medications when opened. The DON stated the pharmacy takes care of that. The surveyor reviewed the list of recommended insulin storage protocol on 11/2/18. Recommended expiration dates for [MEDICATION NAME] and [MEDICATION NAME] R (3-ml cartridges) was 28 days. Recommended expiration dates for [MEDICATION NAME] R (prefilled and 1.5 ml cartridges) was 30 days. No further information was provided prior to the exit conference on 11/2/18. 2. The facility staff failed to ensure that the narcotic box on the medication cart was locked on unit 5A and failed to ensure that nebulizer packages and inhalers were dated on the medication carts on unit 5A and 5B. On 10/31/18 at 9:14 am, the surveyor checked the medication cart on unit 5A with LPN # 2 (licensed practical nurse). While checking the medication cart, the surveyor was able to open the narcotic box on the medication cart without a key. LPN # 2 stated, I don't know why it's not locked. The surveyor also observed two packages of [MEDICATION NAME] and [MEDICATION NAME] Inhalation Solution that were opened and undated. The packages contained documentation that included but was not limited to: Once removed from the foil pouch, the individual vials should be used within two weeks. LPN # 2 reviewed the packages along with the surveyor and agreed that there were no open dates documented on the packages. The surveyor also observed an [MEDICATION NAME] Diskus that was in use and was undated. The manufacturer's package insert for the [MEDICATION NAME] Diskus contained documentation that included but was not limited to: Write the date you opened the foil pouch in the first blank line on the label. Write the use by date in the second blank line on the label. That date is one month after the date you wrote in the first line. LPN # 2 reviewed the [MEDICATION NAME] Diskus along with the surveyor and agreed that there were no open or use by dates documented on the [MEDICATION NAME] Diskus inhaler. On 10/31/18 at 9:26 am, the surveyor checked the medication cart on unit 5B along with RN # 2 (registered nurse). The surveyor observed two open packages of [MEDICATION NAME] and [MEDICATION NAME] Inhalation that were opened and undated. The packages contained documentation that included but was not limited to: Once removed from the foil pouch, the individual vials should be used within two weeks. RN # 2 reviewed the packages along with the surveyor and agreed that there were no open dates documented on the packages. The surveyor also observed a [MEDICATION NAME] Diskus that was in use and undated on the medication cart. The manufacturer's package insert contained documentation that included but was not limited to: Write the date you opened the foil pouch in the first blank line on the label. Write the use by date on the second blank line on the label. If you are using [MEDICATION NAME] Diskus 50 mcg (micrograms) that date is six weeks after the date you wrote on the first line. On 10/31/18 at 2:50 pm, the director of nursing and the quality assurance coordinator was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/2/18. 5. The facility staff failed to document the opened date on a medication and failed to discard an opened medication after the expiration date that were stored in the East wing medication refrigerator and failed to discard an opened vial of medication after the expiration date in the Mid-East wing medication refrigerator. On 10/31/18 at 10:06 am, the surveyor observed [MEDICATION NAME] Purified Protein (TB Test) 5 TU/0.1 ml 1 ml (10 tests) in the medication refrigerator on the East Wing. These TB test had an expiration date of 10/28/18 on them. The surveyor also observed at 10:09 am, Influenza Vaccine 5 ml (milliliter) multi use vial opened with no opened date documented on it. The surveyor showed these to RN (registered nurse) #1 and she stated, That vial of TB test should had been discarded by the expiration date and not left in the refrigerator and the flu vaccine should had been dated when the vial was opened and used for the first time. The surveyor went to the Mid-East medication refrigerator and at approximately 10:45 am observed a multi-use vial of [MEDICATION NAME] Purified Protein (TB Test) 5 TU/0.1 ml 1 ml (10 tests) documented on it with an opened date of 8/27/18 and the expiration date of 9/27/18. The surveyor showed this to RN #1 at the time it was observed by the surveyor. RN #1 stated, That should had been discarded by staff when the staff checks it and saw that it was expired on 9/27/18 and not left in there until now. The surveyor notified the director of nursing and QA (quality assurance) nurse of the above documented findings on 10/31/18 at 2:15 pm. No further information was provided to the surveyor prior to the exit conference on 11/2/18.

Based on staff interviews and clinical record reviews, the facility staff failed to identify discrepancies on the narcotic sheets involving residents on 7 of 8 nursing units in the facility. (South Wing, East Wing, Mid-East Wing, Rehab Wing, South Terrace, Garden Terrace and North Terrace) 1. The staff pharmacist failed to identify discrepancies on the monthly drug regimen review for the residents on South Wing, East Wing, Mid-East Wing and the Rehab Wing. Resident #161 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/11/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #161 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. The surveyor conducted a clinical record review on 10/31 thru 11/2/18 on Resident #161. During this review, the surveyor reviewed the narcotic sheet for the [MEDICATION NAME] that Resident #161 was receiving. On the narcotic sheet, it had Resident #161's name on it along with the following physician ordered medication, [MEDICATION NAME] 12 mcg/hr. (micrograms/hour) patch Apply 1 patch [MEDICATION NAME] every 72 hours for pain. Apply with 25 mcg patch to total 37 mcg/hr. This narcotic sheet had the following documentation of dates and times of other resident's being administrated the narcotic patch from Resident #161's narcotic record: · 10/27/18 at 8 am, Resident #18 received one [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. · 10/30/18 at 8 am, Resident #18 received 1 [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. Upon the surveyor discovering the sharing of the above documented narcotic on 11/1/18 at approximately 2:30 pm, the surveyor reviewed all the narcotic sheets on the South Wing, East Wing, Mid-East Wing and the Rehab nursing units and the following was discovered: A. Resident #19 had a narcotic sheet for [MEDICATION NAME] 5-325 mg (milligram) tablets and on 10/16/18 at 3:15 pm, Resident #238 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet. Resident #238 had a physician order [REDACTED]. B. Resident #90 had a narcotic sheet for [MEDICATION NAME] 5 mg tablets in which Resident #316 had been administrated 1 tablet on 2/27/18 at 4:00 pm and again on 2/28/18 at 6:15 pm but on this date and time the resident was given ½ tablet. Upon further review in Resident #316's clinical record, the resident had a physician order [REDACTED].½ tablet instead of 1 tablet. · Resident #171 had also been administrated 1 tablet of [MEDICATION NAME] 5 mg on 3/7/18 at 8:20 pm from Resident #90's above documented narcotic sheet. Resident #171 had a physician order [REDACTED]. · Resident # 345 had also been administrated 2 tablets of [MEDICATION NAME] 5 mg on 5/15/18 at 7 pm from Resident #90's above documented narcotic sheet. Resident #345 had a physician order [REDACTED]. C. Resident #91 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #161 was given 1 tablet of [MEDICATION NAME] 5-325 mg on 10/4/18 at 9:30 pm. Resident #161 had a physician order [REDACTED]. D. Resident #111 had a narcotic sheet for [MEDICATION NAME] 4 mg/ml (milligram/milliliter) in which Resident #170 had been administrated 2 mg of [MEDICATION NAME] on 10/8/18 at 1 pm. Resident #170 had a physician order [REDACTED]. · Resident #347 was administrated [MEDICATION NAME] 2 mg on 10/13/18 at 12:15 pm and again on 10/14/18 at 8:47 am from Resident #111's narcotic sheet. Resident #347 had a physician order [REDACTED]. E. Resident #152 had a narcotic sheet for [MEDICATION NAME] 25 mcg/hr. patch that Resident #161 was administrated 1 patch of [MEDICATION NAME] on 10/29 18 at 6 pm. Resident #161 had a physician order [REDACTED]. F. Resident #163 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 3/12/18 and again on 6/20/18 at 8 pm. Resident #19 had a physician order [REDACTED]. G. Resident #205 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #349 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 1/8/18 at 8 am and again on 1/8/18 at 2 pm. Resident #349 had a physician order [REDACTED]. · Resident #348 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet on 2/19/18 at 4 pm from Resident #205's narcotic sheet. Resident #348 had a physician order [REDACTED]. · H. Resident #238 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/16/18 at 8:15 pm. Resident #19 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #238's narcotic sheet. Resident #19 had a physician order [REDACTED]. I. Resident #253 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 1 tablet of [MEDICATION NAME] on the following dates and times: 10/26/18 at 11:19 pm, 10/28/18 at 9:46 am, 10/28/18 at 4:08 pm, 10/28/18 at 8:38 pm, 10/29/18 at 1:51 am, 10/29/18 at 8:30 am, 10/30/18 at 12:05 am, 10/30/18 at 5:49 pm, 10/30/18 at 6:49 pm, 10/31/18 at 6:02 X 2 entries to total 2 tablets given, and on 10/31/18 at 9 am X 2 entries to total 2 tablets given. Resident #350 had a physician order [REDACTED]. · Resident #351 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/27/18 at 8:07 pm from Resident #253's narcotic sheet. Resident #351 had a physician order [REDACTED]. · Resident #352 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/28/18 at 8:33 pm from Resident #253's narcotic sheet. Resident #352 had a physician order [REDACTED]. · Resident #544 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/30/18 at 4:36 am and again on 10/30/18 at 6:55 pm from Resident #253's narcotic sheet. Resident #544 had a physician order [REDACTED]. · J . Resident #544 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 2 tablets of [MEDICATION NAME] 5-235 mg on 10/31/18 at 8:28 pm and again on 11/1/18 at 3:15 am. Resident #350 had a physician order [REDACTED]. K Resident #257 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times from Resident #257's narcotic sheet: 10/19/18 at 8:25 am, 10/20/18 at 9:45 am, 10/21/18 at 3:23 am, at 9:25 am and at 11:36 pm, 10/22/18 at 7:39 am and at 7:26 pm, and 10/23/18 at 6:30 am. Resident #145 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times: 10/20/18 at 5:17 pm, 10/21/18 at 9:55 am, 10/22/18 at 5:18 pm and at 11:30 pm from Resident #257's narcotic sheet. Resident #344 had a physician order [REDACTED]. L.Resident #344 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 2:46 pm. · Resident #238 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #344's narcotic sheet. Resident #238 had a physician order [REDACTED]. M. Resident #545 had a narcotic sheet for [MEDICATION NAME] 7.5-325 mg tablets in which Resident #185 had been administrated 1 tablet of [MEDICATION NAME] 7.5-325 mg on 10/31/18 at 5 am and again at 2:58 pm from Resident #545's narcotic sheet. Resident #185 had a physician order [REDACTED]. The surveyor requested and reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. On 11/2/18 at approximately 3:30pm, the surveyor interviewed LPN (Licensed Practical Nurse) #1. The surveyor asked LPN #1 if you were administrating medications and noted that you were out of a particular medication, like a narcotic, what would she do. LPN #1 stated that she would borrow that particular medication from another resident that had it. LPN #1 also stated if the medication that you needed was a narcotic you would sign out for it on the resident's narcotic sheet that you were borrowing it from. The surveyor requested that the pharmacist on duty for this day (11/1/18) come and speak to the surveyor. The pharmacist on duty for 11/1/18 came to the surveyor approximately 3:45 pm and the surveyor asked the pharmacist the same question as proposed to LPN#1 as documented above. The surveyor also asked the pharmacist if the staff was able to share medications. The pharmacist replied No, they are not to share any medications at all. If they are out of a particular medication then they are to notify pharmacy of this. The surveyor notified the director of nursing of the above documented findings on 11/2/18 at 9:30 am in the conference room. The surveyor asked the director of nursing for the pharmacy reviews on the above documented residents for the above documented dates of the times that the narcotics were borrowed from another resident. The director of nursing stated that she would have all the completed ones from (MONTH) to (MONTH) (YEAR) because this was just 11/2 and the (MONTH) ones had not been completed as of today. The surveyor received 2 pharmacy reviews that had documentation by the pharmacist regarding a different issue with 2 residents. The remaining residents had pharmacy reviews for each of the above documented months except for the month of (MONTH) and which stated No pharmacy recommendations. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance nurse (QA) and registered nurse (RN) #1 on 11/2/18 at 11:46 am in the conference room along with 3 of the survey team members in attendance. The pharmacist was asked during this time that the time the drug regimen reviews were being performed by himself if the narcotic records were checked. The pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what which residents were documented as being signed out for narcotics on each of the narcotic sheets. The pharmacist stated, I have only completed up to the month of (MONTH) for the monthly pharmacy reviews because today is just 11/2 and the (MONTH) ones are not due yet. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both of them replied No. The pharmacist was asked how long the narcotic sheets were kept on hand for record in the facility. The pharmacist stated I don't keep them but now after talking to you I will. No further information was provided to the surveyor prior to the exit conference on 11/2/18. 2. The facility pharmacist failed to identify discrepancies on the narcotic logs during the monthly drug regimen review for residents on South Terrace, Garden Terrace and North Terrace. This discrepancy affected seven residents. The residents affected were Resident #85, Resident #14, Resident #43, Resident #142, Resident #159, Resident #60, and Resident #42. (A). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] during the monthly (MONTH) (YEAR) drug regimen review for Resident #85. The facility staff borrowed a [MEDICATION NAME] from Resident #85's [MEDICATION NAME] box for Resident #9. The clinical record of Resident #85 was reviewed 10/30/18 through 11/2/18. Resident #85 was admitted to the facility 2/9/16 with [DIAGNOSES REDACTED]. Resident #85's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/14/18 assessed the resident with short term memory problems, long term memory problems and severely impaired cognitive skills for daily decision making. Resident #85's (MONTH) (YEAR) physician's orders [REDACTED].#85's orders included an order for [REDACTED].**Remove old patch prior to applying new one. Resident #85's [MEDICATION NAME] narcotic log was reviewed. Resident #85 received [MEDICATION NAME]es on 10/21/18 at 9:00 a.m., 10/24/18 at 9:00 a.m., 10/27/18 at 9:00 a.m., and 10/30/18 at 9:00 a.m. as documented on the (MONTH) (YEAR) electronic Medication Administration Record [REDACTED] On the [MEDICATION NAME] log dispensed for Resident #85, the staff have also documented that Resident #9 had received a [MEDICATION NAME] from Resident #85's box on 10/26/18 at 8:00 p.m. There was not a narcotic log for Resident #9's [MEDICATION NAME]. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#9 and Resident #85 from the director of nursing on 11/1/18 at 8:00 p.m. Resident #85's (MONTH) (YEAR) pharmacy review was conducted on 10/17/18. There were no discrepancies addressed on the review. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (B). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] with Tylenol 5-325 ([MEDICATION NAME]) during the (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) drug regimen review for Resident #14. The facility staff borrowed [MEDICATION NAME] with Tylenol 5-325 ([MEDICATION NAME]) from Resident #14's box to administer to Resident #143 (ten pills), Resident #353 (1 pill), Resident #444 (3 pills), Resident #18 (1 pill), and Resident #68 (1 pill) and Resident #293 (two pills). The clinical record of Resident #14 was reviewed 10/30/18 through 11/2/18. Resident #14 was admitted to the facility 7/1/13 with [DIAGNOSES REDACTED]. Resident #14's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/18/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. Resident #14's (MONTH) (YEAR) physician's orders [REDACTED]. The narcotic record for Resident #14's narcotic [MEDICATION NAME] with Tylenol 5-325 was reviewed. The narcotic log documented that 30 pills of [MEDICATION NAME] with Tylenol 5-325 had been dispensed on 3/9/18. The narcotic record log had six other residents name written on the narcotic log from (MONTH) (YEAR) through (MONTH) (YEAR). Resident #143 was administered ten (10) pills from Resident #14's card on 10/13/18 at 12:00 a.m., 10/13/18 at 4:00 a.m., 10/13/18 at 12:00 noon, 10/13/18 at 4:00 p.m., 10/13/18 at 8:00 p.m., 10/14/18 at 12:00 a.m., 10/14/18 at 8:00 a.m., 10/14/18 at 12:00 noon, 10/14/18 at 4:00 p.m., and 10/14/18 at 8:00 p.m. Resident #353 received one (1) pill on 7/2/18. Resident #444 received three (3) pills from Resident #14's card in (MONTH) (YEAR) on 4/26/18 at 9:00 a.m., 4/26/18 at 9:00 p.m., and 4/27/18 at 9:00 a.m. Resident #18 received one (1) pill on 5/8/18 from Resident #14's card. Resident #68 received one (1) pill from Resident #14's card on 8/16/18. Resident #293 received two (2) pills from resident #14's card on 10/6/18 and 10/7/18. The surveyor requested the face sheet, the monthly drug regimen reviews for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), and the (MONTH) physician's orders [REDACTED]. Resident #14's (MONTH) (YEAR) pharmacy review was conducted on 10/17/18. There were no discrepancies addressed on the review. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (C). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] 5-325 mg (milligrams) during (MONTH) (YEAR) drug regimen review for Resident #43. The facility staff borrowed fifteen (15) [MEDICATION NAME] 5-325 from Resident #43's box to administer to Resident #142. The facility staff failed to ensure Resident #142's [MEDICATION NAME] 5-325 mg (milligrams) was available for administration in (MONTH) (YEAR). The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The facility nurses borrowed fifteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #142 on 10/23/18 at 6:00 p.m., 10/24/18 at 8:00 a.m., 10/24/18 at 6:00 p.m., 10/25/18 at 8:00 a.m., 10/25/18 at 6:00 p.m., 10/26/18 at 8:00 a.m., 10/26/18 at 6:00 p.m., 10/27/18 at 8:00 a.m., 10/27/18 at 6;00 p., 10/28/18 at 8:00 a.m., 10/28/18 at 6:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 6:00 p.m., 10/30/18 at 8:00 a.m., and 10/30/18 at 6:00 p.m. The surveyor requested the Resident #142's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. Resident #43's (MONTH) (YEAR) monthly drug regimen review was completed on 10/25/18 with no issues identified. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (D). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] 5-325 during the monthly (MONTH) (YEAR) drug regimen review for Resident #43. The facility staff borrowed fourteen [MEDICATION NAME] 5-325mg (milligrams) from Resident #43's [MEDICATION NAME] 5-325 mg to administer to Resident #97. The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The facility nurses borrowed fourteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #97 on 10/27/18 at 2:00 p.m., 10/27/18 at 8:00 p.m., 10/28/18 at 2:00 p.m., 10/28/18 at 8:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 2:00 p.m., 10/29/18 at 8:00 p.m., 10/30/18 at 8:00 a.m., 10/30/18 at 2:00 p.m., 10/3018 at 8:00 p.m., 10/31/18 at 8:00 a.m., 10/31/18 at 2:00 p.m., 11/1/18 at 8:00 a.m., and 11/1/18 at 2:00 p.m. The surveyor requested the Resident #97's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. Resident #43's (MONTH) (YEAR) monthly drug regimen review was completed on 10/25/18 with no issues identified. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (E). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] 5-325 during the monthly (MONTH) (YEAR) drug regimen review for Resident #142. The facility staff borrowed one [MEDICATION NAME] 5-325mg (milligrams) from Resident #142's [MEDICATION NAME] 5-325 mg to administer to Resident #97. The clinical record of Resident #142 was reviewed 10/30/18 through 11/2/18. Resident #142 was admitted to the facility 2/14/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #142's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #142's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed Resident #142's narcotic record for [MEDICATION NAME] 5-325 on 11/1/18. One [MEDICATION NAME] 5-325 had been administered to Resident #97 on 10/31/18 at 7:00 p.m. for Resident #142's dispensed medication card. Resident #142's (MONTH) (YEAR) drug regimen review did not identify any irregularities completed on 10/9/18. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (F). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME] 25 mcg (microgram)/hr (hour) patch during the monthly (MONTH) (YEAR) drug regimen review for Resident #142. The facility staff borrowed one [MEDICATION NAME] 25 mcg/hr patch from Resident #142 to administer to Resident #52. The clinical record of Resident #142 was reviewed 10/30/18 through 11/2/18. Resident #142 was admitted to the facility 2/14/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #142's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #142's (MONTH) (YEAR) physician's orders [REDACTED]. Remove old patch before applying new one. The surveyor reviewed Resident #142's narcotic record for [MEDICATION NAME] ([MEDICATION NAME]) patch on 11/1/18. One [MEDICATION NAME] 25 mcg patch had been administered to Resident #52 on 10/30/18 at 10:00 a.m. from Resident #142's dispensed medication card. Resident #142's (MONTH) (YEAR) drug regimen review did not identify any irregularities completed on 10/9/18. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (G). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME]-5325 tablet during the monthly (MONTH) (YEAR) drug regimen review for Resident #159. The facility staff borrowed five (5) [MEDICATION NAME] 5-325 tablet from Resident #159 to administer to Resident #43 and one (1) to administer to Resident #97. The clinical record of Resident #159 was reviewed 10/30/18 through 11/2/18. Resident #159 was admitted to the facility 4/29/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #159's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/14/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #159's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed Resident #159's narcotic record for [MEDICATION NAME] 5-325 tablet on 11/1/18. Five [MEDICATION NAME] 5-325 had been administered to Resident #43 on 10/19/18 at 9:00 p.m., 10/20/18 at 8:00 a.m., 10/21/18 at 9:00 a.m., 10/22/18 at 8:30 a.m., and 10/22/18 at 8:00 p.m. One [MEDICATION NAME] 5-325 had been administered to Resident #97 on 10/28/18 at 8:00 a.m. Resident #159's (MONTH) (YEAR) drug regimen review did not identify any irregularities completed on 10/9/18. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. No further information was provided prior to the exit conference on 11/2/18. (H). The facility pharmacist failed to identify the inaccurate narcotic record for [MEDICATION NAME]-5325 tablet during the monthly (MONTH) (YEAR) drug regimen review for Resident #42. The facility staff borrowed one (1) [MEDICATION NAME] 5-325 tablet for Resident #230. The clinical record of Resident #42 was reviewed 10/30/18 through 11/2/18. Resident #42 was admitted to the facility 8/11/15 with [DIAGNOSES REDACTED]. Resident #42's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15. Resident #42's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed Resident #42's narcotic record for [MEDICATION NAME] 5-325 tablet on 11/1/18. One [MEDICATION NAME] 5-325 had been administered to Resident #230 on 10/4/18 at 8:54 p.m. from Resident #42's [MEDICATION NAME] 5-325 tablet card. Resident #42's (MONTH) (YEAR) drug regimen review did not identify any irregularities completed on 10/8/18. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at

Based on staff interview and clinical record review, the facility staff failed to ensure routine physician ordered medications were available for administration on 7 of 8 nursing unit in the nursing facility. (South Wing, East Wing, Mid-East Wing, Rehab Wing, South Terrace, Garden Terrace and North Terrace) 1. The facility staff failed to ensure routine physician ordered medications were available for administration and not having to borrow from other resident's in the facility that involved a 27 residents. (Resident #161,Resident #19, Resident # 90, Resident #91, Resident #111, Resident #152, Resident #163, Resident #205, Resident #238, Resident #253, Resident #257, Resident #344, Resident #18, Resident # 145, Resident #170, Resident #171, Resident #185, Resident # 345, Resident #346, Resident #347, Resident #348, Resident #349, Resident #350, Resident #351, Resident #352, Resident #544 and Resident #545) The pharmacist failed to reconcile narcotic sheets with the above documented residents and failed to keep on hand a record available of the narcotic sheets. Resident #161 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/11/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #161 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. · The surveyor conducted a clinical record review on 10/31 thru 11/2/18 on Resident #161. During this review, the surveyor reviewed the narcotic sheet for the [MEDICATION NAME] that Resident #161 was receiving. On the narcotic sheet, it had Resident #161's name on it along with the following physician ordered medication, [MEDICATION NAME] 12 mcg/hr. (micrograms/hour) patch Apply 1 patch [MEDICATION NAME] every 72 hours for pain. Apply with 25 mcg patch to total 37 mcg/hr. This narcotic sheet had the following documentation of dates and times of other resident's being administrated the narcotic patch from Resident #161's narcotic record: · 10/27/18 at 8 am, Resident #18 received one [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. · 10/30/18 at 8 am, Resident #18 received 1 [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. Upon the surveyor discovering the sharing of the above documented narcotic on 11/1/18 at approximately 2:30 pm, the surveyor reviewed all the narcotic sheets on the South Wing, East Wing, Mid-East Wing and the Rehab nursing units and the following was discovered: A. Resident #19 had a narcotic sheet for [MEDICATION NAME] 5-325 mg (milligram) tablets and on 10/16/18 at 3:15 pm, Resident #238 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet. Resident #238 had a physician order [REDACTED]. B. Resident #90 had a narcotic sheet for [MEDICATION NAME] 5 mg tablets in which Resident #316 had been administrated 1 tablet on 2/27/18 at 4:00 pm and again on 2/28/18 at 6:15 pm but on this date and time the resident was given ½ tablet. Upon further review in Resident #316's clinical record, the resident had a physician order [REDACTED].½ tablet instead of 1 tablet. · Resident #171 had also been administrated 1 tablet of [MEDICATION NAME] 5 mg on 3/7/18 at 8:20 pm from Resident #90's above documented narcotic sheet. Resident #171 had a physician order [REDACTED]. · Resident # 345 had also been administrated 2 tablets of [MEDICATION NAME] 5 mg on 5/15/18 at 7 pm from Resident #90's above documented narcotic sheet. Resident #345 had a physician order [REDACTED]. C. Resident #91 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #161 1 tablet on 10/4/18 at 9:30 pm. Resident #161 had a physician order [REDACTED]. D. Resident #111 had a narcotic sheet for [MEDICATION NAME] 4 mg/ml (milligram/milliliter) in which Resident #170 had been administrated 2 mg of [MEDICATION NAME] on 10/8/18 at 1 pm. Resident #170 had a physician order [REDACTED]. · Resident #347 was administrated [MEDICATION NAME] 2 mg on 10/13/18 at 12:15 pm and again on 10/14/18 at 8:47 am from Resident #111's narcotic sheet. Resident #347 had a physician order [REDACTED]. E. Resident #152 had a narcotic sheet for [MEDICATION NAME] 25 mcg/hr. patch that Resident #161 was administrated 1 patch of [MEDICATION NAME] on 10/29 18 at 6 pm. Resident #161 had a physician order [REDACTED]. F. Resident #163 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 3/12/18 and again on 6/20/18 at 8 pm. Resident #19 had a physician order [REDACTED]. G. Resident #205 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #349 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 1/8/18 at 8 am and again on 1/8/18 at 2 pm. Resident #349 had a physician order [REDACTED]. · Resident #348 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet on 2/19/18 at 4 pm from Resident #205's narcotic sheet. Resident #348 had a physician order [REDACTED]. H. Resident #238 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/16/18 at 8:15 pm. Resident #19 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #238's narcotic sheet. Resident #19 had a physician order [REDACTED]. I. Resident #253 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 1 tablet of [MEDICATION NAME] on the following dates and times: 10/26/18 at 11:19 pm, 10/28/18 at 9:46 am, 10/28/18 at 4:08 pm, 10/28/18 at 8:38 pm, 10/29/18 at 1:51 am, 10/29/18 at 8:30 am, 10/30/18 at 12:05 am, 10/30/18 at 5:49 pm, 10/30/18 at 6:49 pm, 10/31/18 at 6:02 X 2 entries to total 2 tablets given, and on 10/31/18 at 9 am X 2 entries to total 2 tablets given. Resident #350 had a physician order [REDACTED]. · Resident #351 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/27/18 at 8:07 pm from Resident #253's narcotic sheet. Resident #351 had a physician order [REDACTED]. · Resident #352 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/28/18 at 8:33 pm from Resident #253's narcotic sheet. Resident #352 had a physician order [REDACTED]. · Resident #544 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/30/18 at 4:36 am and again on 10/30/18 at 6:55 pm from Resident #253's narcotic sheet. Resident #544 had a physician order [REDACTED]. J. Resident #544 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 2 tablets of [MEDICATION NAME] 5-235 mg on 10/31/18 at 8:28 pm and again on 11/1/18 at 3:15 am. Resident #350 had a physician order [REDACTED]. K. Resident #257 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times from Resident #257's narcotic sheet: 10/19/18 at 8:25 am, 10/20/18 at 9:45 am, 10/21/18 at 3:23 am, at 9:25 am and at 11:36 pm, 10/22/18 at 7:39 am and at 7:26 pm, and 10/23/18 at 6:30 am. Resident #145 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times: 10/20/18 at 5:17 pm, 10/21/18 at 9:55 am, 10/22/18 at 5:18 pm and at 11:30 pm from Resident #257's narcotic sheet. Resident #344 had a physician order [REDACTED]. L. Resident #344 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 2:46 pm. · Resident #238 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #344's narcotic sheet. Resident #238 had a physician order [REDACTED]. M. Resident #545 had a narcotic sheet for [MEDICATION NAME] 7.5-325 mg tablets in which Resident #185 had been administrated 1 tablet of [MEDICATION NAME] 7.5-325 mg on 10/31/18 at 5 am and again at 2:58 pm from Resident #545's narcotic sheet. Resident #185 had a physician order [REDACTED]. The surveyor requested and reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. On 11/2/18 at approximately 3:30pm, the surveyor interviewed LPN (Licensed Practical Nurse) #1. The surveyor asked LPN #1 if you were administrating medications and noted that you were out of a particular medication, like a narcotic, what would she do. LPN #1 stated that she would borrow that particular medication from another resident that had it. LPN #1 also stated if the medication that you needed was a narcotic you would sign out for it on the resident's narcotic sheet that you were borrowing it from. The surveyor requested that the pharmacist on duty for this day (11/1/18) come and speak to the surveyor. The pharmacist on duty for 11/1/18 came to the surveyor approximately 3:45 pm and the surveyor asked the pharmacist the same question as proposed to LPN#1 as documented above. The surveyor also asked the pharmacist if the staff was able to share medications. The pharmacist replied No, they are not to share any medications at all. If they are out of a particular medication then they are to notify pharmacy of this. The surveyor notified the director of nursing of the above documented findings on 11/2/18 at 9:30 am in the conference room. The surveyor asked the director of nursing for the pharmacy reviews on the above documented residents for the above documented dates of the times that the narcotics were borrowed from another resident. The surveyor received 2 pharmacy reviews that had documentation by the pharmacist regarding a different issue with 2 residents. The remaining residents had pharmacy reviews for each of the above documented months that stated No pharmacy recommendations. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance nurse (QA) and registered nurse (RN) #1 on 11/2/18 at 11:46 am in the conference room along with 3 of the survey team members in attendance. The pharmacist was asked during this time that the time the drug regimen reviews were being performed by himself if the narcotic records were checked. The pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what which residents were documented as being signed out for narcotics on each of the narcotic sheets. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both of them replied No. The pharmacist was asked how long the narcotic sheets were kept on hand for record in the facility. The pharmacist stated I don't keep them but now after talking to you I will. No further information was provided to the surveyor prior to the exit conference on 11/2/18. 2. The facility staff failed to ensure routine prescribed drugs were available for administration to eighteen (18) residents on South Terrace, Garden Terrace and North Terrace. The residents effected were Resident #9, Resident #143, Resident #142, Resident #43, Resident #97, Resident #18, Resident #42, Resident #230, Resident #353, Resident #52, Resident #60, Resident #14, Resident #85, Resident #106, Resident #444, Resident #159, Resident #68, and Resident #293. The facility staff also failed to ensure the narcotic records were completed and retained. (A). The facility staff failed to ensure Resident #9's [MEDICATION NAME] was available for administration. However, a [MEDICATION NAME] had been used from Resident #85's [MEDICATION NAME] box. The clinical record of Resident #9 was reviewed 10/30/18 through 11/2/18. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/15/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #9's (MONTH) (YEAR) and (MONTH) (YEAR) physician's orders [REDACTED].#9's orders included an order for [REDACTED].**Remove old patch prior to applying new one. Resident #9 received a [MEDICATION NAME] on 10/26/18 at 8:00 p.m. as documented on the (MONTH) (YEAR) electronic Medication Administration Record [REDACTED]. However, a [MEDICATION NAME] had been used from Resident #85's [MEDICATION NAME] box. Licensed practical nurse #4 borrowed a [MEDICATION NAME] 12.5 mcg patch from Resident #85's [MEDICATION NAME] box to administer to Resident #9. When the [MEDICATION NAME] was removed on 10/29/18 at 8:00 p.m., there was no documentation where the [MEDICATION NAME] was discarded/wasted. The surveyor was unable to locate the disposition of the used [MEDICATION NAME]. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#9 and Resident #85 from the director of nursing on 11/1/18 at 8:00 p.m. The surveyor reviewed the concerns with the director of nursing on 11/2/18 at 8:00 a.m. regarding the licensed practical nurse borrowing [MEDICATION NAME] for Resident #9's administration on 10/26/18 from Resident #85's [MEDICATION NAME] box. No further information was provided prior to the exit conference on 11/2/18. (B). The facility staff failed to ensure Resident #143's medications were available for administration. Ten administrations of [MEDICATION NAME] with Tylenol ([MEDICATION NAME]) 5-325 were borrowed from Resident #14's [MEDICATION NAME]. The clinical record of Resident #143 was reviewed 10/30/18 through 11/2/18. Resident #143 was admitted to the facility 8/8/12 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #143's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/8/18 assessed the resident with a BIMS (brief interview for mental status) as 6 out of 15. Resident #143's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) electronic medication administration records (eMARs). Resident #143 received [MEDICATION NAME] 5-325 mg on 10/13/18 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and on 10/14/18 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The surveyor was unable to locate the narcotic log for Resident #143's narcotic log for [MEDICATION NAME] with Tylenol. However, the surveyor found Resident #143's name recorded on Resident #14's [MEDICATION NAME] with Tylenol narcotic record ten different times. The times recorded on the narcotic sheet were the dates and times recorded on Resident #143's eMARs. Six different nurses borrowed [MEDICATION NAME] with Tylenol from Resident #14's card and administered the medication to Resident #143. The medication was borrowed. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#143 and Resident #14 from the director of nursing on 11/1/18 at 8:00 p.m. The surveyor informed the director of nursing of the above concern with the nurses borrowing medication ([MEDICATION NAME] with Tylenol) from Resident #143 to administer to Resident #14 on 11/2/18 at 8:00 a.m. (C). The facility staff failed to ensure Resident #142's [MEDICATION NAME] 5-325 mg (milligrams) was available for administration in (MONTH) (YEAR). The facility staff borrowed fifteen (15) doses of [MEDICATION NAME] 5-325 mg from Resident #43. The clinical record of Resident #142 was reviewed 10/30/18 through 11/2/18. Resident #142 was admitted to the facility 2/14/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #142's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #142's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records (eMARs) were reviewed. The nursing staff documented Resident #142 was administered [MEDICATION NAME] 5-325 on 10/23/18-10/30/18. A review of the narcotic book failed to produce a narcotic log for Resident #142's [MEDICATION NAME] 5-325 mg. The surveyor reviewed Resident #43's narcotic log for [MEDICATION NAME] 5-325 mg. Fifteen doses of Resident #43's [MEDICATION NAME] 5-325 mg were used to administer to Resident #142 on 10/23/18 at 6:00 p.m., 10/24/18 at 8:00 a.m. and 6:00 p.m., 10/25/18 at 8:00 a.m. and 6:00 p.m., 10/26/18 at 8:00 a.m. and 6:00 p.m., 10/27/18 at 8:00 a.m. and 6:00 p.m., 10/28/18 at 8:00 a.m. and 6:00 p.m., 10/29/18 at 8:00 a.m. and 6:00 p.m., and 10/30/18 at 8:00 a.m. and 6:00 p.m. The facility nurses borrowed fourteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #142. The (MONTH) (YEAR) eMARS were reviewed for [MEDICATION NAME] 25 mcg administration dates. Resident #142 was administered [MEDICATION NAME] 25 mcg patch on 10/2/18, 10/5/18, 10/8/18, 10/11/18, 10/14/18, 10/17/18, 10/20/18, 10/23/18, 10/26/18 and 10/29/18. Resident #142's Narcotic record for [MEDICATION NAME] 25 mcg was reviewed. [MEDICATION NAME] 25 mcg had been signed out on 10/11/18-through 10/29/18. The narcotic record did not have evidence of [MEDICATION NAME] wastage when removed from the resident. The surveyor requested the Resident #142's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns with the director of nursing on 11/2/18 at 8:00 a.m. regarding the nursing staff borrowing medications from Resident #43 to administer to Resident #142 and the facility staff failing to document [MEDICATION NAME] wastage. No further information was provided prior to the exit conference on 11/2/18. (D). The facility staff failed to ensure Resident #97's medication ([MEDICATION NAME] 5-325 mg (milligrams)) was available for administration. The facility staff borrowed [MEDICATION NAME] 5-325 mg from Resident #142 to administer to Resident #97. The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #97's [MEDICATION NAME] 5-325 was administered from Resident #142's card on 10/30/18 at 7:00 p.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #142's face sheets, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #142 and administering the medication to Resident #97 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (E). The facility staff failed to ensure Resident #43's [MEDICATION NAME] was available for administration 5 days in (MONTH) (YEAR). [MEDICATION NAME] was borrowed from Resident #159. The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records (eMARs) were reviewed. Resident #43 was administered [MEDICATION NAME] 5-325 tablet bid from 10/1/18 through 10/31/18. The surveyor reviewed the Narcotic Record for Resident #43's [MEDICATION NAME] 5-325. Resident #43 had two cards for [MEDICATION NAME] 5-325; however, Resident #43's [MEDICATION NAME] 5-325 administered on 10/19/18 at 9:00 p.m., 10/20/18 at 8:00 a.m., 10/21/18 at 9:00 a.m., 10/22/18 at 8:30 a.m. and 10/22/18 at 8:00 p.m. were recorded on Resident #159's [MEDICATION NAME] 5-325 narcotic record. The staff had borrowed [MEDICATION NAME] 5-325 from Resident #159's [MEDICATION NAME] 5-325 card to administer to Resident #43. The surveyor informed the director of nursing of the above concern with borrowing medications on 11/1/18 at 8:00 p.m. and requested the face sheets, (MONTH) (YEAR) physician's orders [REDACTED].#43 and Resident #159. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #159 and administering the medication to Resident #43 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (F). The facility staff failed to ensure Resident #97's [MEDICATION NAME] 5-325 was available for administration in (MONTH) (YEAR). [MEDICATION NAME] 5-325 was borrowed from Resident #159's [MEDICATION NAME] card on 10/28/18 at 8:00 a.m. The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #97's [MEDICATION NAME] 5-325 was administered from Resident #159's card on 10/28/18 at 8:00 a.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #159's face sheets, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #159 and administering the medication to Resident #97 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (G). The facility staff failed to ensure Resident #97's [MEDICATION NAME] 5-325 was available for administration in (MONTH) (YEAR). The facility staff borrowed [MEDICATION NAME] 5-325 from Resident #43 fourteen times in (MONTH) (YEAR). The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #197's [MEDICATION NAME] 5-325 was administered from Resident #43's card fourteen times in (MONTH) (YEAR)-10/27/18 at 2:00 p.m., 10/27/18 at 8:00 p.m., 10/28/18 at 2:00 p.m., 10/28/18 at 8:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 2:00 p.m., 10/29/18 at 8:00 p.m., 10/30/18 at 8:00 a.m., 10/30/18 at 2:00 p.m., 10/30/18 at 8:00 p.m.,10/31/18 at 8:00 a.m., 10/31/18 at 2:00 p.m., 11/1/18 at 8:00a.m., and 11/1/18 at 2:00 p.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #159's face sheets, (MONTH) (YEAR) and (MONTH) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #43 and administering the medication to Resident #97 with the director of nursing on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (H). The facility staff failed to ensure Resident #52's [MEDICATION NAME] was available for administration. The facility staff borrowed a [MEDICATION NAME] from Resident #142. The clinical record of Resident #52 was reviewed 10/30/18 through 11/2/18. Resident #52 was admitted to the facility 8/24/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #52's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/2/18 assessed the resident with a BIMS (brief interview for mental status) as 14 out of 15. Resident #52's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records had documentation that Resident #52 was administered the [MEDICATION NAME] on 10/3/18, 10/6/18, 10/9/18, 10/12/18, 10/15/18, 10/18/18, 10/21/18, 10/24/18, 10/27/18 and 10/30/18. The surveyor reviewed the Narcotic Record Logbook and was unable to locate a narcotic record for Resident #52's [MEDICATION NAME]. The surveyor reviewed all of the narcotic records in the log book and found that Resident #52's [MEDICATION NAME] applied on 10/30/18 had been removed from Resident #142's [MEDICATION NAME] box and recorded on Resident #142's [MEDICATION NAME] narcotic record. <BR

Based on staff interview and clinical record review, the facility staff failed to follow professional standards of practice involving medication administration on 7 of 8 nursing unit in the facility. (South Wing, East Wing, Mid-East Wing, Rehab, South Terrace, Garden Terrace and North Terrace) 1. The facility staff borrowed or shared medications during a review of Resident #161's narcotic sheets for [MEDICATION NAME]. There were a total of 2 residents that were discovered by the surveyor to either be the giver or borrower of the narcotic medications. The following residents were subjected to the practice of borrowing and sharing medications: [REDACTED]#238, Resident #253, Resident #257, Resident #344, Resident #18, Resident # 145, Resident #170, Resident #171, Resident #185, Resident # 345, Resident #347, Resident #348, Resident #349, Resident #350, Resident #351, Resident #352, Resident #544 and Resident #545. Resident #161 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/11/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #161 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. The surveyor conducted a clinical record review on 10/31 thru 11/2/18 on Resident #161. During this review, the surveyor reviewed the narcotic sheet for the [MEDICATION NAME] that Resident #161 was receiving. On the narcotic sheet, it had Resident #161's name on it along with the following physician ordered medication, [MEDICATION NAME] 12 mcg/hr. (micrograms/hour) patch Apply 1 patch [MEDICATION NAME] every 72 hours for pain. Apply with 25 mcg patch to total 37 mcg/hr. This narcotic sheet had the following documentation of dates and times of other resident's being administrated the narcotic patch from Resident #161's narcotic record: · 10/27/18 at 8 am, Resident #18 received one [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. · 10/30/18 at 8 am, Resident #18 received 1 [MEDICATION NAME] 12 mcg/hr. patch . This resident had the same physician order [REDACTED]. Upon the surveyor discovering the sharing of the above documented narcotic on 11/1/18 at approximately 2:30 pm, the surveyor reviewed all the narcotic sheets on the South Wing, East Wing, Mid-East Wing and the Rehab nursing units and the following was discovered: A. Resident #19 had a narcotic sheet for [MEDICATION NAME] 5-325 mg (milligram) tablets and on 10/16/18 at 3:15 pm, Resident #238 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet. Resident #238 had a physician order [REDACTED]. B. Resident #90 had a narcotic sheet for [MEDICATION NAME] 5 mg tablets in which Resident #316 had been administrated 1 tablet on 2/27/18 at 4:00 pm and again on 2/28/18 at 6:15 pm but on this date and time the resident was given ½ tablet. Upon further review in Resident #316's clinical record, the resident had a physician order [REDACTED].½ tablet instead of 1 tablet. · Resident #171 had also been administrated 1 tablet of [MEDICATION NAME] 5 mg on 3/7/18 at 8:20 pm from Resident #90's above documented narcotic sheet. Resident #171 had a physician order [REDACTED]. · Resident # 345 had also been administrated 2 tablets of [MEDICATION NAME] 5 mg on 5/15/18 at 7 pm from Resident #90's above documented narcotic sheet. Resident #345 had a physician order [REDACTED]. C. Resident #91 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #161 1 tablet on 10/4/18 at 9:30 pm. Resident #161 had a physician order [REDACTED]. D. Resident #111 had a narcotic sheet for [MEDICATION NAME] 4 mg/ml (milligram/milliliter) in which Resident #170 had been administrated 2 mg of [MEDICATION NAME] on 10/8/18 at 1 pm. Resident #170 had a physician order [REDACTED]. · Resident #347 was administrated [MEDICATION NAME] 2 mg on 10/13/18 at 12:15 pm and again on 10/14/18 at 8:47 am from Resident #111's narcotic sheet. Resident #347 had a physician order [REDACTED]. E. Resident #152 had a narcotic sheet for [MEDICATION NAME] 25 mcg/hr. patch that Resident #161 was administrated 1 patch of [MEDICATION NAME] on 10/29 18 at 6 pm. Resident #161 had a physician order [REDACTED]. F. Resident #163 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 3/12/18 and again on 6/20/18 at 8 pm. Resident #19 had a physician order [REDACTED]. G. Resident #205 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #349 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 1/8/18 at 8 am and again on 1/8/18 at 2 pm. Resident #349 had a physician order [REDACTED]. · Resident #348 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet on 2/19/18 at 4 pm from Resident #205's narcotic sheet. Resident #348 had a physician order [REDACTED]. H. Resident #238 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/16/18 at 8:15 pm. Resident #19 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #238's narcotic sheet. Resident #19 had a physician order [REDACTED]. I. Resident #253 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 1 tablet of [MEDICATION NAME] on the following dates and times: 10/26/18 at 11:19 pm, 10/28/18 at 9:46 am, 10/28/18 at 4:08 pm, 10/28/18 at 8:38 pm, 10/29/18 at 1:51 am, 10/29/18 at 8:30 am, 10/30/18 at 12:05 am, 10/30/18 at 5:49 pm, 10/30/18 at 6:49 pm, 10/31/18 at 6:02 X 2 entries to total 2 tablets given, and on 10/31/18 at 9 am X 2 entries to total 2 tablets given. Resident #350 had a physician order [REDACTED]. · Resident #351 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/27/18 at 8:07 pm from Resident #253's narcotic sheet. Resident #351 had a physician order [REDACTED]. · Resident #352 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/28/18 at 8:33 pm from Resident #253's narcotic sheet. Resident #352 had a physician order [REDACTED]. · Resident #544 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/30/18 at 4:36 am and again on 10/30/18 at 6:55 pm from Resident #253's narcotic sheet. Resident #544 had a physician order [REDACTED]. J. Resident #544 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 2 tablets of [MEDICATION NAME] 5-235 mg on 10/31/18 at 8:28 pm and again on 11/1/18 at 3:15 am. Resident #350 had a physician order [REDACTED]. K. Resident #257 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times from Resident #257's narcotic sheet: 10/19/18 at 8:25 am, 10/20/18 at 9:45 am, 10/21/18 at 3:23 am, at 9:25 am and at 11:36 pm, 10/22/18 at 7:39 am and at 7:26 pm, and 10/23/18 at 6:30 am. Resident #145 had a physician order [REDACTED]. · Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times: 10/20/18 at 5:17 pm, 10/21/18 at 9:55 am, 10/22/18 at 5:18 pm and at 11:30 pm from Resident #257's narcotic sheet. Resident #344 had a physician order [REDACTED]. L. Resident #344 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 2:46 pm. · Resident #238 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #344's narcotic sheet. Resident #238 had a physician order [REDACTED]. · M. Resident #545 had a narcotic sheet for [MEDICATION NAME] 7.5-325 mg tablets in which Resident #185 had been administrated 1 tablet of [MEDICATION NAME] 7.5-325 mg on 10/31/18 at 5 am and again at 2:58 pm from Resident #545's narcotic sheet. Resident #185 had a physician order [REDACTED]. The surveyor requested and reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. On 11/2/18 at approximately 3:30pm, the surveyor interviewed LPN (Licensed Practical Nurse) #1. The surveyor asked LPN #1 if you were administrating medications and noted that you were out of a particular medication, like a narcotic, what would she do. LPN #1 stated that she would borrow that particular medication from another resident that had it. LPN #1 also stated if the medication that you needed was a narcotic you would sign out for it on the resident's narcotic sheet that you were borrowing it from. The surveyor requested that the pharmacist on duty for this day (11/1/18) come and speak to the surveyor. The pharmacist on duty for 11/1/18 came to the surveyor approximately 3:45 pm and the surveyor asked the pharmacist the same question as proposed to LPN#1 as documented above. The surveyor also asked the pharmacist if the staff was able to share medications. The pharmacist replied No, they are not to share any medications at all. If they are out of a particular medication then they are to notify pharmacy of this. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance nurse (QA) and registered nurse (RN) #1 on 11/2/18 at 11:46 am in the conference room along with 3 of the survey team members in attendance. The pharmacist was asked during this time that the time the drug regimen reviews were being performed by himself if the narcotic records were checked. The pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what which residents were documented as being signed out for narcotics on each of the narcotic sheets. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. The director of nursing and the pharmacist had stated no. The surveyor requested for the standard of practice for nursing in administrating medications. The director of nursing stated We go by our policies and procedures for that. No further information was provided to the surveyor prior to the exit conference on 11/2/18. 2. The facility staff failed to follow professional standards of practice for medication administration on the South Terrace, Garden Terrace and North Terrace that affected eighteen residents. The nursing staff failed to obtain narcotic medications from the pharmacy and instead borrowed the medication from other residents who had the medication in the medication cart. Three residents did not have documentation that the medication borrowed was actually administered (Resident #18, Resident #68 and Resident #353). (A). The facility staff failed to ensure Resident #9's [MEDICATION NAME] was available for administration. However, a [MEDICATION NAME] had been used from Resident #85's [MEDICATION NAME] box. The clinical record of Resident #9 was reviewed 10/30/18 through 11/2/18. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/15/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #9's (MONTH) (YEAR) and (MONTH) (YEAR) physician's orders [REDACTED].#9's orders included an order for [REDACTED].**Remove old patch prior to applying new one. Resident #9 received a [MEDICATION NAME] on 10/26/18 at 8:00 p.m. as documented on the (MONTH) (YEAR) electronic Medication Administration Record [REDACTED]. However, a [MEDICATION NAME] had been used from Resident #85's [MEDICATION NAME] box. Licensed practical nurse #4 borrowed a [MEDICATION NAME] 12.5 mcg patch from Resident #85's [MEDICATION NAME] box to administer to Resident #9. When the [MEDICATION NAME] was removed on 10/29/18 at 8:00 p.m., there was no documentation where the [MEDICATION NAME] was discarded/wasted. The surveyor was unable to locate the disposition of the used [MEDICATION NAME]. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#9 and Resident #85 from the director of nursing on 11/1/18 at 8:00 p.m. The surveyor reviewed the concerns with the director of nursing on 11/2/18 at 8:00 a.m. regarding the licensed practical nurse borrowing [MEDICATION NAME] for Resident #9's administration on 10/26/18 from Resident #85's [MEDICATION NAME] box. No further information was provided prior to the exit conference on 11/2/18. (B). The facility staff failed to ensure Resident #143's medications were available for administration. Ten administrations of [MEDICATION NAME] with Tylenol ([MEDICATION NAME]) 5-325 were borrowed from Resident #14's [MEDICATION NAME]. The clinical record of Resident #143 was reviewed 10/30/18 through 11/2/18. Resident #143 was admitted to the facility 8/8/12 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #143's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/8/18 assessed the resident with a BIMS (brief interview for mental status) as 6 out of 15. Resident #143's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) electronic medication administration records (eMARs). Resident #143 received [MEDICATION NAME] 5-325 mg on 10/13/18 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and on 10/14/18 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The surveyor was unable to locate the narcotic log for Resident #143's narcotic log for [MEDICATION NAME] with Tylenol. However, the surveyor found Resident #143's name recorded on Resident #14's [MEDICATION NAME] with Tylenol narcotic record ten different times. The times recorded on the narcotic sheet were the dates and times recorded on Resident #143's eMARs. Six different nurses borrowed [MEDICATION NAME] with Tylenol from Resident #14's card and administered the medication to Resident #143. The medication was borrowed. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#143 and Resident #14 from the director of nursing on 11/1/18 at 8:00 p.m. The surveyor informed the director of nursing of the above concern with the nurses borrowing medication ([MEDICATION NAME] with Tylenol) from Resident #143 to administer to Resident #14 on 11/2/18 at 8:00 a.m. (C). The facility staff failed to ensure Resident #142's [MEDICATION NAME] 5-325 mg (milligrams) was available for administration in (MONTH) (YEAR). The facility staff borrowed fifteen (15) doses of [MEDICATION NAME] 5-325 mg from Resident #43. The clinical record of Resident #142 was reviewed 10/30/18 through 11/2/18. Resident #142 was admitted to the facility 2/14/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #142's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #142's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records (eMARs). The nursing staff documented Resident #142 was administered [MEDICATION NAME] 5-325 on 10/23/18-10/30/18. A review of the narcotic book failed to produce a narcotic log for Resident #142's [MEDICATION NAME] 5-325 mg. The surveyor reviewed Resident #43's narcotic log for [MEDICATION NAME] 5-325 mg. Fifteen doses of Resident #43's [MEDICATION NAME] 5-325 mg were used to administer to Resident #142 on 10/23/18 at 6:00 p.m., 10/24/18 at 8:00 a.m. and 6:00 p.m., 10/25/18 at 8:00 a.m. and 6:00 p.m., 10/26/18 at 8:00 a.m. and 6:00 p.m., 10/27/18 at 8:00 a.m. and 6:00 p.m., 10/28/18 at 8:00 a.m. and 6:00 p.m., 10/29/18 at 8:00 a.m. and 6:00 p.m., and 10/30/18 at 8:00 a.m. and 6:00 p.m. The facility nurses borrowed fourteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #142. The (MONTH) (YEAR) eMARS were reviewed for [MEDICATION NAME] 25 mcg administration dates. Resident #142 was administered [MEDICATION NAME] 25 mcg patch on 10/2/18, 10/5/18, 10/8/18, 10/11/18, 10/14/18, 10/17/18, 10/20/18, 10/23/18, 10/26/18 and 10/29/18. Resident #142's Narcotic record for [MEDICATION NAME] 25 mcg was reviewed. [MEDICATION NAME] 25 mcg had been signed out on 10/11/18-through 10/29/18. The narcotic record did not have evidence of [MEDICATION NAME] wastage when removed from the resident. The surveyor requested the Resident #142's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns with the director of nursing on 11/2/18 at 8:00 a.m. regarding the nursing staff borrowing medications from Resident #43 to administer to Resident #142 and the facility staff failing to document [MEDICATION NAME] wastage. No further information was provided prior to the exit conference on 11/2/18. (D). The facility staff failed to ensure Resident #97's medication ([MEDICATION NAME] 5-325 mg (milligrams)) was available for administration. The facility staff borrowed [MEDICATION NAME] 5-325 mg from resident #142 to administer to Resident #97. The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #97's [MEDICATION NAME] 5-325 was administered from Resident #142's card on 10/30/18 at 7:00 p.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #142's face sheets, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #142 and administering the medication to Resident #97 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (E). The facility staff failed to ensure Resident #43's [MEDICATION NAME] was available for administration 5 days in (MONTH) (YEAR). [MEDICATION NAME] was borrowed from Resident #159. The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records (eMARs) were reviewed. Resident #43 was administered [MEDICATION NAME] 5-325 tablet bid from 10/1/18 through 10/31/18. The surveyor reviewed the Narcotic Record for Resident #43's [MEDICATION NAME] 5-325. Resident #43 had two cards for [MEDICATION NAME] 5-325; however, Resident #43's [MEDICATION NAME] 5-325 administered on 10/19/18 at 9:00 p.m., 10/20/18 at 8:00 a.m., 10/21/18 at 9:00 a.m., 10/22/18 at 8:30 a.m. and 10/22/18 at 8:00 p.m. were recorded on Resident #159's [MEDICATION NAME] 5-325 narcotic record. The staff had borrowed [MEDICATION NAME] 5-325 from Resident #159's [MEDICATION NAME] 5-325 card to administer to Resident #43. The surveyor informed the director of nursing of the above concern with borrowing medications on 11/1/18 at 8:00 p.m. and requested the face sheets, (MONTH) (YEAR) physician's orders [REDACTED].#43 and Resident #159. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #159 and administering the medication to Resident #43 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (F). The facility staff failed to ensure Resident #97's [MEDICATION NAME] 5-325 was available for administration in (MONTH) (YEAR). [MEDICATION NAME] 5-325 was borrowed from Resident #159's [MEDICATION NAME] card on 10/28/18 at 8:00 a.m. The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #97's [MEDICATION NAME] 5-325 was administered from Resident #159's card on 10/28/18 at 8:00 a.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #159's face sheets, (MONTH) (YEAR) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #159 and administering the medication to Resident #97 on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (G). The facility staff failed to ensure Resident #97's [MEDICATION NAME] 5-325 was available for administration in (MONTH) (YEAR). The facility staff borrowed [MEDICATION NAME] 5-325 from Resident #43 fourteen times in (MONTH) (YEAR). The clinical record of Resident #97 was reviewed 10/30/18 through 11/2/18. Resident #97 was admitted to the facility 2/20/09 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #97's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/21/18 assessed the resident with a BIMS (brief interview for mental status) of 4 out of 15. Resident #97's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records were reviewed. Resident #97 was administered [MEDICATION NAME] 5-325 every day in (MONTH) tid at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The surveyor reviewed the Narcotic Record Logbook but was unable to find the narcotic record for Resident #97's [MEDICATION NAME] 5-325. A review of all the narcotic records in the log was done. Resident #197's [MEDICATION NAME] 5-325 was administered from Resident #43's card fourteen times in (MONTH) (YEAR)-10/27/18 at 2:00 p.m., 10/27/18 at 8:00 p.m., 10/28/18 at 2:00 p.m., 10/28/18 at 8:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 2:00 p.m., 10/29/18 at 8:00 p.m., 10/30/18 at 8:00 a.m., 10/30/18 at 2:00 p.m., 10/30/18 at 8:00 p.m.,10/31/18 at 8:00 a.m., 10/31/18 at 2:00 p.m., 11/1/18 at 8:00a.m., and 11/1/18 at 2:00 p.m. The surveyor informed the director of nursing on 11/1/18 at 8:00 p.m. and requested Resident #97 and Resident #159's face sheets, (MONTH) (YEAR) and (MONTH) physician orders [REDACTED]. The surveyor reviewed the concerns of borrowing [MEDICATION NAME] from Resident #43 and administering the medication to Resident #97 with the director of nursing on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (H). The facility staff failed to ensure Resident #52's [MEDICATION NAME] was available for administration. The facility staff borrowed a [MEDICATION NAME] from Resident #142. The clinical record of resident #52 was reviewed 10/30/18 through 11/2/18. Resident #52 was admitted to the facility 8/24/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #52's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/2/18 assessed the resident with a BIMS (brief interview for mental status) as 14 out of 15. Resident #52's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) electronic medication administration records had documentation that Resident #52 was administered the [MEDICATION NAME] on 10/3/18, 10/6/18, 10/9/18, 10/12/18, 10/15/18, 10/18/18, 10/21/18, 10/24/18, 10/27/18 and 10/30/18. The surveyor reviewed the Narcotic Record Logbook and was unable to locate a narcotic record for Resident #52's [MEDICATION NAME]. The surveyor reviewed all of the narcotic records in the log book and found that Resident #52's [MEDICATION NAME] applied on 10/30/18 had been removed from Resident #142's [MEDICATION NAME] box and recorded on Resident #142's [MEDICATION NAME] narcotic record. The surveyor informed the director of nursing of the above concern on 11/1/18 at 8:00 p.m. and requested the face sheet, (MONTH) (YEAR) physician's orders [REDACTED].#142 and Resident #52. The surveyor reviewed the concerns with borrowing medications between residents with the director of nursing on 11/2/18 at 8:00 a.m. No further information was provided prior to the exit conference on 11/2/18. (I). The facility staff failed to ensure Resident #106's medication was available for administration. The facility staff borrowed [MEDICATION NAME] injectable from Resident #60. The c

Based on staff interview and clinical record review, the facility staff failed to protect a resident's right to be free from misappropriation of resident property and/or exploitation on 7 of 8 nursing units in the facility. (East Wing, Mid-East, South Wing, Rehab, South Terrace, Garden Terrace and North Terrace Nursing Units) 1. The facility staff misappropriated 12 resident's (Resident #161,Resident #19, Resident #90, Resident #91, Resident #111, Resident #152, Resident #163, Resident #205, Resident #238, Resident #253, Resident #257 and Resident #344) narcotics when the nursing staff on East Wing, Mid-East, South Wing and the Rehab nursing units used prescription dispensed medications for 16 residents ( Resident #18, Resident #19, Resident # 145, Resident #170, Resident #171, Resident #185, Resident #238, Resident # 345, Resident #346, Resident #347, Resident #348, Resident #349, Resident #350, Resident #351, Resident #352, Resident #544 and Resident #545) without gaining their permission to use their medications. Resident #161 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/11/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #161 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. The surveyor conducted a clinical record review on 10/31 thru 11/2/18 on Resident #161. During this review, the surveyor reviewed the narcotic sheet for the [MEDICATION NAME] that Resident #161 was receiving. On the narcotic sheet, it had Resident #161's name on it along with the following physician ordered medication, [MEDICATION NAME] 12 mcg/hr. (micrograms/hour) patch Apply 1 patch [MEDICATION NAME] every 72 hours for pain. Apply with 25 mcg patch to total 37 mcg/hr. This narcotic sheet had the following documentation of dates and times of other resident's being administrated the narcotic patch from Resident #161's narcotic record: 10/27/18 at 8 am, Resident #18 received one [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. 10/30/18 at 8 am, Resident #18 received 1 [MEDICATION NAME] 12 mcg/hr. patch. This resident had the same physician order [REDACTED]. Upon the surveyor discovering the sharing of the above documented narcotic on 11/1/18 at approximately 2:30 pm, the surveyor reviewed all the narcotic sheets on the South Wing, East Wing, Mid-East Wing and the Rehab nursing units and the following was discovered: A. Resident #19 had a narcotic sheet for [MEDICATION NAME] 5-325 mg (milligram) tablets and on 10/16/18 at 3:15 pm, Resident #238 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet. Resident #238 had a physician order [REDACTED]. B. Resident #90 had a narcotic sheet for [MEDICATION NAME] 5 mg tablets in which Resident #316 had been administrated 1 tablet on 2/27/18 at 4:00 pm and again on 2/28/18 at 6:15 pm but on this date and time the resident was given ½ tablet. Upon further review in Resident #316's clinical record, the resident had a physician order [REDACTED].½ tablet instead of 1 tablet. Resident #171 had also been administrated 1 tablet of [MEDICATION NAME] 5 mg on 3/7/18 at 8:20 pm from Resident #90's above documented narcotic sheet. Resident #171 had a physician order [REDACTED]. Resident # 345 had also been administrated 2 tablets of [MEDICATION NAME] 5 mg on 5/15/18 at 7 pm from Resident #90's above documented narcotic sheet. Resident #345 had a physician order [REDACTED]. C. Resident #91 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #161 1 tablet on 10/4/18 at 9:30 pm. Resident #161 had a physician order [REDACTED]. D. Resident #111 had a narcotic sheet for [MEDICATION NAME] 4 mg/ml (milligram/milliliter) in which Resident #170 had been administrated 2 mg of [MEDICATION NAME] on 10/8/18 at 1 pm. Resident #170 had a physician order [REDACTED]. Resident #347 was administrated [MEDICATION NAME] 2 mg on 10/13/18 at 12:15 pm and again on 10/14/18 at 8:47 am from Resident #111's narcotic sheet. Resident #347 had a physician order [REDACTED]. E. Resident #152 had a narcotic sheet for [MEDICATION NAME] 25 mcg/hr. patch that Resident #161 was administrated 1 patch of [MEDICATION NAME] on 10/29 18 at 6 pm. Resident #161 had a physician order [REDACTED]. F. Resident #163 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 3/12/18 and again on 6/20/18 at 8 pm. Resident #19 had a physician order [REDACTED]. G. Resident #205 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #349 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 1/8/18 at 8 am and again on 1/8/18 at 2 pm. Resident #349 had a physician order [REDACTED]. Resident #348 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg tablet on 2/19/18 at 4 pm from Resident #205's narcotic sheet. Resident #348 had a physician order [REDACTED]. H. Resident #238 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #19 was administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/16/18 at 8:15 pm. Resident #19 had a physician order [REDACTED]. Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #238's narcotic sheet. Resident #19 had a physician order [REDACTED]. I. Resident #253 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 1 tablet of [MEDICATION NAME] on the following dates and times: 10/26/18 at 11:19 pm, 10/28/18 at 9:46 am, 10/28/18 at 4:08 pm, 10/28/18 at 8:38 pm, 10/29/18 at 1:51 am, 10/29/18 at 8:30 am, 10/30/18 at 12:05 am, 10/30/18 at 5:49 pm, 10/30/18 at 6:49 pm, 10/31/18 at 6:02 X 2 entries to total 2 tablets given, and on 10/31/18 at 9 am X 2 entries to total 2 tablets given. Resident #350 had a physician order [REDACTED]. Resident #351 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/27/18 at 8:07 pm from Resident #253's narcotic sheet. Resident #351 had a physician order [REDACTED]. Resident #352 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/28/18 at 8:33 pm from Resident #253's narcotic sheet. Resident #352 had a physician order [REDACTED]. Resident #544 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/30/18 at 4:36 am and again on 10/30/18 at 6:55 pm from Resident #253's narcotic sheet. Resident #544 had a physician order [REDACTED]. J. Resident #544 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #350 had been administrated 2 tablets of [MEDICATION NAME] 5-235 mg on 10/31/18 at 8:28 pm and again on 11/1/18 at 3:15 am. Resident #350 had a physician order [REDACTED]. K. Resident #257 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times from Resident #257's narcotic sheet: 10/19/18 at 8:25 am, 10/20/18 at 9:45 am, 10/21/18 at 3:23 am, at 9:25 am and at 11:36 pm, 10/22/18 at 7:39 am and at 7:26 pm, and 10/23/18 at 6:30 am. Resident #145 had a physician order [REDACTED]. Resident #344 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on the following dates and times: 10/20/18 at 5:17 pm, 10/21/18 at 9:55 am, 10/22/18 at 5:18 pm and at 11:30 pm from Resident #257's narcotic sheet. Resident #344 had a physician order [REDACTED]. L. Resident #344 had a narcotic sheet for [MEDICATION NAME] 5-325 mg tablets in which Resident #145 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 2:46 pm. Resident #238 had been administrated 1 tablet of [MEDICATION NAME] 5-325 mg on 10/31/18 at 8:14 pm from Resident #344's narcotic sheet. Resident #238 had a physician order [REDACTED]. M. Resident #545 had a narcotic sheet for [MEDICATION NAME] 7.5-325 mg tablets in which Resident #185 had been administrated 1 tablet of [MEDICATION NAME] 7.5-325 mg on 10/31/18 at 5 am and again at 2:58 pm from Resident #545's narcotic sheet. Resident #185 had a physician order [REDACTED]. The surveyor requested and reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. On 11/2/18 at approximately 3:30pm, the surveyor interviewed LPN (Licensed Practical Nurse) #1. The surveyor asked LPN #1 if you were administrating medications and noted that you were out of a particular medication, like a narcotic, what would she do. LPN #1 stated that she would borrow that particular medication from another resident that had it. LPN #1 also stated if the medication that you needed was a narcotic you would sign out for it on the resident's narcotic sheet that you were borrowing it from. The surveyor requested that the pharmacist on duty for this day (11/1/18) come and speak to the surveyor. The pharmacist on duty for 11/1/18 came to the surveyor approximately 3:45 pm and the surveyor asked the pharmacist the same question as proposed to LPN#1 as documented above. The surveyor also asked the pharmacist if the staff was able to share medications. The pharmacist replied No, they are not to share any medications at all. If they are out of a particular medication then they are to notify pharmacy of this. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance nurse (QA) and registered nurse (RN) #1 on 11/2/18 at 11:46 am in the conference room along with 3 of the survey team members in attendance. The pharmacist was asked during this time that the time the drug regimen reviews were being performed by himself if the narcotic records were checked. The pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what which residents were documented as being signed out for narcotics on each of the narcotic sheets. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. The director of nursing and the pharmacist had stated no. The surveyor asked the pharmacist if he had notified anyone as to correcting the charges for the residents that had been charged for the narcotics that had been dispensed to the resident's on the narcotic sheets and when a resident was discovered as to had been receiving narcotic medications from other resident's narcotic sheets. The pharmacist stated that he did not know that there had been sharing of narcotic medications until now. The surveyor requested and received the end of the month charges for (MONTH) (YEAR) for Resident #253. The surveyor noted that on 10/12/18 Resident #253 had been dispensed and charged for 75 tablets of [MEDICATION NAME] 5-325 mg. During the discovery of sharing of narcotics, the surveyor noted that Resident #253 had a total of 17 tablets of [MEDICATION NAME] 5-325 mg tablets that had been administrated to 4 other residents from 10/26/18 thru 10/31/18. The residents involved that received these tablets from Resident #253 were Resident #350, Resident #351, Resident #352 and Resident #544. On the end of the month charges for (MONTH) (YEAR), Resident #253 had no documentation of credits being given for the [MEDICATION NAME] 5-325 mg tablets that the other stated above residents received from Resident #253's narcotic sheets. The surveyor did not review any other end of the month charges for the remaining residents involved in either receiving or sharing of the above documented narcotic medications due to the magnitude and numbers involved. No further information was provided to the surveyor prior to the exit conference on 11/2/18. 2. The facility staff failed to protect a resident's right to be free from misappropriation of resident property and/or exploitation. The facility staff misappropriated seven resident's narcotics when the nursing staff on the South Terrace, Garden Terrace, and North Terrace used prescription dispensed medications for seven residents without gaining their permission to use their medications (Resident #85, Resident #14, Resident #43, Resident #142, Resident #159, Resident #60 and Resident #42) to administer to thirteen (13) residents (Resident #9, Resident #143, Resident #353, Resident #444, Resident #18, Resident #68, Resident #293, Resident #142, Resident #97, Resident #52, Resident #43, Resident #230, and Resident #106). The thirteen residents identified as the recipient of the medications also had prescriptions for those same narcotics as the giver. F Tag 602 reads in part Misappropriation of resident property, as defined at §483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Another example of misappropriation of resident property is the diversion of a resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. (2a). The facility staff borrowed a [MEDICATION NAME] from Resident #85's [MEDICATION NAME] box for Resident #9. The clinical record of Resident #85 was reviewed 10/30/18 through 11/2/18. Resident #85 was admitted to the facility 2/9/16 with [DIAGNOSES REDACTED]. Resident #85's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/14/18 assessed the resident with short term memory problems, long term memory problems and severely impaired cognitive skills for daily decision making. Resident #85's (MONTH) (YEAR) physician's orders [REDACTED].#85's orders included an order for [REDACTED].**Remove old patch prior to applying new one. Resident #85's [MEDICATION NAME] narcotic log was reviewed. Resident #85 received [MEDICATION NAME]es on 10/21/18 at 9:00 a.m., 10/24/18 at 9:00 a.m., 10/27/18 at 9:00 a.m., and 10/30/18 at 9:00 a.m. as documented on the (MONTH) (YEAR) electronic Medication Administration Record [REDACTED] On the [MEDICATION NAME] log dispensed for Resident #85, the staff have also documented that Resident #9 had received a [MEDICATION NAME] from Resident #85's box on 10/26/18 at 8:00 p.m. There was not a narcotic log for Resident #9's [MEDICATION NAME]. The surveyor requested the (MONTH) (YEAR) physician's orders [REDACTED].#9 and Resident #85 from the director of nursing on 11/1/18 at 8:00 p.m. Resident #85's (MONTH) (YEAR) pharmacy review was conducted on 10/17/18. There were no discrepancies addressed on the review. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both responded no. The surveyor reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. No further information was provided prior to the exit conference on 11/2/18. (2b). The facility staff borrowed [MEDICATION NAME] with Tylenol 5-325 ([MEDICATION NAME]) from Resident #14's box to administer to Resident #143 (ten pills), Resident #353 (1 pill), Resident #444 (3 pills), Resident #18 (1 pill), and Resident #68 (1 pill) and Resident #293 (two pills). The clinical record of Resident #14 was reviewed 10/30/18 through 11/2/18. Resident #14 was admitted to the facility 7/1/13 with [DIAGNOSES REDACTED]. Resident #14's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/18/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. Resident #14's (MONTH) (YEAR) physician's orders [REDACTED]. The narcotic record for Resident #14's narcotic [MEDICATION NAME] with Tylenol 5-325 was reviewed. The narcotic log documented that 30 pills of [MEDICATION NAME] with Tylenol 5-325 had been dispensed on 3/9/18. The narcotic record log had six other residents name written on the narcotic log from (MONTH) (YEAR) through (MONTH) (YEAR). Resident #143 was administered ten (10) pills from Resident #14's card on 10/13/18 at 12:00 a.m., 10/13/18 at 4:00 a.m., 10/13/18 at 12:00 noon, 10/13/18 at 4:00 p.m., 10/13/18 at 8:00 p.m., 10/14/18 at 12:00 a.m., 10/14/18 at 8:00 a.m., 10/14/18 at 12:00 noon, 10/14/18 at 4:00 p.m., and 10/14/18 at 8:00 p.m Resident #353 received one (1) pill on 7/2/18. Resident #444 received three (3) pills from Resident #14's card in (MONTH) (YEAR) on 4/26/18 at 9:00 a.m., 4/26/18 at 9:00 p.m., and 4/27/18 at 9:00 a.m. Resident #18 received one (1) pill on 5/8/18 from Resident #14's card. Resident #68 received one (1) pill from Resident #14's card on 8/16/18. Resident #293 received two (2) pills from resident #14's card on 10/6/18 and 10/7/18. The surveyor requested the face sheet, the monthly drug regimen reviews for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), and the (MONTH) physician's orders [REDACTED]. Resident #14's (MONTH) (YEAR) pharmacy review was conducted on 10/17/18. There were no discrepancies addressed on the review. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both responded no. The surveyor requested the end of the month charges for (MONTH) (YEAR) for Resident #14. The surveyor reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. No further information was provided prior to the exit conference on 11/2/18. (2c). The facility staff borrowed fifteen (15) [MEDICATION NAME] 5-325 from Resident #43's box to administer to Resident #142. The facility staff failed to ensure Resident #142's [MEDICATION NAME] 5-325 mg (milligrams) was available for administration in (MONTH) (YEAR). The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The facility nurses borrowed fifteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #142 on 10/23/18 at 6:00 p.m., 10/24/18 at 8:00 a.m., 10/24/18 at 6:00 p.m., 10/25/18 at 8:00 a.m., 10/25/18 at 6:00 p.m., 10/26/18 at 8:00 a.m., 10/26/18 at 6:00 p.m., 10/27/18 at 8:00 a.m., 10/27/18 at 6;00 p., 10/28/18 at 8:00 a.m., 10/28/18 at 6:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 6:00 p.m., 10/30/18 at 8:00 a.m., and 10/30/18 at 6:00 p.m. The surveyor requested the Resident #142's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. Resident #43's (MONTH) (YEAR) monthly drug regimen review was completed on 10/25/18 with no issues identified. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both responded no. The surveyor requested the end of the month charges for (MONTH) (YEAR) for Resident #43. The surveyor reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursing personnel have access to schedule II controlled drugs. 2. Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. 3. If the count is correct a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of resident b. Name and strength of drug c. Quantity received d. Number on hand e. Name of physician f. Prescription number g. Name of issuing pharmacy h. Date and time received i. Time of administration j. Method of administration k. Signature of person receiving medication, and l. Signature of nurse administering medication 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count immediately. The on-coming nurse must count and visualize the controlled drugs. Discrepancies must be documented and reported to the nursing supervisor/director of nursing services. 8. The nursing supervisor/director of nursing services or designee is responsible for investigating discrepancies to determine the cause of such occurrences. 9. If a discrepancy occurs, the director of nursing services is to report verbally to the administrator and pharmacist. 10. The administrator or designee will contact appropriate authorities. No further information was provided prior to the exit conference on 11/2/18. (2d). The facility staff borrowed fourteen [MEDICATION NAME] 5-325mg (milligrams) from Resident #43's [MEDICATION NAME] 5-325 mg to administer to Resident #97. The clinical record of Resident #43 was reviewed 10/30/18 through 11/2/18. Resident #43 was admitted to the facility 5/12/08 with [DIAGNOSES REDACTED]. Resident #43's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15 /15. Resident #43's (MONTH) (YEAR) physician's orders [REDACTED]. The facility nurses borrowed fourteen doses of [MEDICATION NAME] 5-325 mg from Resident #43 to administer to Resident #97 on 10/27/18 at 2:00 p.m., 10/27/18 at 8:00 p.m., 10/28/18 at 2:00 p.m., 10/28/18 at 8:00 p.m., 10/29/18 at 8:00 a.m., 10/29/18 at 2:00 p.m., 10/29/18 at 8:00 p.m., 10/30/18 at 8:00 a.m., 10/30/18 at 2:00 p.m., 10/3018 at 8:00 p.m., 10/31/18 at 8:00 a.m., 10/31/18 at 2:00 p.m., 11/1/18 at 8:00 a.m., and 11/1/18 at 2:00 p.m. The surveyor requested the Resident #97's face sheet, (MONTH) physician orders, (MONTH) (YEAR) medication administration records, Resident #43's face sheet, (MONTH) (YEAR) physician orders [REDACTED]. Resident #43's (MONTH) (YEAR) monthly drug regimen review was completed on 10/25/18 with no issues identified. The surveyor interviewed the pharmacist, the director of nursing, the quality assurance registered nurse and registered nurse #3 on 11/2/18 at 11:46 a.m. The pharmacist was asked during the drug regimen review if the narcotic records are checked and the pharmacist stated he only checks the narcotic records for completeness and doesn't review them in details as to what residents are on the log. Both the pharmacist and the director of nursing were asked if they had informed the staff to borrow medications from one resident for another. Both responded no. The surveyor requested the end of the month charges for Resident #43. The surveyor reviewed the facility policy on controlled medications on 11/2/18. The policy read in part 1. Only authorized licensed nursi

Based on resident interview, staff interview, and clinical record review, facility staff failed to provide for the resident's right to choose activities and associates within the community for 1 of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITION] or [MEDICAL CONDITION], and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off the nursing unit. During an interview on 10/30/2018, Rresident #263 reported that his main social activity was sitting outside smoking and talking with the other men. He wasn't interested in group activities. He reported that he had not been allowed to smoke since he was hospitalized with an infection. He said that he isn't allowed in the (wheel) chair now. The surveyor asked if he had been told why he couldn't smoke. He said the people running the place decided he had to wear a patch instead. He did not want to wear the patch and said he had been telling them every day that he didn't want it and that he wanted to smoke. On 10/31/18 8:30 AM, the surveyor spoke with the resident again. He stated that every time he asked to go to smoke, he was given different reasons he couldn't smoke. He said they hadn't let him smoke since he came from the hospital. They have said now that he can't go smoke until at least Monday (the next Monday was 11/5). He did not know why Monday. The resident stated I'd like to be able to go smoke one. I'd like to get back in my chair, but they say I'd fall out of it. I'm supposed to be having therapy. On 10/31/18 at 02:20 PM, the director of nursing (DON) reported she won't allow him to go outside to smoke, or to stores with family because his family are drug users. On 11/1/18 at 2:30 PM, the DON said she did not say it right yesterday. She said she did not tell the resident he could not smoke. She said she told him he needed to sign out when he left. She said she had told him not to wheel around the parking lot because people drive too fast in the parking lot and he could get hit. On 11/01/18 at 3:21 PM the DON stated that she didn't mean to say what she did. She she said she meant that staff had told her that they heard he smelled like marijuana when he had been out with the family members, who were known drug addicts. She said she had a note written sometime in the past and she could provide a witness because she never talked to anyone without a witness. On 11/1/18 at 4 PM, the DON brought a printed Registered Nurse progress note dated 11/1/18 3:41 PM (nurse) and myself spoke with resident about his desire to smoke. We told him that if he desired to smoke that the CNA could get him up and a staff member could assist him to the smoking area. We reminded him if he had on a [MEDICATION NAME] it could make him sick. If he desires we could ask his doctor to d/c (discontinue) the [MEDICATION NAME]. We discussed it with him if the staff had been getting him up and he said he thought he had gotten up. We told him if he had any concerns to ask for (DON) or (nurse). He thanked us for stopping by. The DON stated that she wanted to take care of this herself and said she told Resident #263 that he could smoke today if he wanted to because he wasn't wearing a patch. The DON stated, while addressing other issues with surveyors, on 11/1/18 after 4 PM, that the resident couldn't smoke because he had agreed to the order for nicotine patches while he was in the hospital. On 10/31/18, the surveyor spoke by phone with the resident's power of attorney (POA). The surveyor asked about activities and preferences. The POA said that staff were getting the resident up to a recliner every other day. She said they did not get him up on days her daughter visited him instead of the POA. She said the resident feels angry and frustrated because he has no control over his life and and he doesn't want anyone to tell him what to do. She said he asks to smoke every day. Staff have been telling him he can not. (LPN 1) told him no, not until at least Monday The POA approves of staff preventing the resident from smoking. She said that yesterday (10/30) the resident had refused the nicotine patch and she had persuaded (LPN 1) to sneak a patch on him while he was distracted. She said that made him less angry and agitated. Clinical record review revealed a Safe Smoking assessment dated [DATE] conducted by a registered nurse indicated that the resident met all safe smoking criteria. Comments: Alert, oriented to person, place, time; always with family/friend when smoking; good safety awareness re:smoking materials; smoking materials kept at Nurse's station. Physician orders [REDACTED]. The residents' comprehensive plan of care, initiated 9/1/16, had not been updated to indicate that the resident's smoking was to be restricted or to reflect a smoking cessation plan. A physician readmission note dated 10/23/18 at 10:01 AM indicated under status that the resident was a an active tobacco user. There was no indication that the physician discussed a smoking cessation plan with the resident. A social services note dated 10/31/18 at 11:00 PM indicated .Prior to going out to the hospital, he would go out to smoke with family several times daily. Since, he came back from (hospital), he has an order for [REDACTED]. The surveyor was unable to locate any other evidence of smoking cessation interventions. The director of nursing and the quality assurance nurse were made aware of the concern throughout the survey process.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for 4 of 39 residents in the survey sample (Residents #14, #72, #55 and #209). The findings included: 1. For resident #14, facility staff failed to obtain a written advance directive prior to initiating a no cardiopulmonary resuscitation order. Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment with assessment reference date [DATE], the resident scored ,[DATE] on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITION] or [MEDICAL CONDITION]. The resident exhibited behavioral symptoms not directed toward others on ,[DATE] of the 7 days prior to the assessment. During clinical record review on [DATE], the surveyor noted a physician order [REDACTED]. The surveyor reported the concern to the director of nursing and the quality assurance nurse on [DATE]. On [DATE], the surveyor received copies of the resident's record with a note which stated (resident #14) only has MD order for no CPR. 2. The facility staff failed to ensure Resident #72 had a complete and accurate DDNR (Durable Do Not Resuscitate). Resident #72 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #72 was also coded as requiring extensive assistance of 1 staff member for dressing and being totally dependent on 1 staff member for personal hygiene and bathing. The surveyor conducted a clinical record review on Resident #43 on [DATE]. During this review, it was noted by the surveyor that the DDNR dated for [DATE] was not filled out completely. Section 1 of the DDNR read in part, I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The boxes beside #1 and #2 were blank. Section 2 read If you checked 2 above, check A, B, or C below: These three boxes below were blank. The surveyor notified the DON (director of nursing) and the QA nurse of the above documented findings on [DATE] at 2 pm. No further information was provided to the surveyor prior to the exit conference on [DATE]. 3. The facility staff failed to have a DDNR (Durable Do Not Resuscitate) executed for Resident #55. Resident #55 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 8 out of a possible score of 15. Resident #55 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent of 1 staff member for bathing. The surveyor performed a clinical record review on Resident #55. During this review, it was noted by the surveyor that there was a physician order [REDACTED]. There was no DDNR signed by the resident or responsible party that stated the resident's request or wishes for No CPR. The surveyor interviewed the DON (director of nursing) on [DATE] at 1:30 pm by the surveyor. The surveyor asked the DON if this resident or his responsible party had signed a DDNR, in which the resident's wishes were documented regarding No CPR. The DON stated to the surveyor that when the physician writes the order for No CPR, the staff follows the direction of the physician order. The surveyor notified the DON and the QA nurse of the above documented findings on [DATE] at 2 pm. The surveyor asked them if there was any other documentation besides the physician order [REDACTED]. The DON stated, I don't have anything else. No further information was provided to the surveyor prior to the exit conference on [DATE]. 4. The facility staff failed to have a DDNR (Durable Do Not Resuscitate) executed for Resident #209. Resident #209 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #209 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent of 1 staff member for bathing. The surveyor performed a clinical record review on Resident #209 on [DATE]. During this review, the surveyor noted there was a physician order [REDACTED]. There was no DDNR signed by the resident or responsible party that stated the resident's request or wishes for No CPR. The surveyor interviewed the DON (director of nursing) on [DATE] at 1:30 pm. The surveyor asked the DON if this resident or his responsible party had signed a DDNR, in which the resident's wishes were documented regarding No CPR. The DON stated to the surveyor that when the physician writes the order for No CPR, the staff follows the direction of the physician order. The surveyor notified the DON (director of nursing) and the QA nurse on [DATE] at 2 pm. The surveyor asked them if there was any other documentation besides the physician order [REDACTED]. The DON stated, I don't anything else. No further information was provided to the surveyor prior to the exit conference on [DATE].

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure the dignity of 3 of 39 residents was maintained (Resident #18, Resident #285, and Resident #55). The findings included: 1. The wound care registered nurse #1 signed the tape after the tape had been applied to Resident #18's dressings on both legs. Resident #18 was admitted to the facility 11/12/14 with diagnoses, that included but not limited to [MEDICAL CONDITIONS], chronic venous hypertension with ulcer of left lower extremity, major [MEDICAL CONDITION], obesity, type 2 diabetes mellitus, hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #18's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/16/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #18's current comprehensive care plan dated 2/4/18 identified the resident to be at risk for skin breakdown per Braden scale-13. Interventions included to perform wound care as ordered. The surveyor observed wound care to Resident #18's bilateral legs on 10/31/18 at 10:27 a.m. with the wound care registered nurse #1 and the restorative certified nursing assistant #1. Resident #18's physician orders for wound care read Clean LLL (left lower leg) with NS (normal saline), pat dry, apply moisturizing lotion and wrap with ace wrap qd (everyday) for skin integrity and circulation. Clean RLL (right lower leg) with NS, pat dry, apply Silver calcium alginate and ABD pad (as needed), wrap with ace wrap qd and prn (whenever necessary). Upon completion of wound care to both lower extremities, the wound care registered nurse #1 applied a large piece of tape to both of the ace wraps. The wound care R.N. #1 then signed and dated the tape after the tape had been applied to the dressings. The wound was on the shin of Resident #18's right lower leg. The surveyor requested the facility policy on dressing changes from the director of nursing on 10/31/18. The policy for dressings-clean was reviewed 10/31/18. Procedure: 12. Apply dressings. Secure with tape if necessary. The surveyor informed the director of nursing (DON) and the quality assurance (QA) registered nurse of the above concern on 11/1/18 at 8:00 p.m. The DON stated she would expect the nurse to write the initials and date on the tape before the tape was applied to the dressing and requested the facility's policy on resident rights. The facility's Residents' Rights was reviewed 11/2/18. Residents' Rights read in part under N. Quality of Life that it is the desire of the facility to care for you in a manner and in an environment that maintains and enhances your dignity and respect, recognizing your individuality. No further information was provided prior to the exit conference on 11/2/18. 2. The facility staff initialed and dated a dressing after it had been placed on Resident # 285. Resident # 285 was a [AGE] year-old-female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 285 was reviewed on 10/31/18 at 10:34 am. The most recent MDS assessment (minimum data set) was a 14-day scheduled assessment with an ARD (assessment reference date) of 10/18/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 285 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 285 was cognitively intact. Section M of the MDS assesses skin conditions. In Section M1040, the facility staff documented that Resident # 285 had skin tear(s) during the look back period for the 10/18/18 ARD. The plan of care for Resident # 285 was reviewed and revised on 10/6/18. The facility staff documented a focus area for Resident # 285 as, Resident # 285 is at risk for skin breakdown. Interventions included but were not limited to: Cleanse right forearm and apply dsg (dressing) as ordered. Resident # 285 had current orders that were initiated by the physician on 10/5/18 that included but was not limited to: Cleanse right forearm with NS (normal saline) pat dry and apply xeroform and top dressing Q3D (every 3 days) and PRN (as needed) until healed. On 10/31/18 at 9:55 am, the surveyor observed LPN # 1 (licensed practical nurse) providing wound care to Resident # 285's right forearm. The surveyor observed LPN # 1 cover Resident # 285's wound to her right forearm with a dressing and initial and date the dressing after it had been applied to Resident # 285's right forearm. On 11/2/18 at 10:32 am, the director of nursing was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/2/18. 3. The facility staff failed to provide dignity during a wound care observation to Resident #55. Resident #55 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/4/18 the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 8 out of a possible score of 15. Resident #55 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the wound care observation on 10/31/18 at approximately 11:15 am, the wound care nurse performed the dressing change to the resident's left heel, left foot and right stump as ordered by the physician. The wound care nurse applied tape to the above documented areas, wrote in pen her initials along with the date and time that the dressings were applied. The surveyor notified the DON (director of nursing) and the QA nurse on 11/1/18 at approximately 11 am. The surveyor asked the DON if the above documented actions of the wound care nurse were appropriate and/or acceptable to do. The DON stated, She should had wrote on the tape before applying it to the resident. No further information was provided to the surveyor prior to the exit conference on 11/2/18.

Based on staff interview, facility document review, clinical record review , and in the course of a complaint investigation, the facility staff failed to ensure 1 of 30 residents was free from abuse(Resident #1). The findings include: The facility staff failed to ensure Resident #1 was free from abuse. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly MDS with a reference date of 5/29/16 was reviewed. The resident was assessed with [REDACTED]. The resident was assessed requiring total assistance of 2 persons for toileting, dressing, bed mobility, transfers, bathing, and hygiene. The resident was coded to resist care. The comprehensive care plan was reviewed. The care plan included a problem listed the resident was alert but delusional and had episodes of being combative and resistive to care. The interventions included to attempt redirection techniques when resident became confused and provide support and reassurance when expressing negative ideations. The director of nursing (DON) was interviewed on 8/10/16 at 1:45 p.m. about the incident. The DON stated a family member had provided her with a video taken in the resident's room from a nannie cam set up by the family member. The DON stated she viewed the video and immediately terminated the certified nursing assistant (CNA#1) involved. The police were notified, APS notified, DHP notified, and the Office of Licensure and Certification notified. The video was viewed by two members of the survey team. The surveyors observed CNA#1 enter Resident #1's room on 3/15/16. CNA#1 approached the bed and did not speak to the resident. CNA#1 pulled the covers off the resident and roughly pulled off the blue booties the resident had on her feet. She then pulled the resident's gown off and roughly pulled it off her arms and rubbed it in the resident's face. The resident was holding up in hands in a defensive manner. CNA#1 then stepped out of view and water could be heard running. The resident was left uncovered at this time. CNA#1 returned with a pan of water for bathing. She grabbed the resident's arm and jerked her up and roughly turned her to her side and pushed on her, then grabbed her arm and pulled her up and then grabbed her hair and lifted the resident off the bed. The CNA spoke to the resident and could be heard saying I hope you do spit on me. CNA#1 then glanced to the door and could be seen spitting in the resident's face which she roughly wiped off. At this point a voice could be heard and a family member entered the room. CNA#1 then handled and spoke to the resident in gentle manner as she spoke with the family member. The DON provided the facility investigation into the incident. The DON provided the facility plan of correction as follows: The CNA was terminated and Resident #1 was examined and no injuries noted. All residents cared for by CNA#1 were assessed and interviewed if possible and none had any complaints. All staff were inserviced on Caring for Residents with Dementia, Resident Rights, and Treating Residents with Respect and Dignity. Resident #1 will have 2 CNAs whenever she requires care and house RN supervisors will monitor care more closely for all residents. The nannie cam will remain in place without audio and only pointed towards Resident #1. The completion date was noted to be 3/31/16. The DON and quality assurance director were informed on 8/10/16 at 4:00 p.m. that this complaint would be substantiated as a past non compliance issue.