Health inspection·November 21, 2023

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 observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of proper for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. Residents Affected - Few The facility failed to prevent the misappropriation of Resident #1's Belsomra, a medication to help with sleeping. This failure could place residents at risk for not receiving prescribed medications. Findings included: Review of Resident #1's undated face sheet reflected the resident was admitted [DATE]. Her diagnoses included chronic respiratory failure (inability of the lungs to get enough oxygen to the body), sepsis (an infection in the blood), cognitive communication deficit (communication problem related to cognition rather than language or speech), hypertension (high blood pressure), cerebral infarction (stroke), type 2 diabetes mellitus (a problem with how the body regulates blood sugar), anxiety (intense feelings of fear or terror), and depression (persistent feeling of sadness and loss of interest). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMs score of 14 indicating intact cognition. She was documented as receiving a hypnotic during the 7-day look back period. Review of Resident #1's physician orders dated 7/11/23 reflected an active order for Belsomra 10mg oral at bedtime. Review of Resident #1's Medication Administration Record (MAR) dated 11/1/23 through 11/21/23 reflected the Belsomra had not been administered the night of 11/13/23 because the medication was unavailable. Review of the facility's investigation of the missing Belsomra medication reflected on 11/14/23 at 6:12 AM, the DON was notified by LVN A of a med discrepancy for Resident #1. LVN A stated the narcotic count sheet reflected 10 tablets but there were only 6 on the medication cart. LVN A told the DON that MA C had counted the medications and told RN B there was a discrepancy. LVN A told the DON, RN B had already left the building. Review of the controlled drug receipt/record/disposition form reflected RN B signed the form on 11/13/23 with the quantity received marked as 10. Page 1 of 3 455497 455497 11/21/2023 Creekside Terrace Rehabilitation 1555 Powell Avenue Belton, TX 76513

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/21/23 at 12:55 PM with LVN A, she stated she had worked at the facility going on two years. She stated she had recent in-service on controlled medications and diversion. She stated the controlled meds were counted every time the keys change hands. She stated on her halls the med aides worked from 6:00 AM until 2:00 PM and then from 4 PM until 8:00 PM so the meds were counted multiple times throughout her shift. She stated if there was a med discrepancy, the DON was notified immediately. She stated she nor the other nurse or med aide could leave the building. During an interview on 11/21/23 at 1:00 PM with the DON, she stated she received a phone call in the morning reporting the narcotic count was off with four pills missing. She was informed the off-going nurse (RN B) had already left the building. She stated she called him, and he was loud and cursing and, all over the place. She stated that during the second call to RN B, he first said he could not remember if the medication was sealed and bagged but later, he stated it was sealed but he took it out of the bag when he locked it in his medication cart. The DON stated RN B admitted he had put the medication cart keys in the drawer at the nurse's station. She stated she was not able to determine who took the medications but, by leaving the keys in the drawer, he allowed everyone access to the medication cart. She stated RN B was suspended pending the investigation then after conversations with cooperate and human resources, RN B was terminated. She stated the facility did not have cameras, so she was not able to see who took the medications. During an interview on 11/21/23 at 1:10 PM with MA D, she stated she had worked at the facility full time since 2018. She stated she had recent training on counting controlled medications. She stated she had to count at the start of her shift and again before leaving. She stated if there was a discrepancy in the count that was not easily resolved, the charge nurse or DON was notified immediately. She stated staff could not leave the facility until the discrepancy was resolved. She stated the keys were kept in her pocket throughout the shift, but if she left the floor, she gave the keys to the nurse. During a telephone interview on 11/21/23 at 1:48 PM with the police detective assigned to the case, he stated he had not yet been in contact with RN B. During an interview on 11/21/23 at 3:26 PM with the DON, she stated it did not meet her expectations that controlled medications would be missing. She stated the suspected staff member was out of the building and there were systems in place to prevent it from happening again. Observation and interview on 11/21/23 at 2:50 PM revealed Resident #1 awake in a wheelchair in her room. She stated she slept well most nights but occasionally had trouble falling asleep. She stated she did not remember if she had missed any doses of the sleep medication recently. A telephone message was left on 11/21/23 at 3:25 PM for RN B requesting a return call. A return call was not received before close of business 11/21/23. Review of the facility's policy regarding Loss or Theft of Medications, revised 4/1/22 reflected in part, Staff should immediately report any discrepancies or a suspected theft or loss of drugs from an onsite store to a supervisor/manager or the Director of Nursing for appropriate investigation for possible diversion. Review of the facility's policy regarding storage and reconciliation of controlled substances revised 4/1/22 reflected in part, 1. Only authorized staff, licensed nurses and pharmacy personnel will have access to controlled medications. 3. All controlled medications must be maintained in separately 455497 Page 2 of 3 455497 11/21/2023 Creekside Terrace Rehabilitation 1555 Powell Avenue Belton, TX 76513

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few locked, permanently affixed compartments. The access key to controlled medications is not the same key which gives access to other medications. Duplicate keys to all medication storage areas, including those for controlled medications, are kept by the Director of Nursing. A. The authorized staff member will have the controlled substance key(s) in his/her possession at all times while on duty. 4A. At the end of every shift the nurse/authorized staff member reporting on duty and the nurse/authorized staff member reporting off duty meet at the designated medication cart or storage area to count all controlled substance drugs. 455497 Page 3 of 3