Health inspection·May 1, 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 Based on closed record review, review of a facility self reported incident (SRI), interview and facility policy and procedure review the facility failed to prevent the misappropriation of narcotic pain medication. This affected two residents (#103 and #115) of 11 residents identified to receive narcotic medication. The facility census was 67. Residents Affected - Few Findings include: Review of a facility self reported incident tracking number, 233848 revealed on 04/10/23 the facility reported an allegation of misappropriation to the State agency. A brief description of the incident revealed the nurse signed out medication at 6:00 P.M. and 2:00 A.M. of an as needed dose of narcotic medication for Resident #115. The nurse stated, I signed it out early so I wouldn't forget later. The resident always asked for it. An interview on 04/27/23 at 10:30 A.M. with the Administrator and Assistant Director of Nursing (ADON) revealed an investigation was conducted related to misappropriation of narcotic medications involving Licensed Practical Nurse (LPN) #259. The Administrator stated she was made aware of the allegation on the morning of 04/10/23 when LPN #63 asked Resident #103 if he would like pain medication before therapy since his last dose was at 2:00 A.M. Resident #103 stated his last medication was received at 10:00 P.M. and he did not receive pain medication at 2:00 A.M. This opened the investigation of misappropriation. A facility investigation included a review of narcotic count sheets which revealed Resident #103 had a dose of medication signed out on 04/09/23 at 2:00 A.M. A count of his as needed narcotic pain medication revealed the count from the blister pack and the count sheet matched. Review of like residents found Resident #115's narcotic count sheet had a time written over a time on 04/09/23. An interview with LPN #43 on 04/10/23 (no time noted), revealed she had signed out Resident #115's narcotic pain medication on 04/09/23 at 3:30 P.M. and on the medication administration record (MAR). The MAR had one dose of the narcotic pain medication signed out for Resident #115 at 3:30 P.M. Review of the narcotic count sheet, revealed the time on 04/09/23 at 3:30 P.M. was changed to 10:30 A.M. and a dose of narcotic pain medication was signed out at 6:00 P.M. and 1:00 A.M. LPN #43 stated she did not change the time. An interview per the Administrator on 04/10/23, (no written statement), with Resident #115 revealed he did not receive the 1:00 A.M. dose of medication and his last dose was around 8:00 P.M. An interview with LPN #259 on 04/10/23, (the facility provided a typed statement with no signature) revealed LPN #259 stated she signed both doses of as needed pain medication at the same time so she would not forget later and indicated Resident #115 always asked for medication in the night. The LPN was Page 1 of 2 365398 365398 05/01/2023 Best Care Health and Rehabilitation 2159 Dogwood Ridge Road Wheelersburg, OH 45694

F 0602 suspended on 04/10/23 pending the investigation and subsequently resigned on 04/10/23. Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation determined the facility reported three doses of narcotic pain medication were stolen. The facility identified two former residents, Resident #103 and #115 were affected by the stolen medications. The facility investigation determined LPN #259 had stolen the narcotic pain medications that were documented on the count sheet but not on the MAR. The medications were not replaced by the facility to the residents. Residents Affected - Few Review of the facility policy titled Identifying Exploitation, Resident theft and exploitation, dated 04/2021 revealed the facility failed to recognize the misappropriation of the residents property as stated in the policy. This deficiency represents non-compliance investigated under Control Number OH00142113. 365398 Page 2 of 2