Mn Veterans Home - Luverne

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide safe transfer for 1 of 1 resident (R1) who required the use of a mobility van mechanical lift. This resulted in actual harm when R1 fell from the mobility van to the ground which resulted in significant ongoing pain, administration of pain narcotics and a decrease in activities of daily living (ADL)s. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, no behaviors, and no rejection of cares. R1 required staff assist with dressing, personal hygiene, and transferring. R1 required a manual wheelchair but was independent with mobility. R1's diagnoses included heart failure, arthritis, aphasia (language disorder that affects how you communicate), hemiplegia (paralysis on one side of body), and seizure disorder. R1 denied having pain but did receive scheduled pain medication.R1's pain assessment dated [DATE], identified R1 did not have any pain or hurting in the five days prior with no other information provided. R1's care plan revised on 9/12/25, directed assist of one to two staff with stand-aid lift, and large harness and one staff assist with upper and lower body dressing.On 12/22/25 at 12:50 p.m., a Plan of Care Note indicated R1 had a fall while getting out of the facility van at his appointment destination. The note further identified the facility van driver noted R1 to have a laceration to back of head, right wrist, and ambulance was called.Hospital ED noted dated 12/22/25 at 1:46 p.m., identified R1 had mild wedging (wedge fracture) of T1, L1, and moderate wedging of LA. The report also identified the fractures are age indeterminate (unsure of age), old but there were no comparison studies. The bones are demineralized which limits detection of nondisplaced acute fracture; with the limitation, there is no definite acute fracture or dislocation identified in the cervical spine.Hospital discharge notes dated 12/25/25 at 10:38 a.m., indicated back pain was musculoskeletal pain; imaging did show some concern of wedging though uncertain on chronicity (age of fracture). Supportive care with plan for therapy consults and pain medication was needed.On 12/26/25 at 1:08 p.m., a Hospital Return Note identified R1 returned to facility after hospitalization for chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, right wrist wound, and lower back pain. The note further identified R1 was not alert or oriented per baseline and complained of lower back pain during transferring and rolling in bed. R1 was unable to rate pain due to cognition but did attempt to swing out at staff related to the pain and Hydrocodone (narcotic pain medication) ordered for pain. R1 returned with a large hematoma and jagged skin tear to his right hand and a red area to the back of his head.On 12/26/25 on 3:07 p.m., therapy note indicated R1 transferred poorly, demonstrated increased confusion, and had some pain. R1 to utilize a full body lift for transfers and care plan updated.On 1/1/26, R1 required assistance with eating and pain with repositioning was 5-6/10 (pain scale of zero as no pain and ten as the worst pain).Physician visit note dated 1/2/26 at 10:45 a.m., identified R1's physician saw him for the one-week post fall visit and indicated when R1 fell from the facility van, he suffered from a new onset of back pain. Physician review of the hospital notes indicated the concern was for chronic vertebral compression fractures, lumbar region times two but also concerned because he had over this area. The note also identified R1 had become more lethargic and not eating well after the start of the fentanyl patch and discontinued the medication and reassess the next week. Noted that R1 had changed from his baseline. Impression noted as recent fall with new compression fractures versus back pain and chronic compression fractures.On 1/2/26 at 6:55 p.m., assessment reference date (ARD) Charting identified R1 was needing more assistance with ADLs; assist of 1-2 staff with dressing, transfers, and repositioning; assist of 2 staff needed for bed mobility and changing incontinent products; 2 staff needed for transferring with full body lift; and staff assist needed with locomotion. R1 has had increased pain but had improved slightly.R1's Pain Interview for MDS dated [DATE], identified R1 had frequent pain that interfered with therapy and day to day activities almost constantly. R1 rated his pain a 9 on a 0-10 pain scale and verbal descriptor identified very severe, horrible as the intensity of his pain.On 1/6/26 at 1:21 p.m., registered nurse (RN) manager follow up post incident note identified the facility van driver had lowered the lift ramp to the ground and went inside to assist resident onto lift, not realizing lift was on the ground and pushed R1 backwards and off the edge, causing wheelchair to tip over backwards. R1 landed on his hands and knees on the lift ramp and 911 was called to take R1 to emergency room (ER) for evaluation. Outcome showed no broken bones or internal bleeding noted; R1 sustained abrasion to posterior scalp and skin tear to right hand/wrist; complained of back pain but no acute injuries noted on imaging. A change of condition MDS initiated related to resident pain and change in transferring abilities.Physician visit note dated 1/6/26 at 2:00 p.m., identified R1 was seen for follow up to back pain and increase somnolence (sleepiness) and staff needed to move R1 every four hours and that triggered pain. The note further indicated R1's compression fracture was thought to possibly be new but was hard to say; at the very least it was exacerbated by his recent injury. Plan was to increase the Norco (hydrocodone with acetaminophen) to every four hours as needed.R1's care plan updated 1/9/26, maximal assistance of 2 with upper and lower body dressing using the log roll due to back pain; transfer with stand-aid lift with 1-2 and large harness and full body lift with assist of two and large sling as needed; and maximum assistance with rolling in bed, maximum assist with sitting to lying and lying to sitting on the side of the bed related to back pain.1/9/26 2:56 p.m., physician notified that R1 continues to have 5-9 (out of 10) pain ratings at times since fentanyl patch (narcotic pain patch) was discontinued.1/9/26 at 10:36 p.m., R1 refused to get up from bed for supper after multiple attempts and reapproaching resident. R1 did not want to eat when offered as he stated, pain bad with a yelling voice and pushed staff away.R1's December 2025 medication administration record (MAR) identified:-Acetaminophen 1000 mg twice daily for polyosteoarthritis and only identifying pain level of 2 during 9 of 43 administrations and pain level of 3 during 1 of 43 administrations, with an average pain level of .50 over the 21 day period (42 administrations) until 12/26/25 hospital return. R1's documented pain levels ranged from 2-9 from 12/26/25 to 12/31/25, which averaged a pain level of 4.27. -Start date of 12/26/25, fentanyl transdermal patch (narcotic analgesic) 72 micrograms per hour (mcg/hr.) every 72 hours for severe back pain;-Lidocaine (medication to block pain signals to the brain) external patch 5% to back one time a day related to low back pain to apply two patches daily and remove per schedule- hydrocodone-acetaminophen (narcotic analgesic) 5-325 milligrams (mg) one tablet every six hours as needed for pain greater than a 4 out of 10 (received eleven as needed doses between 12/26/25 and 12/30/25)R1's January 2026 MAR indicated (1/1/26-1/16/26): -lidocaine external patch twice daily;- acetaminophen 1000 mg twice daily; with pain rating from 1-10, and an average pain level of 5 over 16 days.-fentanyl transdermal patch every 72 hours until 1/2/26.As Needed (PRN) Medications-hydrocodone -acetaminophen 5-325mg one tablet every six hours as needed for low back pain and was increased to every four hours on 1/6/26. R1 received 21 as needed doses for pain ratings that ranged from 1 to 10 between 1/1/26 and 1/13/26, with an average pain level of 6.7. -oxycodone (narcotic pain medication) one tablet every four hours as needed for pain was ordered on 1/9/26. R1 received ten as needed doses for pain ratings ranging from 2-8 between 1/9/26 and 1/12/26.Observation on 1/13/26 at 1:30 p.m. and 2:40 p.m., R1 was noted to be in recliner chair with eyes closed and headphones on. R1 did open his eyes to voice but then closed them again. Follow up observation on 1/14/26 at 11:13 a.m., noted R1 to bed in bed with eyes closed and did not respond to voice.Interview on 1/14/26 at 11:32 a.m., family member (FM)-A indicated R1 had a fall and was having back pain and was not coming back like he was. FM-A stated R1 had three vertebrae that had hairline fractures but was not sure if they were new or old ones [fractures].During an interview on 1/13/26 at 1:30 p.m., the facility safety officer (SO) indicated he did all the training for the staff regarding the facility mobility van and lift when new staff was hired or began to use the van. The SO denied doing yearly refresher trainings, competencies, or that he had any documentation or proof of training or competency on the employees that are authorized to drive the van and wheelchair lift. The SO stated he was in the process of coming up with one. The SO identified he was aware of R1' fall off the van's wheelchair lift and described it as the driver (D)-A unfolded and lowered the lift to the ground instead of just unfolding it and did not attach the safety belt so when R1 was pushed out of the van, the lift platform was not there and R1 and the wheelchair fell to the ground. The SO stated he inspected the van and lift following R1's fall from the van and found it to be in normal working order. The SO denied having a policy or lift manual for the vehicle but demonstrated the lift instructions posted on the van doors.During an interview on 1/14/26 at 10:40 a.m., D-A had been driving the facility van for approximately four years and received training when he started driving the van but just recently did some retraining on the facility van after R1's fall. D-A further indicated the facility was short of van drivers, and he had been working quite a few extra shifts. D-A stated he was overworked, stressed out and was distracted while unloading R1 from the van after transporting him to an appointment. D-A further stated, while unloading R1 from the facility van, he had lowered the lift platform to assure it was on level ground but forgot to bring the lift back up to the van; he entered the van and pushed R1's wheelchair backward and the lift platform was not there so the resident fell out backward with the wheelchair landing on top of him on the ground. D-A immediately went into the clinic to get R1 help and called 9-1-1. D-A stated the training stated he should have properly turned R1 around so he was forward facing and did not apply the safety belt. D-A expressed remorse about R1's fall incident and has since received retraining and cut back on driving hours.During an interview on 1/13/26 at 3:50 p.m., D-B identified as an authorized driver of the facility vans and used the wheelchair lift on the van for approximately seven years. D-B stated she received training from her supervisor when she first started driving and when the facility got a new van, they received a quick rundown on operating the van but did not include any wheelchair lift training. D-B also denied receiving a formal competency training or annual training, but the facility has implemented annual training and competency for all staff that are authorized to drive the van after R1's fall from the van.During an interview on 1/14/26 at 11:32 a.m., family member (FM)-A stated she was aware of R1's fall from the van and that R1 had been having a lot of pain in his back especially bad when he moves. FM-A stated the x-rays found R1 had three hairline fractures in his vertebrae but was not sure if they were old or new fractures. FM-A further stated, it is hard to visit him now because he is so sleepy, further identified that the facility staff were having a hard time controlling R1's pain and the pain medications were making him too sleepy so they cut back on the pain medications and then he had horrible pain so they put him back on the pain medications. FM-A stated, I am very uneasy about his [R1's] progress; he is just not coming back like he was.During an interview on 1/14/26 at 1:51 p.m., registered nurse (RN)-A identified R1 had some back and leg pain prior to his fall from the van lift but not to the extent R1 has pain now after the fall. RN-A further identified R1 had significant pain when staff reposition or transfer him. RN-A further indicated R1 had a change in condition after the fall from the van lift as he was usually alert and oriented but is now very confused and did not even know who his wife was. R1 required more assistance with activities of daily living (ADL)s, not eating well, did not have the stamina he used to have, not going to activities like he used to, more constipation issues, and was very sleepy when he got his pain medications. RN-A stated R1 still had significant bruising on his right arm, and they were still treating the injury on his right hand but the bruising on the back of his head had improved.During interview on 1/13/26 at 4:11 p.m., the administrator identified that during the root cause analysis (RCA) following R1's 12/22/25 fall from van wheelchair lift, the facility noted there was no annual training and no policy on the van's wheelchair lift.The facility provided a list of six staff that were authorized to use the facility mobility vans and wheelchair lifts. The facility also has three mobility vans with lifts in use.The facility did not have policies on the operation of the van, the wheelchair lift, or on transporting residents outside of the facility.The Past Noncompliance began on 12/22/25. The deficient practice was corrected by 12/31/25, after the facility implemented a systemic plan that included the following actions: D-A and all facility van drivers and wheelchair lift operators were retrained and assured competent prior to allowing staff to transport residents. Additionally, a standard of work (policy) was formulated on 1/9/26 to ensure staff have the proper protocol in writing to follow the van/transporting residents; initiated annual training and competency to all van operators; and the SO was educated on his requirement to ensure proper documentation for qualifications, education, and competency of the van operators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure 1 of 1 narcotic emergency kit (E-Kit) was replaced prior to the pharmacy date of expiration documented on top of kit. This had the potential to affect all residents.
Findings include:
Observation on [DATE] at 4:40 p.m. with registered nurse (RN)-A of the [NAME] Wing medication room, identified the narcotic E-Kit, with a red numbered tag lock, and a bright green pharmacy sticker which listed the expiration date of [DATE]. The label directed to notify pharmacy 7 days prior to this date for replacement.
Interview on [DATE] at 4:42 p.m. with RN-A reported the narcotic E-Kit was checked during each shift narcotic count, but there was no individual log signed that the E-kit had been checked and verified the medication had not expired. She reported the only documentation that the count was accurate was in the narcotic book that was signed by both the on-coming and off-going staff members. RN-A reported the expiration sticker should have been noted and the pharmacy notified of the need to provide a new E-Kit as directed on the sticker dated [DATE].
Observation and interview with the director of nursing (DON) identified the narcotic E-Kit contained two outdated medications: Morphine Sulfate 20 milligrams/milliliter (mg/ml) (pain medication) 15 ml bottle with the pharmacy label identifying an expiration date of [DATE], Lorazepam 1 mg tablets (6) with expiration dates of [DATE] (anti-anxiety medication). The DON reported her expectation was for staff to observe the label on the outside of the E-Kit when it was checked with each narcotic count. She was unaware of how the label noting an expiration date of [DATE] was not caught between the multiple shift narcotic counts that had taken place between [DATE] and [DATE]. The DON reported the consultant pharmacist was in the facility monthly, but she was not aware of how often they checked the E-Kits but there should be a system of the pharmacy being aware of when the E-Kit needed to be replaced.
Interview on [DATE], at 4:51 p.m. with the consultant pharmacist reported she performed medication review at the facility monthly, but she had not checked the E-Kits and reported they should have been checked for expiration dates.
Interview on [DATE] at 8:32 a.m. with the Minnesota Veterans Home Pharmacy manager reported the pharmacy supplied the E- Kits. He would expect the consultant pharmacist to monitor the E-Kits for outdates in addition to the nursing staff while performing narcotic counts on a per shift basis. He reported the pharmacy should have been notified 7 days prior to the expiration date to allow time for a replacement kit to be provided to the facility.
Review of the [DATE] Minnesota Department of Veterans Affairs Medication Storage and Security policy identified medication storage areas were to be routinely monitored by nursing staff to prevent use of outdated or discontinued medications.
Review of the [DATE] Operating procedure for pharmaceutical services identified both the registered pharmacist and the consulting pharmacist who provided monthly in facility medication reviews were responsible for the provision of pharmacy services. An E-Kit was supplied by the central pharmacy and scheduled II-IV medications were to be reconciled with each shift change. The consulting pharmacist was to review the E-Kit during the monthly review.

Based on interview and record review, the facility failed to compete a thorough investigation when it was reported a potential misappropriation of resident property/potential drug diversion had occurred.
Findings include:
Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) and the 5-day investigation identified LPN-C had found a green tote containing medication including narcotics had been left by the delivery driver inside one of the doors at the facility unattended. LPN-C retrieved the bin and delivered the medication to each wing. When she delivered the medication from the bin to the [NAME] Wing (GW), she was unable to locate the RN so she told LPN-A that she was placing the medication delivery on the table in the report room. LPN-A responded verbally that she would take care of it. The medication was left on the table for an unknown length of time, unattended and not locked. Later that day the after shift report LPN-B went into the medication room and opened the cupboard that holds the narcotic medication emergency kit (E-kit). There were 2 kits in the cupboard, the new one and the old one. He reached up to remove the two kits from the cupboard and the red zip tie lock fell of the new E-kit. The zip tie appeared to have been cut. He noted the E-kit had not been verified and he added it to the narcotic count book. He called the evening supervisor a RN-B and reported the incident. RN-B, RN-C, and LPN-B completed a count of the narcotic E-kit and found it to be short 1 hydrocodone (narcotic used for pain relief) tablet. The E-kit count was then counted again by LPN-B, and the director of nursing (DON) and it was confirmed that the e-kit was short one hydrocodone tablet. Review of the narcotic medication logbooks identified inconsistencies in R1's medication count page 29. The page had 4 entries all signed by LPN-A. The numbers in the column titled amount remaining had been written over with black ink several times and the numbers appeared to have been changed. The entries were no longer legible. The page had been torn out of the bound book and then taped back in and line was drawn through the page with a note transferred to page 31 written at the bottom. The facility investigation identified in an interview with LPN-A that she was not aware that she could not alter the entries or tear a page out of the narcotic logbook. LPN-A identified that she realized during her shift that R1's hydrocodone medication was short 1 tablet, so she went into the med room and cut the zip tie lock off the E-kit and removed a hydrocodone tablet, she did not sign the narcotic medication out and did not notify anyone at the facility at that she had removed it. She later found the missing tablet partially punched out of R1's blister pack of hydrocodone and taped it back in. She left the other hydrocodone tablet that she had removed from the E-kit in the medication cart and planned to destroy it later that day but forgot. The next day 6/16/24, a clear medication cup was found in another wing on a medication tray. LPN-A said when she came in that morning, she found the cup in the med cart but did not know that was the hydrocodone tablet and she placed the tablet on the tray. LPN-A said she was not always completing her triple checks while administering medication. The investigation noted finding that staff had violated several facility medication policies.
Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door unattended, the bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered GW medications and E-kit the RN on that wing was not available so she told LPN-A that she placed the medications on the table in the report room, LPN-A responded verbally she would take care of it. She then left the area. She identified that following this incident she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked but did not recall seeing the DON complete any additional training, audits, or competencies.
Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and he recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident.
Interview on 7/10/24 at 11:31 a.m., with DON agreed with the above findings and identified she audited all of the narcotic count logbooks in the facility of the current medication counts, but made no documentation to show that had been completed. She ensured the narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document her findings anywhere. She agreed that she should have included that information in her final investigation summary.
Interview on 7/10/24 at 4:09 p.m., with the consulting pharmacist identified she was not aware the facility had an incident of potential diversion. No one had called her to notify her or to request any guidance in this matter. If the facility had called her, she would have reviewed the investigation, the narcotic count, the facility policies, and offered guidance to the facility. Depending on her findings She would have likely recommended re-training, and ongoing documented audits for a period of time. She identified the facility does not typically notify her until the next QAPI meeting and that meeting had not taken place yet.
Review of the 6/22/23. Vulnerable Adult-Resident Protection Plan policy identified misappropriation of resident property (aka their medication) was defined as a deliberate misplacement, exploitation, temporary, or permanent use of a resident's belonging or money without the resident's consent. Any staff who become aware of an allegation of misappropriation were to report the incident to their supervisor and facility leadership, and state agency and federally required entities. The investigation policy does note in the event of a suspicion of a crime, it is to be reported to law enforcement. It does not it state nurses involved who are terminated as a result of their practice or concerns over an investigation will be reported to their Board of Nursing.

Based on interview, and record review the facility failed to ensure 1 of 1 package of routine and controlled narcotic medication, delivered by a package delivery service, was immediately secured into staff custody upon arrival, and when transported by staff and delivered to another unit.
Findings include:
Interview on 7/10/24 at 1:42 p.m., with LPN-C identified on 6/15/24, she realized medication had not been delivered to the wing, so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door unattended. The bin was secured with 2 plastic zip ties. She delivered the medications to the appropriate wings. She told licensed practical nurse (LPN)-A that she placed the newly delivered medication on the table in the unlocked report room. LPN-A responded verbally she would take care of it. LPN-C. LPN-C failed to notify the DON or administrator of the lack of the delivery driver to drop off medication in a hand off and not leave the medication unattended where potential diversion could occur from passers-by.
Interview on 7/10/24 at 11:31 a.m., with DON identified she had not been notified of the unsecured medication left by the delivery driver at the time LPN-C became aware. She also discovered during her investigation medications had been left unsecured in the break room by LPN-C and LPN-A and were not directly handed off to be secured immediately by staff. She agreed medications had the potential to be diverted if not secured appropriately upon arrival to the facility and once at the facility. She had not educated staff. She did however, notify the pharmacist of the medications being left unsecured at the door to the pharmacist.
Interview on 7/10/24 at 2:46 p.m., with the pharmacist identified the facility notified him of the medications being delivered and left by the door unattended. He notified the package delivery company of the concerns and directed them to ensure medications delivered to the facility in the future must be handed off to a person and not left unattended.
Review of the 3/30/23, Controlled Medication Policy identified that all new schedule II-IV medications (narcotic) orders will be entered into a bound narcotic book upon arrival and count will be verified. Licensed nurses will account for all narcotic medications and verify the count at the end of each shift. If any discrepancies are noted, the nurse manager was to be notified. There was no mention of ensuring immediate custody occurred as soon as medication was brought from the delivery driver, nor was there any indication for staff to report immediately to management if that occurred in the future so immediate action and education could be provided.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1), was free from potential misappropriation of property and/or potential drug diversion of ordered narcotic pain medication.
Findings include:
Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his findings. RN-B and RN-C reviewed the narcotic count books against the actual narcotic pill count for each medication. The narcotic book showed inconsistencies and had been signed out by LPN-A for the day shift of 6/15/24. The narcotic count was correct for 26 tablets, but the 26th dose foil seal was noted as broken and a tablet was taped back into the blister pack. RN-B and RN-C reported their findings to the DON. The DON interviewed LPN-B, RN-B, and RN-C then verified and added the counts from the narcotic E-kit to the narcotic count book. The old E-kit was short 1 hydrocodone tablet and contained 6 hydrocodone tablets but only contained 5. It was reported that earlier that day RN-C delivered the E-kit to the [NAME] Wing (GW) to LPN-A. Several entries in the narcotic book for R1's hydrocodone had been written over by LPN-A. The page had a line through it and the count had been transferred to another new page by LPN-A. DON and LPN-B then examined the blister pack containing R1's hydrocodone tablets and identified the blister pack foil seal of the 26th dose had been broken and a tablet had been taped back in. The DON and LPN-B destroyed the 26th dose because the seal had been compromised. DON then called RN-C to review the findings. During that call, RN-C reported LPN-C had delivered the medications from the pharmacy delivery to the green wing, RN-C did not receive them from LPN-C but when she returned from a resident room at approximately 10:30 a.m., she found the medications were sitting on the back desk in the report room. She reported she saw that there was a narcotic e-kit there with an intact red lock tag on it. She placed the E-kit in the locked medication room. On 6/16/24, the DON returned to the facility to investigate further. RN-C reported on 6/15/24 at approximately 9:15 a.m., she had been in the special care unit (SCU) and found a clear medication cup on a tray with an opened, single-pill blister pack of hydrocodone labeled Found floor-MJ with a pill inside. RN-C observed Page 29 of the green wing narcotic book (the log sheet containing R1's hydrocodone narcotic count) had been ripped out and then taped back in. Before LPN-A could be interviewed by facility management on 6/16/2, she left the facility that morning reporting a family emergency and did not return and could not be reached for interview. LPN-A was notified via phone that she would be placed on investigatory leave effective immediately and pending the outcome of the investigation. There was no mention that facility had notified law enforcement, or that they had verified the medication that had been found in the compromised packaging prior to destroying them.
Review of the 6/21/24, 5 day investigation report to the SA identified on 6/20/24 at 9:00 a.m., LPN-A was contacted for interview. LPN-A reported she was not certain if she was present when the new narcotic medications had been delivered to the facility and had not accepted any medications to stock. LPN-A then noted she may have received the medication delivery. LPN-A admitted she had cut the lock on the old narcotic E-kit because when she had counted her medications in her cart, she found she was short 1 hydrocodone for R1. She reported she decided to take 1 from the E-kit to replace it so her count would be correct. LPN-A then stated she went back to the cart with the hydrocodone medication from the E-kit. When she proceeded to do the count again, she stated R1's hydrocodone was partially punched out and hanging from the back of the their blister pack card. She reported she taped the back of the blister pack and placed the extra single dose from the E-kit in her pocket. She then reported later that morning she placed the extra dose in a med cup and wrote Destroy on the cup and left it in the med cart. She said she forgot to tell anyone about it. LPN-A never reported to any staff the count was allegedly off or that she had taken a single dose of hydrocodone from the E-Kit. She did admit to altering the narcotic logbook on page 29 of R1's hydrocodone medication, in an attempt to make the count right and had ripped page 29 out of the log book but then taped it back into the book. She reported she did not know she could not change, alter, or write over entries in a narcotic count logbook or tear pages out. The DON noted she had reviewed R1's medical record and identified he had not shown any signs or symptoms of increased pain, or distress, she re-educated staff via email reminding them to not leave narcotic medication unattended and to always use two licensed nurses to count narcotics at the end of each shift. The investigation made no mention that they had notified their consulting pharmacist for guidance, that they notified law enforcement of the suspicion of a crime, or completed any audits or competencies to ensure deficient practice had been corrected.
R1's 6/19/24, Minimum Data Set (MDS) assessment identified he had admitted to the facility in March of 2023. R1 was dependent on staff for all activities of daily living (ADL's) and had diagnosis of lower back pain and neuropathy.
R1's June 2024 administration record identified he was administered one hydrocodone 5/325 milligrams (mg) three times daily. The administration record identified LPN-A had signed off in the electronic medical record that she had administered the medication on 6/15/24 at 8:00 a.m., and 12:00 p.m.
Review of the narcotic book page 29 identified R1's hydrocodone medication, 1 tablet had been signed out as given by LPN-A on 6/15/24 at 8:56 a.m., and 1 tablet was signed out as given at 12:00 p.m. There were 4 entries on the page, under the column labeled Amount Remaining listed the number of tablets left after each administration. The numbers were clearly hand-written over several times with black ink and barely legible. Each of the entries were signed in black ink by LPN-A The page had been torn out of the bound book, then taped back in. The page had a line through it with a note transferred to page 31.
Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning on 6/15/24,the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door. The bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered medications and E-kit, the RN on that wing was not available so she told LPN-A she placed the medications on the table in the report room. LPN-A responded verbally she would take care of it. LPN-C then left the area. Following the incident, she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked but did not recall seeing the DON complete any additional training, audits, or competencies.
Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and reported that he came in for his shift and when he went into the medication room and unlocked the cupboard there was the new kit and the old kit. He reached up to grab them out of the cupboard and the zip tie fell off the E-kit. The tail end of the zip tie was not long like it normally was, and it was obvious it had been cut. He reported it to the on-call RN. He and the DON completed the count of R1's hydrocodone tablets and found the last dose had been opened. He and the DON had to destroy it because the package had been compromised. He recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident. There was no indication the medication had been left for law enforcement as potential evidence of a crime, as the actual pill inside had not been verified to be hydrocodone.
Interview on 7/10/24 at 11:31 a.m., with the DON identified she agreed with the above findings. She noted she audited all of the narcotic count logbooks in the facility. She ensured narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document it anywhere. She agreed that she should have included that information in her final investigation summary. She identified R1's hydrocodone tablet and the tablet found on the counter in the report room both had to be destroyed because the integrity of the packaging had been broken. She did not report the findings to the police, the pharmacy consultant who provides oversite to the facility, or the board of nursing because she could not determine if LPN-A had taken the narcotic medication out of the facility, and she believed the two tablets that were found were likely the 2 tablets that were missing. LPN-A had been terminated as a result of the incident. The DON had only reviewed the current narcotic count and had not looked at past resident administrations LPN-A had administered to see if there was potential increase in pain over shifts she had worked where medication was otherwise not normally given, or if there had been other instances of errors/documentation issues from LPN-A in the counting of narcotics.
Review of the facilities 7/13/23, Drug Disposition policy identified diversion of medications is the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use. Medications will be disposed of if it was dispensed in error and the medication will be destroyed. Staff were to follow the facility policy for medication destruction and use 2 licensed nurses to destroy the medication and record it in the narcotic logbook.
Review of the 8/2/19, Operating Procedure: L Controlled Medication Record policy identified staff were to properly record and reconcile controlled narcotic medication each shift with 2 nurses verifying each record. Discrepancies were to be reported. There was no mention of what staff should do if there was a suspicion of a crime, potential evidence gathering, notification of law enforcement etc.

Based on interview and record review, the facility failed to report to the law enforcement a suspicion of potential drug diversion and failed to notify the Board of Nursing for 1 of 1 nurse (licensed practical nurse (LPN)-A) whose employment was terminated.
Findings include:
Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his findings. RN-B and RN-C reviewed the narcotic count books against the actual narcotic pill count for each medication. The narcotic book showed inconsistencies and had been signed out by LPN-A for the day shift of 6/15/24. The narcotic count was correct for 26 tablets, but the 26th dose foil seal was noted as broken and a tablet was taped back into the blister pack. RN-B and RN-C reported their findings to the director of nursing (DON). The DON interviewed LPN-B, RN-B, and RN-C then verified and added the counts from the narcotic E-kit to the narcotic count book. The old E-kit was short 1 hydrocodone tablet and contained 6 hydrocodone tablets but only contained 5. It was reported that earlier that day RN-C delivered the E-kit to the [NAME] Wing (GW) to LPN-A. Several entries in the narcotic book for R1's hydrocodone had been written over by LPN-A. The page had a line through it and the count had been transferred to another new page by LPN-A. DON and LPN-B then examined the blister pack containing R1's hydrocodone tablets and identified the blister pack foil seal of the 26th dose had been broken and a tablet had been taped back in. The DON and LPN-B destroyed the 26th dose because the seal had been compromised. DON then called RN-C to review the findings. During that call, RN-C reported LPN-C had delivered the medications from the pharmacy delivery to the green wing, RN-C did not receive them from LPN-C but when she returned from a resident room at approximately 10:30 a.m., she found the medications were sitting on the back desk in the report room. She reported she saw that there was a narcotic e-kit there with an intact red lock tag on it. She placed the E-kit in the locked medication room. On 6/16/24, the DON returned to the facility to investigate further. RN-C reported on 6/15/24 at approximately 9:15 a.m., she had been in the special care unit (SCU) and found a clear medication cup on a tray with an opened, single-pill blister pack of hydrocodone labeled Found floor-MJ with a pill inside. RN-C observed Page 29 of the green wing narcotic book (the log sheet containing R1's hydrocodone narcotic count) had been ripped out and then taped back in. Before LPN-A could be interviewed by facility management on 6/16/2, she left the facility that morning reporting a family emergency and did not return and could not be reached for interview. LPN-A was notified via phone that she would be placed on investigatory leave effective immediately and pending the outcome of the investigation. There was no mention that facility had notified law enforcement, or that they had verified the medication that had been found in the compromised packaging prior to destroying them.
Review of the 6/21/24, 5-day investigation report to the SA identified on 6/20/24 at 9:00 a.m., LPN-A was contacted for interview. LPN-A reported she was not certain if she was present when the new narcotic medications had been delivered to the facility and had not accepted any medications to stock. LPN-A then noted she may have received the medication delivery. LPN-A admitted she had cut the lock on the old narcotic E-kit because when she had counted her medications in her cart, she found she was short 1 hydrocodone for R1. She reported she decided to take 1 from the E-kit to replace it so her count would be correct. LPN-A then stated she went back to the cart with the hydrocodone medication from the E-kit. When she proceeded to do the count again, she stated R1's hydrocodone was partially punched out and hanging from the back of their blister pack card. She reported she taped the back of the blister pack and placed the extra single dose from the E-kit in her pocket. She then reported later that morning she placed the extra dose in a med cup and wrote Destroy on the cup and left it in the med cart. She said she forgot to tell anyone about it. LPN-A never reported to any staff the count was allegedly off or that she had taken a single dose of hydrocodone from the E-Kit. She did admit to altering the narcotic logbook on page 29 of R1's hydrocodone medication, in an attempt to make the count right and had ripped page 29 out of the logbook but then taped it back into the book. She reported she did not know she could not change, alter, or write over entries in a narcotic count logbook or tear pages out. The DON had reviewed R1's medical record and identified he had not shown any signs or symptoms of increased pain, or distress, she re-educated staff via email reminding them to not leave narcotic medication unattended and to always use two licensed nurses to count narcotics at the end of each shift. The investigation made no mention the facility notified law enforcement.
Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning on 6/15/24, the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door. The bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered medications and E-kit, the RN on that wing was not available so she told LPN-A she placed the medications on the table in the report room. LPN-A responded verbally she would take care of it. LPN-C then left the area. Following the incident, she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked.
Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and reported that he came in for his shift and when he went into the medication room and unlocked the cupboard there was the new kit and the old kit. He reached up to grab them out of the cupboard and the zip tie fell off the E-kit. The tail end of the zip tie was not long like it normally was, and it was obvious it had been cut. He reported it to the on-call RN. He and the DON completed the count of R1's hydrocodone tablets and found the last dose had been opened. He and the DON had to destroy it because the package had been compromised. He recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident. There was no indication the medication had been left for law enforcement as potential evidence of a crime, as the actual pill inside had not been verified to be hydrocodone.
Interview on 7/10/24 at 11:31 a.m., with the DON identified she agreed with the above findings. She noted she audited all of the narcotic count logbooks in the facility. She ensured narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document it anywhere. She agreed that she should have included that information in her final investigation summary. She identified R1's hydrocodone tablet and the tablet found on the counter in the report room both had to be destroyed because the integrity of the packaging had been broken. She did not report the findings to the police, the pharmacy consultant who provides oversite to the facility, or the board of nursing because she could not determine if LPN-A had taken the narcotic medication out of the facility, and she believed the two tablets that were found were likely the 2 tablets that were missing. LPN-A had been terminated as a result of the incident. The DON had only reviewed the current narcotic count and had not looked at past resident administrations LPN-A had administered to see if there was potential increase in pain over shifts she had worked where medication was otherwise not normally given, or if there had been other instances of errors/documentation issues from LPN-A in the counting of narcotics.
Interview on 7/10/24 at 4:09 p.m., with the consulting pharmacist identified she was not aware the facility had an incident of potential diversion. No one had called her to notify her or to request any guidance in this matter. If the facility had called her, she would have reviewed the investigation, the narcotic count, the facility policies, and offered guidance to the facility. Depending on her findings, she would have likely recommended re-training, and ongoing documented audits for a period of time. She identified the facility does not typically notify her until the next QAPI meeting and that meeting had not taken place yet.
Review of the 6/21/23 facility Vulnerable Adult-Resident Protection Plan Policy identified the facility will report to the state licensing authorities (board of nursing) and to law enforcement any knowledge it has of actions which may need to be reported to the licensing board which would indicate unfitness for services as a licensed professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority) for 1 of 1 resident (R49) with new onset of mental illness.
Findings include:
R49's 4/5/23, Initial Pre-admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II PASARR to be completed.
R49's 4/12/23, admission Minimum Data Set (MDS) assessment identified R49 was admitted on [DATE]. R49's cognition was intact with diagnoses of anxiety, depression and Post Traumatic Stress Disorder. R49 had disorganized thinking, felt tired and having little energy, feeling bad about himself or feeling like he let his family down, and had trouble concentrating during the 14-day assessment period. Additionally, R49's 7/13/23, quarterly MDS identified R49 continued to have disorganized thinking, had little interest or pleasure in doing things, feeling down, depressed or hopeless, thought he would be better off dead, or of hurting himself in someway during the 14-day assessment period.
R49's 4/12/23, progress note identified social services had assessed R49 following a conversation he had with the therapist that day. The mental help provider had been contacted and R49 had a crisis assessment completed to determine a need for crisis counseling or if a session could wait until Monday.
R49's 4/17/23, Mental Health Consult note identified R49 had been seen and had a history of working with a psychiatrist in the past related to suicidal thoughts. R49 plan to continue to work with the Mental Health provider here at the facility.
R49's undated, Medical Diagnoses identified upon admission he had diagnoses of anxiety, depression, obsessive-compulsive personality disorder. On 5/11/23 a new diagnosis of suicidal ideation was noted.
Interview on 10/3/23 at 11:38 a.m., with licensed social worker (LSW)-A identified if a resident was to receive a new mental health diagnosis, she would contact Senior Linkage to see if a Level II Preadmission Screening and Annual Resident Review (PASARR) would need to be completed. The LSW noted R49's suicidal statements were to be taken seriously, and the facility completed a suicidal risk assessment and made a referral to a mental health provider. She confirmed R49 had received a new diagnosis of suicidal ideation on 5/11/23, and she had not notified senior linkage of the new diagnosis for a Level II screening for additional services that may be needed.
Review of 1/20/23, (PASARR) Policy identified a mental disorder was often associated with significant distress or disability. A resident with a new possible serious mental disorder or related condition should be referred for a level II screening to Senior Linkage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure nursing assistant (NA) staff correctly transferred 1 of 1 resident (R47) resident with use of 2 staff during a mechanical sit to stand lift transfer to ensure his safety.
Findings included:
On 10/2/23 at 1:52 p.m., R47 stated that he needs two staff to assist him with transferring, with the mechanical lift, when he gets in and out of recliner.
On 10/2/23 at 2:31 p.m., nursing assistant (NA)-A brought a mechanical lift into R47's room and assisted R47 with transferring from recliner to wheelchair with one staff.
R47's annual Minimum Data Set (MDS) dated [DATE], identified R47 was cognitively intact and required extensive assistance from two staff for transfers. R47's diagnoses included Parkinson's disease (condition that affects the brain and causes problems with movement, balance, and coordination), myasthenia gravis (neuromuscular disorder that leads to weakness of skeletal muscles) and dependence on other enabling machines and devices.
R47's care plan dated 8/11/23, identified R47 needed assistance of two staff with a stand-aid lift (mechanical sit to stand lift) for transfers.
On 10/4/23 at 10:22 a.m., NA-B stated R47 utilizes a mechanical lift with assistance of two staff at all times for transfers.
On 10/4/23 at 10:41 a.m., registered nurse (RN)-C stated that R47 is an assist of two staff with the mechanical lift for all transfers.
On 10/4/23 at 11:28 a.m., director of nursing (DON) stated that staff are aware of what type of assistance a resident need from the care plan. DON confirmed that R47's care plan indicated that R47 needs two staff for transfers with the mechanical lift. The DON stated it is important to ensure staff are following the care plan for resident's safety.
The Transfers policy dated 5/4/23, indicated residents will be prepared for a transfer and complete the transfer by referring to the resident's care plan for specific transfer directions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure side rails were assessed to determine appropriateness and safety of use for 4 of 4 residents (R9, R16, R30 and R31) who was observed to have a side rails affixed to their beds.
Findings include:
R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and required extensive assistance with bed mobility and transfers. R9's diagnoses included traumatic brain dysfunction (head injury causing damage to the brain by external force or mechanism), hemiplegia (condition that causes paralysis or weakness on one side of the body) and contracture of muscle, multiple sites.
R9's care plan dated 7/7/23, included that R9 utilized bilateral assist device bars on bed to assist with bed mobility. Additionally, the care plan included that R9 needs assistance of two staff to boost up in bed.
On 10/2/23 at 2:25 p.m., Observed R9's bed had 1/2 side rails affixed to the head of bed on both sides of bed.
R9's medical record lacked evidence an assessment had been completed to determine necessity and whether R9 could safely use side rails. Additionally, R9's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained.
R16's annual MDS dated [DATE], identified R16 had moderate cognitive impairment and required extensive assistance with bed mobility and transfers. R16's diagnoses included Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), non-Alzheimer's dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems due to causes other than Alzheimer disease), anxiety disorders and repeated falls.
R16's care plan dated 9/26/23, included that R16 needs assistance of two staff with bed mobility and transfers. Care plan does not indicate bed rails.
On 10/2/23 at 1:59 p.m., Observed R16's bed had 1/2 side rails affixed to the head of bed on both sides of bed.
R16's medical record lacked evidence an assessment had been completed to determine necessity and whether R16 could safely use side rails. Additionally, R16's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained.
R30's quarterly MDS dated [DATE], identified R30 had moderate cognitive impairment and required extensive assistance with bed mobility and transfers. R30's diagnoses included stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), hemiplegia affecting left side of body.
R30's care plan dated 9/15/23, included that R30 utilized bilateral assist device bars on bed to assist with bed mobility.
On 10/2/23 at 5:07 p.m., Observed R30's bed had 1/2 side rails affixed to the head of bed on both sides of bed.
R30's medical record lacked evidence an assessment had been completed to determine necessity and whether R30 could safely use side rails. Additionally, R30's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained.
R31's quarterly MDS dated [DATE], identified R31 was cognitively intact and required supervision with bed mobility and transfers. R31's diagnoses included chronic kidney disease.
R31's care plan dated 9/11/23, included that R31 is independent with bed mobility and transfers. Care plan does not indicate bed rails.
On 10/2/23 at 4:59 p.m., Observed R31's bed had 1/2 side rails affixed to the head of bed on both sides of bed.
R31's medical record lacked evidence an assessment had been completed to determine necessity and whether R31 could safely use side rails. Additionally, R31's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained.
On 10/4/23 at 10:22 a.m., nursing assistant (NA)-B stated R9 is minimally able to reposition self while in bed. NA-B stated R16 is dependent on all activities of daily living (ADL's) and is not able to reposition self in bed. NA-B stated R30 is moderately able to reposition self in bed. R30 can roll to the left and is able to use side rail for turning. NA-B stated R31 is independent with all ADL's and uses the side rails to get in and out of bed.
On 10/4/23 at 10:41 a.m., registered nurse (RN)-C stated that she was not sure who was responsible for assessments of the side rails and indicated that therapy may perform them.
On 10/4/23 at 11:28 a.m., the director of nursing (DON) stated physical therapy are to assess for side rails. DON stated once physical therapy assesses resident and deemed it appropriate for resident to use side rail, then an assessment would be completed by the nurse. Care plan would be updated, risks/benefits would be discussed with resident and/or resident's representative and a consent form would be obtained. DON stated this is a new process and confirmed that R9, R16, R30 and R31 did not have assessments and/or risk/benefits completed. DON stated assessment of side rails is important to ensure appropriateness and safety for the resident.
The Bed Inspection policy dated 5/10/18 indicated residents will be screened to determine the level a resident's independence with bed mobility. Staff were to assess the need for special equipment or accessories (e.g., positioning bar, half, or quarter rail for positioning). Assess the resident to identify appropriate alternative(s) prior to installing bed rails, and assess the resident for risk of entrapment from bed rails prior to installation. The increased risk would be largely due to unsafe moving about the bed, or ill-advised attempts to exit from the bed. Additionally, untimely responses to care increased the risk of entrapment. No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, may increase resident safety risk. Staff were to review the risk and benefits with resident and resident representative and obtain informed consent.