Forest Health & Rehab Center

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

never gets [his/her] meds [medications] at night when the ‘black nurse with braids on top of her head in a ball works. This description matches that of the LPN who was suspended and has resigned. 4/14-4/15/25 Residents on LPNs assignment who are able to be interviewed were assessed for any change in condition that could have resulted from not receiving their prescribed medications. No identified findings. 4/15-4/17

the DON/Designee interviewed staff that worked the past 72 hours with LPN and asked about unusual behaviors of if they heard any complaints from the residents about care services - no negative findings.

There was however a consistent theme of the LPN taking excessively long breaks. 4/17/25 HR [human resources]/designee reviewed the RN [registered nurse] [LPN] and 5 other random employees files to ensure that they were still in good standing to work at the facility - no negative findings. To identify other like residents: 4/15/25 DON/Designee interviewed residents about care services including medication pass specific to not receiving and 2 resident [names], stated [he/she] never gets [his/her] meds at night when the black nurse with braids on top of her head in a ball works. This description matches that of the LPN who was suspended and has resigned. 4/14-4/15/25 Residents on LPNs assignment who are able to be interviewed were assessed for any change in condition that could have resulted from not receiving their prescribed medications. No identified findings. To prevent this from recurring: The DON/Designee educated all licensed nurses on drug diversion and medication rights as well as notifying administrator in the event diversion is suspected. Completed by 4/21/25. All staff was re-educated on the abuse policy with emphasis

on misappropriation - completed by 4/21/25. A systemic change was put in effect for use of the proper shift change controlled substance inventory count sheets. Any staff on PTO [paid time off]/vacation will be educated prior to working. All newly hired staff will be educated on said process during orientation. To Monitor and maintain ongoing compliance: The DON/Designee will audit random narcotic sheets to ensure that there is no s/s [signs/symptoms] of drug diversion weekly x 12 weeks. The DON/Designee will interview 3 random residents to ensure that they have no issues with not receiving pain medications weekly x 4 weeks then monthly x 2 months. The results of the audit will be forwarded to the facility QAPI [quality assurance performance improvement] committee for further review and recommendations. The facility completed an ad hoc QAPI meeting. Conclusion: [facility name] takes the care and services of our residents very seriously and continues to work diligently to ensure the safety of our residents. The facility completed all necessary steps for a sufficient correction action plan and met the requirements of past non-compliance as set forth by the State Operation Manual. We respectfully request you review our documentation and consider past noncompliance. Alleged POC [plan of correction]: 4/21/25. This document was signed by the Administrator, DON, ADON, East Unit Manager, [NAME] Unit Manger and SSD. The facility immediately implemented corrective actions after they became aware of the allegation. During the recertification survey conducted from 09/09/2025 to 09/13/2025, there was evidence the corrected actions had been implemented from 04/14/2025 to 04/21/2205 and there were no further concerns identified related to misappropriation of resident property. Staff and resident interviews revealed no concerns related to misappropriation of resident property. Observation of medication administration revealed no concerned related to misappropriation of resident property.

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