Health inspection·November 1, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medication storage observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure controlled substances and narcotic medication were disposed of in a timely manner. This affected four (#30, #88, #91, and #92) of four residents reviewed for disposition of controlled substances and narcotics upon discontinuation of orders or discharge. The facility census was 96. Findings include: 1. Observation of the controlled substance drawer of the Whitney Way medication cart on 10/31/23 at 8:12 A.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #88 had 55 pills of the nerve pain medication Lyrica in 25 milligram (mg) doses located in the drawer. Interview with LPN #200 during the observation on 10/31/23 at 8:12 A.M. verified Resident #88's Lyrica in the medication cart, and stated the Director of Nursing (DON) and unit managers are the only staff members permitted to remove a resident's controlled medications from the medication carts when the orders are discontinued or the resident discharges from the facility. 2. Observation of the controlled substances drawer of the Mckinley and Grant medication cart on 10/31/23 at 8:28 A.M. with LPN #23 revealed Resident #91 had six pills of the narcotic pain medication oxycodone instant release in five (5) mg doses; Resident #91 had 61 pills of Lyrica in 50 mg doses and 22 pills of the narcotic pain medication Dilaudid in two (2) mg doses; and Resident #30 had 20 pills of Dilaudid in 2 mg doses, nine (9) pills of the narcotic pain medication Percocet in 5-325 mg doses, and eight (8) pills of Percocet in 7.5-325 mg doses in the controlled substance drawer. Review of Resident #91's medical record revealed the resident was discharged from the facility on 09/25/23. Review of Resident #92's medical record revealed the resident was discharged from the facility on 10/16/23. Review of Resident #30's medical record revealed a physician order dated 09/25/23 discontinuing the ordered Dilaudid, and an ordered dated 10/07/23 discontinuing the Percocet orders. Interview with the DON on 10/31/23 at 8:54 A.M. stated she had been without a unit manager and usually goes through all the narcotic drawers twice a month. The DON confirmed she had no time to review the controlled substance drawers recently to be able to remove narcotics and controlled substance medications for destruction. The DON confirmed Resident #30, Resident #88, Resident #91, and Resident (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 3 Event ID: 365284 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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)