Based on interview, observation, and record review, it was confirmed the facility failed to provide a safe medication administration system. Findings include, but not limited to:

1. During an unannounced site visit on 08/04/2022, the Compliance Specialist (CS) observed Staff #3 (S3) check Resident #5's (R5) blood sugar levels (CBG) which were found to be at 84. CS observed Staff #2 prepare insulin pen for S3 to administer. CS intervened and prevented S3 from carrying out the administration.

A review of R5's Medication Administration Record and physician orders indicated R5's insulin is to be withheld when CBG are less than 100.

In an interview on 08/04/2022, Staff #4 stated he/she has not provided any training to S3 to administer insulin.

2. On multiple consecutive and individual occasions, Medication Technicians failed to document Narcotic Counts at the beginning and end of their shifts and/or carried out counts without a second staff member present.

On 08/04/2022, these findings were reviewed with and acknowledged by Staff #1 via telephone, Staff #4, and Staff #6.

Based on interview and record review, it was confirmed the facility failed to ensure tracking of controlled substances. Findings include, but not limited to:

A review of the facility's records including Narcotics and Preventing Drug Diversion policy/procedure, dated 10/2018, and Narcotic Shift Count Sign-in/Sign Out sheets for the second and third floor medication carts, dated March 2022 through August 2022, indicated the following:

* "Shift counts are performed at the end of each shift or when the person responsible for medications changes.... If the quantity is verified, the off-going and on-coming med aides both sign the appropriate Narcotic Shift Count form."

* The second floor narcotic counts were not conducted for multiple consecutive days and/or consecutive shifts each month.

*A review of July's second floor narcotic count forms indicated that counts were not conducted for 18 or more days and were signed off by only 1 staff member on 12 or more occasions.

* There was no August 2022 Narcotic Shift Count form for the second floor medication cart.

* The third floor narcotic counts were not conducted for multiple consecutive days and/or consecutive shifts each month, and only signed off by one staff member.

* A review of July's third floor narcotic count forms indicated that counts were not being conducted for 9 or more days and were signed off by only 1 staff member on more than 1 occasion.

In separate interviews on 08/04/2022, Staff #2 and Staff #3 (S2 and S3) stated that controlled substances are to be counted by two staff members at the beginning/end of each shift and both staff must sign off for each med cart. Any discrepancies identified are to be immediately reported.

On 08/04/2022, these findings were reviewed with and acknowledged by Staff #1 via telephone, Staff #4, and Staff #6.

Facility Plan of Correction:

Within 30 days, the Director of Health Services or designee will provide in-servicing to med techs and conduct regular audits.