Health inspection·February 22, 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 interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. Residents Affected - Few The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone-Acetaminophen (Norco) 10-325mg, 30 tablets (a narcotic pain reliever) received from the pharmacy on 12/19/23 and reported missing on 12/20/23. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Review of Resident #1's face sheet printed 02/22/24 reflected a [AGE] year-old female originally admitted to the facility 10/02/22 and readmitted [DATE]. Her diagnoses included type 1 diabetes mellitus (a condition that affects the way the body processes blood sugar), end stage renal disease (loss of function of the kidneys), dependence on renal dialysis (a treatment that assists the body in removing extra fluid and waste from the blood), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), legal blindness, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required moderate assistance with hygiene and bathing and only supervision with most other ADLs. Section J (Health Conditions) the resident had pain occasionally during the assessment period. Review of Resident #1's comprehensive care plan, revised 03/06/23, reflected risk for acute and chronic pain related to a history of rib fractures and chronic pain syndrome. Interventions included administer analgesic (pain medicine), anticipate the need for pain relief, evaluate the effectiveness of pain interventions, monitor for side effects, and the resident prefers to have pain controlled by Hydrocodone-Acetaminophen. Review of Resident #1's physician order dated 11/17/23 reflected Norco oral tablet 10-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1's medication administration record for December 2023, reflected eleven doses of Norco (Hydrocodone-Acetaminophen) were administered during the month. Review of the Provider Investigation Report dated 12/28/23 reflected, on 12/20/23 at 9:00 PM, drug Page 1 of 3 675946 675946 02/22/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diversion was reported. The alleged perpetrator was unknown. Four staff members were named as witnesses. The allegation reflected, Blister pack of 30 Norco (a narcotic pain reliever) along with all documentation missing from medication cart for a single resident (Resident #1). The charge nurse that had been on duty when Norco was received noticed that the blister pack of Norco and documentation was missing when she came back for her shift next day. The report reflected on injury or harm to the resident. The facility notified the police, the medical director, their family, and regional corporate nurse. The resident had no knowledge of the drug diversion. The statements were obtained, and staff were drug tested. The investigation findings confirmed the drug diversion. Review of the pharmacy packing slip dated 12/19/23 reflected 30 hydrocodone/APAP tablets 10-235mg, were delivered to the facility. Review of the business card left by the responding police officer reflected, CASE NO: P23100075 DATE: 12/21/23. During an interview on 2/22/24 at 1:00 PM, the DON stated they did not identify a perpetrator or find the missing medications. She stated, Maybe the medication had been accidently discarded, but that would not have accounted for the missing paperwork. During a phone interview on 2/22/24 at 3:35 with the local police department, the officer stated the case number he provided was not a case number. The call was transferred to the narcotics division, but the call went unanswered. During an interview on 2/22/24 at 3:58 PM, the DON stated after the medication was noticed to be missing, the narcotic drawer was recounted by two staff. The other medication cart was counted, then the nurse's switched carts, and recounted again. She stated they looked at each bubble-pack in both medication carts incase the medication was accidently put in the cart and not the locked drawer. She stated they notified the regional nurse, called the police, and notified family. She stated the pharmacist came to check the facility. She stated the resident had not missed any doses of the medication, there was no adverse effect for the resident. She stated that neither the medications nor the count sheet was ever located. She stated the nurses and medication aides were drug tested and all the results were negative . During an interview on 2/22/24 at 4:12 PM with ADON A, she stated she received 30 Norco tablets from the pharmacy on the night of 12/19/23. She matched the paper to the bubble pack confirming the number of pills delivered. She placed the medication in the narcotics drawer on the medication cart and locked the medication cart. She stated she counted the narcotics drawer at the end of her shift. The next day when she returned to work, she stated she was counting the narcotics with the off going nurse when she noticed the Norco, she received the night before was not in the narcotic drawer. She stated they looked in the other medication cart but could not locate the medication. She stated they notified the DON at that time. She stated she was drug-tested . During an interview on 2/22/24 at 4:23 PM, the ADM stated he was notified when the medication went missing. He stated they investigated and looked for the medication. He stated the police were notified and came to the facility, but they were there for less than five minutes. He stated the staff who had access to the medication all wrote statements and were drug tested. He stated they were not able to identify a perpetrator . Review of the facility policy Identifying Exploitation, Theft, and Misappropriation of Resident 675946 Page 2 of 3 675946 02/22/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0602 Level of Harm - Minimal harm or potential for actual harm Property dated April 2021 reflected in part, 1. Exploitation, theft, and misappropriation of resident property are strictly prohibited. 4. 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. 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication). Residents Affected - Few 675946 Page 3 of 3