Shawnee Gardens Healthcare & Rehab Center

and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property.The facility's Controlled Substance Administration and Accountability policy, dated 01/01/20, directed two licensed nurses to account for all controlled substances and access keys at the end of each shift.The facility put the following corrective actions into place prior to the onsite visit with a compliance date of 08/20/25:The facility reported the liquid morphine discrepancies to the police on 08/20/25.The facility notified the liquid morphine discrepancies to the pharmacy on 08/20/25.Consultant GG inspected the seven bottles of morphine for signs of tampering and reported her findings to the facility.Administrative Nurse D and Consultant GG destroyed the tampered morphine bottles on 08/20/25.The facility replaced R1's morphine as she was the only one actively using it on 08/20/25.The pharmacy planned to bill the facility for the diverted morphine bottles that the residents paid for on 08/20/25.The facility conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 08/20/25.The facility educated Licensed Nurses and Certified Medication Aides (CMA) on Controlled Substances and The Elder Justice Act on 08/20/25.This deficient practice was cited at past noncompliance.

The scope and severity remain an E.

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