Inspection·September 12, 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 review of the medical record , review of the Self-Reported Incident (SRI), interview with staff and review of the facility policy the facility failed to prevent misappropriation of resident narcotics. This affected one resident (R#9) of three residents reviewed for narcotic medication use. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included alcohol abuse with withdrawal complications, diabetes, acute kidney failure, rhabdomyolysis, gout, anxiety disorder, depressive disorder, insomnia, and abnormality of plasma proteins. Review of the physician's orders revealed Resident #9 had orders for Percocet 5/325 milligrams (mg) every four hours as needed for pain dated 07/04/23. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition and experienced pain frequently. The numeric pain rating was an eight on a zero to 10 pain scale with 10 being the worst pain. The resident's pain affected his sleep. Review of the Procare Shift Change report revealed two cards of 30 Percocet 5/325 mg were delivered from pharmacy on 08/17/23 to Resident #9 with the narcotic reference numbers of 1705995. Review of the controlled Medication packing slip from the pharmacy revealed on 08/17/23 Resident #9 received two cards of 30 Percocet with the narcotic reference numbers of 1705995/001 and 1705995/002. Review of the Self-Reported Incident (SRI) dated 8/30/23 at 3:15 A.M. revealed the oncoming afternoon nurse notified the Director of Nursing (DON) the narcotic count was off at shift change during narcotic reconciliation. The DON immediately counted narcotics and medication and medication cart #2 had one card of oxycodone with 18 tablets missing and one controlled drug receipt/record disposition form missing. The outgoing Agency Licensed Practical Nurse (LPN) # 200 admitted to crossing out one card and one sheet on the controlled drug receipt to make the count correct. A statement was collected from LPN #200 and her toxicology screen was negative. She was not 100 percent certain how many cards and sheets were present when she started her shift. The off going Agency LPN #210 did not provide a statement until 24 hours later and she refused to submit to drug test. Both nurses were removed from the schedule permanently. Law enforcement were notified immediately and were onsite for the case. (case #23-46096). All necessary notifications were made, pain assessment completed on all residents on the second floor and all competent residents were interviewed concerning whether or not they receive their as needed and scheduled medications as ordered. During a complete audit of (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 5 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 09/12/2023 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)