Inspection·July 19, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Self-Reported Incident review, medical record review, resident interview, staff interview and policy review the facility failed to prevent misappropriation of resident narcotics. This affected one resident (Resident #20) of four residents reviewed for narcotic medication use. The facility census was 73. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed an admission date of 10/13/22 with diagnoses that included chronic pain syndrome, right above the knee amputation and low back pain. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and experienced pain frequently. The numeric pain rating was 8 on a 0-10 pain scale with 10 being the worst pain. The resident's pain affected his sleep and limited day-to-day activities. Review of the physician orders revealed Oxycodone five milligram (mg) tablet give one 5 mg tablet every six hours as needed for pain, Robaxin 750 mg one tablet four times a day for muscle spasms/pain, and methanol patches topically twice a day for low back pain. Review of Self-Reported Incident Number 237096 dated 07/14/23 revealed it was discovered during change of shift (during narcotic reconciliation) on 07/14/23 at 3:31 P.M. that 11 Oxycodone tablets belonging to Resident #20 were missing from the outside pharmacy container and replaced with loratadine (allergy medication) tablets. This was immediately reported to nursing management who then began the investigation. The police department was called and (the incident) reported. The pharmacy, regional nursing, the administrator, resident and physician were notified. All nurses were instructed to report (to the facility) within several hours for a toxicology (drug) screening. The facility's conclusion/findings revealed the missing medication was not recovered, 11 pills will be replaced by the facility. The outside pharmacy has agreed to package in a unit dose system moving forward. Education was provided to nursing staff and audits were initiated. Review of the Pharmacy Controlled Substance Record for Resident #20's Oxycodone revealed on 07/07/23 the facility was provided with 120 tablets of Oxycodone 5 mg. On 07/14/23, when the misappropriation of the medication was reported, the record indicated 95 Oxycodone tablets remained. Interview with the Director of Nursing and Assistant Director of Nursing on 07/19/23 at 6:40 A.M. verified on 07/14/23 11 of Resident #20's Oxycodone tablets were noted to be replaced with loratadine tablets. This was found during shift change narcotic reconciliation on 07/14/23. They further indicated due to a national shortage of Oxycodone tablets, the facility had to use an alternate pharmacy (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: 365324 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 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 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)