Forest Hill Nursing Center

F-F602

Findings include:

Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation- Reporting and Investigating, with a revision date of 09/2022 revealed under the Policy Interpretation and Implementation .1. If resident .misappropriation of property .is suspected, the suspicion must be reported immediately to . 2. a.

The state licensing/certification agency responsible for surveying/licensing the facility .

Upon entrance to the facility on [DATE REDACTED] at 8:00 AM, the Director of Nursing (DON) confirmed that they had one reportable incident that was a narcotic diversion investigation involving Resident #1 in 09/2024.

Record review of the facility investigation, dated 9/19/24 involving Resident #1, revealed there was no notification of the narcotic diversion investigation to the State Agency.

In an interview with the DON regarding the narcotic diversion investigation on 1/14/25 at 9:10 AM, she revealed on the morning of Monday 9/16/24 the day shift nurse Licensed Practical Nurse (LPN) #1 came to her and let her know that the liquid narcotic for Resident #1 was not the color it should be. She stated the liquid morphine the facility receives is a clear blue color. The DON and LPN #1 together assessed the morphine to be clear once again when pulled in the syringe. The Hospice nurse was called and brought a new bottle of morphine to the facility for Resident #1. The DON revealed the bottle of morphine delivered on 9/6/24 and the new bottle of morphine was delivered on 9/16/24 for Resident #1 were compared, and the bottle dated 9/6/24 was a lighter clear blue color than the new bottle recently delivered. She stated the Morphine in question was removed from the narcotic count and locked up securely. The DON stated she immediately contacted all nurses who had access to the morphine on the 100-hall cart to meet at the clinic at 1:00 PM on 9/16/24 for a random drug screen related to a narcotic concern. She revealed all the nurses complied with doing the random drug screen with no positive results for narcotics, except for LPN #2. She stated that after LPN #2 did not comply with a drug screen, the Administrator reviewed the video footage of

the 100 hallways for the weekend and found on 9/14/24 at approximately 3:00 PM, LPN #2 was observed to position her medication cart in front of room [ROOM NUMBER] with the medication drawers facing the inside of the room. LPN #2 was observed to reach into the narcotic box, pull out the Morphine box, insert the syringe into the morphine bottle, pull back on the syringe, remove the syringe and go into the bathroom of room [ROOM NUMBER]. She then returned to the medication cart, inserted the syringe into the morphine again, pulled back on the syringe, then went back into the bathroom of room [ROOM NUMBER].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 255273 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255273 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkway Health & Rehab LLC 230 River Oaks Drive Canton, MS 39046

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Review of the Order Summary Report for Resident #1 revealed an order for Morphine Sulfate Oral Solution 20 mg (milligram) 5 (five) ml (milliliters): give 0.5 ml sublingual every 4 (four) hours as needed for pain and Level of Harm - Minimal harm or wheezing for 14 days, dated 9/05/24. potential for actual harm

In an interview with the DON on 1/14/25 at 9:00 AM, she revealed she thought she had reported it to the SA, Residents Affected - Few but she was unable to find any documentation that she had reported the incident and confirmed that she should have reported it. She then confirmed the allegation of narcotic diversion should have been immediately reported as part of the investigation process to ensure thorough investigation and follow-up is completed for the investigation.

Review of the Admission Record revealed Resident #1 was admitted by the facility on 10/14/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 255273 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255273 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkway Health & Rehab LLC 230 River Oaks Drive Canton, MS 39046

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 47157

Residents Affected - Few Based on staff interview, record review, and facility policy review, the facility failed to accurately document

the administration of PRN (as needed) pain medication in the electronic medication system for one (1) of three (3) residents reviewed for narcotic administration. Resident #1

Findings include:

Review of the facility policy titled, Controlled Substances, with no revision date revealed, Policy Statement:

The facility complies with the laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled substances .

Review of the facility policy titled, Charting Documentation, with revision date 07/2017 revealed, Policy Interpretation and Implementation: 2.) The following information is to be documented in the resident medical

record .b. Medications administered .

Record review of the Order Summary Report for Resident #1 revealed an order of Morphine Sulfate Oral Solution 20 mg (milligram)/5 (five) ml (milliliters): give 0.5 ml sublingual every 4 (four) hours as needed for pain and wheezing for 14 days dated 9/5/24.

Record review of the individual Patient Narcotic -Controlled Drug form for Resident #1 morphine sulfate revealed on 9/13/24 a dose was signed out by LPN #1 at 9:30 PM; on 9/14/24 five doses of morphine were signed out by LPN #2 at 8:30 AM, 11:00 AM, 2:00 PM, 6:00 PM, and 9:00 PM and on 9/15/24 revealed a dose of morphine was signed out by LPN #2 at 2:00 PM.

Record review of Resident #1's Medication Administration Record (MAR) dated 9/1/24-9/30/24 revealed there was no documentation of a dose of Morphine being given on 9/13/24 at 9:30 PM; on 9/14/24 at 8:30 AM, 11:00 AM 2:00 PM, 6:00 PM and 9:00 PM or on 9/15/24 at 2:00 PM.

In an interview with LPN #1 on 1/14/25 at 10:10 AM, he confirmed that he did administer morphine to Resident #1 on 9/13/24 at 9:30 PM and failed to document the medication that was given. He stated that it is important to sign the MAR, to prove it was given, to let other staff know the time of the last medication, and if

it was effective. He also stated it could be reflective of diversion of narcotics.

In an interview with LPN #3 on 1/14/25 at 3:00 PM she revealed all narcotics should be signed out on the narcotic sheet and on the MAR. She stated if a narcotic is not documented given on the MAR, then it looks like staff did not administer the medication and provides an inaccurate record.

In an interview with the Director of Nursing (DON) on 1/14/25 at 3:05 PM, she confirmed that narcotics should be signed out on the narcotic sheet and on the MAR, otherwise it could appear as if staff were diverting narcotics, or they were missing. She revealed the purpose of documenting narcotic medications given on the medication record is to show staff gave it and are following physician's orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 255273 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255273 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkway Health & Rehab LLC 230 River Oaks Drive Canton, MS 39046

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Record review of the Admission Record revealed Resident #1 was admitted by the facility on 10/14/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 255273