Health inspection·March 16, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interviews, record reviews and policy reviews, the facility failed to ensure accurate accounting of controlled substances for 3 of 7 residents sampled (Residents #20, #57, and #155). Residents Affected - Some The findings include: A review was conducted of the controlled drug declining inventory sheets and the electronic medication administration record. The following discrepancies were identified: Resident # 155 Diazepam (anxiety) 2 mg (milligrams) - 6 tablets were marked as on hand on 3/9/23 on the Controlled Drug Declining Inventory Sheet. Further review of the sheet revealed that one tablet of diazepam was administered on 3/9/23 at 8:30 AM, 3:00 PM, and 9:00 PM, 3/10/23 at 3:00 AM, 1:30 PM, and 11:00 PM, equaling 6 tablets with zero tablets remaining. However, review of the Medication Administration Record (MAR) for March 2023 revealed the medication was documented as administered 4 times (3/9/23 at 8:21 AM and 2:56 PM and 3/10/23 at 11:10 AM and 11:11 PM) indicating that there should be 2 tablets remaining and not zero as documented on the controlled drug inventory sheet. There were 2 tablets that were not documented as given to the resident but were noted as removed from the controlled drug inventory. Resident # 57 Hydrocodone (pain) 10 mg/325 mg - 18 tablets were marked as on hand on 2/17/23 on the Controlled Drug Declining Inventory Sheet. Further review of the sheet revealed that one tablet of Hydrocodone was given on 2/17/23, 2/18/23, 2/20/23 at 6:00 AM and 8:00 PM, 2/21/23 and there was a notation that a tablet was wasted, and the count was decreased to 12 however no date is noted, 2/25/23, 2/27/23, 3/3/23, 3/5/23, 3/7/23, 3/11/23, and 3/14/23 - equaling 14 tablets with 5 tablets noted as remaining on 3/14/23. However, review of the MARs for February and March of 2023 revealed the medication was documented twice as being administered to resident #57, (2/17/23 and 2/18/23) indicating that there should be 16 tablets remaining and not 5 as documented on the controlled drug inventory sheet. There were 11 tablets that were not documented as given to the resident but were noted as removed from the controlled drug inventory. Resident # 20 Clonazepam (anxiety) 0.5 mg - 15 tablets were marked as on hand on 1/20/23 on the Controlled Drug Declining Inventory Sheet. Further review of the sheet revealed that one tablet of the Clonazepam was Page 1 of 2 105975 105975 03/16/2023 Community Health and Rehabilitation Center 3611 Transmitter Road Panama City, FL 32404

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some given on 1/20/23, 1/24/23; 2/1/23, 2/2/23, 2/8/23, 2/11/23, 2/16/23, 2/22/23, and 2/27/23, equaling 9 tablets with 6 tablets noted as remaining on 2/27/23. However, review of the MAR for January 2023-March 2023 revealed the medication was documented as administered 6 times (1/24/23, 2/1/23, 2/2/23, 2/8/23, 2/22/23 and 2/27/23) indicating that there should be 9 tablets remaining and not 6 as documented on the controlled drug inventory sheet. There were 3 tablets that were not documented as given to the resident but were noted as removed from the controlled drug inventory. An interview was conducted on 3/15/2023 at approximately 11:45 AM with the Director of Nursing (DON). The DON stated, I am responsible for making sure the reconciliations are completed with controlled substances. An interview was conducted on 3/16/2023 at approximately 8:27 AM, with the Administrator and the DON regarding the discrepancies on the controlled drug sheets and the MAR. The Administrator stated that a Performance Improvement Plan (PIP) had been completed in November 2022 regarding missing narcotics. The Administrator stated the PIP was done for ten days. She stated that staff were also educated during that time. The Administrator reported no errors were documented for November 2022. The Director of Nursing stated a random sample was completed for narcotics in December 2022 and revealed no discrepancies. A policy review was conducted on 3/15/2023 of the Controlled Substance Storage, which was dated January 2018. The policy states that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The policy states, The Director of Nursing in collaboration with the Pharmacist will maintain the facility's compliance of controlled substances. The Director of Nursing is to document discrepancies and report to the Administrator any irreconcilable discrepancies. The controlled substance accountability record is kept in the MAR or designated book. The records are submitted to the Director of Nursing and kept on file for five years. 105975 Page 2 of 2