Health inspection·March 26, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident's-controlled medications were accounted for and not subjected to misappropriation or diversion for 2 of 6 residents (R3 and R4) reviewed for controlled medications in a sample of 7. This failure has the potential to affect all residents residing at the facility who receive controlled medications. Residents Affected - Few Past Noncompliance: no plan of correction required. This past non-compliance occurred between 03/01/24 and 03/09/24. Findings include: 1. R3's Face Sheet, with an admission date of 01/06/23, documents R3 has diagnoses of but not limited to Acute hematogenous osteomyelitis, left humerus, Gastroesophageal reflux disease (GERD), acute kidney failure, Diabetes Mellitus, chronic pain syndrome, and other specified arthritis. R3's Minimum Data Set, (MDS), dated [DATE], documents R3 is cognitively intact with a Brief Interview for Mental Status, (BIMS), of 15 out of 15. It further documents R3 requires substantial/maximal assistance with oral hygiene, shower/bathe, upper body dressing, bed mobility, dependent with lower body dressing, personal hygiene, transfer, and she is always incontinent of bladder and always continent of bowel. R3's Care Plan, with print date of 03/26/24, documents R3 experiences the presence of frequent pain, goal is to have full pain relief, and interventions are, teach distraction techniques, monitor for worsening of pain symptoms and notify physician of changes, assess pain daily using 1-10 scale, and administer pain medication as needed. R3's Physician's Order, dated 05/28/2023 at 1:34 PM, documents hydrocodone 10 milligrams (mg)-acetaminophen 325 mg tablet:1 tab by mouth (PO) every 4 hours as needed (PRN) for pain. R3's Controlled Drug Record, dated from 02/15/24 through 03/25/24, was reviewed and shows on 03/01/24 at 1:45 AM, R3 was given one tab of her hydrocodone 10mg-acetaminophen 325mg PRN pain medication by V9, Registered Nurse (RN). The pain medication was marked off which then left 43 tablets of R3's PRN pain medication. It also has the date 03/01/24 at 11:45 written underneath the previous entry with just the initials of V3, Licensed Practical Nurse (LPN). The 43 was not marked off, indicating no PRN pain medication was given and there should still be 43 tablets left. R3's Medication Administration Record, (MAR), dated 03/2024, was reviewed and shows R3 received her PRN her hydrocodone 10mg-acetaminophen 325mg pain medication by V9, RN at 1:42 AM on 03/01/24 and Page 1 of 3 145909 145909 03/26/2024 Greenville Nursing & Rehab 400 East Hillview Avenue Greenville, IL 62246

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then she received it again at 9:02 PM on 03/01/24, by V8, LPN. There is no documentation on R3's MAR she received any PRN pain medication from V3, LPN at 11:45 AM or PM on 03/01/24. On 03/25/24 at 1:35 PM, R3 stated she was informed by facility staff that she had a pain pill that was missing. R3 said she usually takes her pain medication at night, and she doesn't take it like she used to. R3 stated the day it was reported to be missing she didn't ask for any pain medication and nor did she receive any of her pain medication. R3 stated the facility replaced the medication and she never had to miss a dose of the pain medication. 2. R4's Face Sheet, with an admission date of 04/19/22, documents R4 has diagnoses of but not limited to chronic pain, chronic lymphocytic leukemia, and chronic kidney disease. R4's MDS, dated [DATE], documents R4 was moderately cognitively impaired with a BIMS of 08/15 and required supervision/touching assistance with dressing, oral hygiene, toileting hygiene, transferring, walking short distances, partial/moderate assistance with shower/bathe, personal hygiene, occasionally incontinent of bladder, and always continent of bowel. R4's Care Plan, print date of 03/26/24, documents end stage disease, goal: Remain comfortable as disease progresses, interventions are but not limited to, provide comfort measures, and evaluate and treat pain. R4's Physician's Orders, dated 07/24/23, documents Hydrocodone-Acetaminophen 5/325mg (Norco) one tab every 4 hours PRN for pain. R4's Physician's Orders, dated 08/01/23, documents Hydrocodone-Acetaminophen 5/325mg take one tablet by mouth daily at bedtime, (HS). R4's Controlled Drug Record, dated 01/08/24 through 03/18/24 shows on 03/01/24 at 3:00 AM, R4 was given one tab of his PRN Norco by V9, RN and 34 was marked off which then left 33 tablets of R4's PRN pain medication. It also has the date 03/01 written underneath the previous entry with no time and V3's, LPN initials and 33 was not marked off indicating it had not been given. So, the controlled drug record documents R4 still has 33 tablets left of the PRN Norco. R4's MAR, dated 03/01/24, documents R4 received his PRN Norco twice on this day, once by V9, RN. R4 did not receive any other Norco PRN medication for this day, but he did receive his scheduled bedtime dose, which was given by V8, LPN at 9:05 PM. There is no documentation on R4's MAR that V3, LPN gave him a PRN dose of pain medication. R3's and R4's Illinois Department of Public Health (IDPH) final report, date of incident: 3/1/24 at 5:55 PM, documents R3, 3/1/1951, BIMS 15, diagnosis include, but are not limited to: angina pectoris, anxiety disorder, depression, GERD, acute kidney failure. R4, 4/5/1941, BIMS 8, diagnosis include, but are not limited to: non-Hodgkin lymphoma, neuropathy, lumbago with sciatica, chronic kidney disease Stage 1. During a change of shift narc (narcotic) count that was completed at approximately 4p (PM), it was found the count was off by two Norco. When questioned about the two missing narcs, V3, Licensed Practical Nurse (LPN) stated she forgot to sign them out. Camera footage was reviewed and floor nurse V3 was observed in the narcotic box in the med (medication) cart around 12:15p. V3 was then observed taking a card from the back of the narcotic box and popped a pill into a med cup. V3 then continued to dispense other non-narcotic medications into 145909 Page 2 of 3 145909 03/26/2024 Greenville Nursing & Rehab 400 East Hillview Avenue Greenville, IL 62246

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few another med cup. After dispensing the medications, V3 did not go into the room of R3 to administer the narcotic that she had dispensed into a med cup by itself. V3 was observed coming out of the room with what appeared as something in her mouth, and she immediately went to the med cart and took a drink of water. Both residents were immediately assessed with no adverse reaction found. Both residents are alert and oriented times four and stated that they did not ask for any pain medication, nor did they receive any PRN pain medications this day. V3 was immediately drug tested at the facility which revealed she was positive for morphine, oxy (oxycodone), benzos (benzodiazepines), and amphetamines. After the positive urine drug screen employee V3 was asked if she had prescriptions for these medications. V3's urine test was negative during her orientation. V3 said she did have prescriptions and would ask her PCP (Primary Care Physician) for them. V3 did not submit anything from her PCP and informed administrator via text that she would not be returning as a floor nurse with us, she had accepted another position. V3 terminated per investigation findings. On 03/26/24 at 1:50 PM, V2, Director of Nursing (DON) stated she would expect the nurse to ensure the do narcotic count at every shift change. If they find any issues to report it to V2 immediately, and to make sure they sign off the narcotics sheet when the medication is given. V2, DON stated she does random narcotic counts, and she did one on 03/01/24. While doing the random narc count 3/01/24 was when the discrepancy was found. When V2 found the discrepancy, she immediately reported it to V1, Administrator and they reviewed the camera. The facility's Abuse Prevention Policy and Procedures, dated 08/16/2021, documents Misappropriation of resident property, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It further documents Employees are required to report any incident, allegation or suspicion of crime or potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 03/05/24. In attendance- V1, Administrator, V2, Director of Nursing (DON), V6, Medical Doctor, V10, Infection Control Preventionist, V11, Regional Clinical Nurse, and V12, MDS Coordinator. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents who receive a controlled substance. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V2, DON provided in-service to all staff regarding abuse. Completed on 03/09/24. Nursing staff regarding counting narcotics. Completed on 03/04/34. 4. Plan to monitor performance to ensure solutions are sustained: Narcotic audits to be conducted by V2, DON daily for a month, then three times a week for one month, then twice a week for one month. 145909 Page 3 of 3