Inspection·November 26, 2019

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility self-reported incident (SRI), interview and policy review, the facility failed to prevent misappropriation of controlled medications. This affected seven residents (Resident #3, Resident #13, Resident #21, Resident #27, Resident #95, Resident #96 and Resident #97) of seven reviewed for misappropriation of medications. This had the potential to affect all residents residing in the facility. The facility census was #40. Residents Affected - Some Findings include: Review of the SRI, tracking number 181304 and the corresponding investigation completed on 10/04/19 revealed on 09/25/19 at 11:14 P.M. the Director of Nursing (DON) was notified the medication count was off by one medication card of narcotics and one narcotic count sheet. On 10/26/19 the DON reviewed all narcotic count sheets and the shift to shift narcotic count sheets for the month of 09/19. Several narcotic count sheets were noted to be missing. The facility checked the September 2019 narcotic delivery report against the current medications in the cart and the completed narcotic count sheets. The DON noted there were multiple medication cards delivered and signed into the medication cart with no narcotic count sheet available. The DON listed the resident's and medications missing and noted a pattern of the same few residents, all with similar medications. Seven residents (Resident #3, Resident #13, Resident #21, Resident #27, Resident #95, Resident #96 and Resident #97) were identified as the residents without narcotic count sheets. Oxycodone (narcotic pain medication), Oxycodone-Acetaminophen (narcotic pain medication) and Hydrocodone-Acetaminophen (narcotic pain medication) were identified as the medications involved. The facility then launched a formal investigation. The police were called. An officer came to the facility and opened a police report (#19-20017) and obtained a list of nurses in facility to begin the investigation. On Friday, 09/27/19, all nurses were contacted by the administrator to come into the facility and complete drug screening. All drug screens came back negative for illicit drugs. The DON went through the shift to shift sheets and cataloged which nurse had signed out the medication for which there were missing count sheets. 28 of 31 medications were signed out on the shift to shift sheets by Licensed Practical Nurse (LPN) #200. On 10/01/19 the decision was made to suspend LPN #200 pending investigation. On 10/02/19 the audit was completed. On 10/03/19 LPN #200's written statement was obtained with no new information noted. LPN #200 was officially terminated on 10/03/19. The facility was awaiting the police decision to charge the nurse or the pharmacy decision that nurse did in fact alter narcotic prescriptions to report nurse to The Ohio Board of Nursing. Interview on 11/24/19 at 10:38 A.M. with the DON and Administrator revealed when they found out about the missing medications they investigated. They interviewed all of the facilities nurses and had all of them drug tested. The residents involved were interviewed and were not found to have been affected by the missing medications. The facility had contacted The Ohio Department of Health (ODH), submitted a SRI, contacted The Ohio Board of Nursing and the local police. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365236 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homestead II 60 Wood St Painesville, OH 44077 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)