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 observation, interview, review of narcotic count sheets and review of facility policy the facility
failed to ensure the shift to shift narcotic count forms were signed by the on coming and off going nurses as
required. This had potential to affect nine residents (#2, #7, #10, #16, #19, #20, #22, #25 and #31) of nine
residents the facility identified as receiving narcotic medications . The facility census was 32.
Findings include:
Observation made on 12/09/24 at 12:41 P.M. of the contingency box medications revealed all narcotics
were accounted for and there was no concern identified related to the narcotic count being inaccurate
however during this observation it was identified there were missing signatures on the shift-to-shift count
sheet. The missing signatures were from 09/18/24 to 12/07/24, and there were a total of 113 missing
signatures.
Observation made on 12/09/24 1:30 P.M. of station one medication cart revealed it was locked, and all
narcotics were accounted for, however, the Controlled Medication Shift Change Log dated 11/12/24 to
12/09/24 revealed there were missing signatures from the ongoing and/or off going nurses on 11/12/24,
11/19/24, 11/25/24, 11/26/24, 11/28/24, 11/29/24, 11/30/24, 12/06/24, and 12/09/24. Additionally,
observation made of the station two medication cart revealed it was locked, and all narcotics were
accounted for, however, the Controlled Medication Shift Change Log dated 11/005/24 to 12/09/24 revealed
there were missing signatures from the ongoing and/or off going nurses on 11/07/24, 11/10/24, 11/12/24,
11/14/24, 11/23/24, 11/24/24, 12/06/24, and 12/09/24.
Interview on 12/09/24 at 1:48 P.M. with the Director of Nursing (DON) revealed all medications were secure,
they confirmed there were multiple missing signatures on the shift-to-shift sheets for both station one and
station two as well as the Contingency Narcotic Box. The DON offered no explanation as to why the nurses
were missing signatures.
Interviews conducted throughout the survey from 12/04/24 to 12/09/24 with Licensed Practical Nurse (LPN)
#801, LPN #804, LPN #805, and LPN #806 revealed they did count the narcotics after each shift but did not
always sign the shift to shift sheets.
Review of the facility policy titled Storage of Controlled Medications, dated June 2017, revealed under the
category titled Change Of Shift Verification-Narcotic Count, at the change of shift , the on-coming and
off-going nurse jointly count all controlled medications in the narcotic box on the medication cart and the
ones in the refrigerator, including discontinued or expired medications and the Shift to Shift Narcotic Count
Verification form will be signed by both the outgoing and the
(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:
365401
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
365401
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Health Care Center
24613 Broadway Avenue
Oakwood Village, OH 44146
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)
F 0755
on-coming nurses at each change of shift.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00159111.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365401
If continuation sheet
Page 2 of 3
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
365401
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Health Care Center
24613 Broadway Avenue
Oakwood Village, OH 44146
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview the facility failed to ensure the refrigerator and microwave located in
the lounge area was kept clean and sanitary. This affected seven Residents (#4, #5, #6, #7, #9, #17, and
#23) of 32 residents living in the facility. The facility census was 32.
Finding include:
Observation was made on 12/05/24 at 2:59 P.M. of the microwave and refrigerator in the lounge area near
station one. The microwave had burnt on food debris and a sticky brown substance all over the inside of it.
The refrigerator had a brown sticky fluid spilled on the inside of it and there was not a temperature log for
this refrigerator.
Interview on 12/05/24 at 3:10 P.M. with the Administrator verified the microwave and refrigerator located in
the lounge near station one were not clean and sanitary. The Administrators stated both should be cleaned
at least weekly. The Administrator stated she was going to throw the microwave away due to its condition
and would have the refrigerator cleaned immediately. When asked who's responsibility it was to clean the
microwave and refrigerator the Administrator stated it was the responsibility of the kitchen staff but she was
going to assign it to the housekeeping staff due to it being located in the lounge. When asked who had
access to use the microwave and refrigerator she stated there were seven residents and families who could
use it to store food and heat up food and staff used it as well.
Interviews on 12/05/24 from 3:15 P.M. to 3:30 P.M. with Residents #4, #5, #6, #7, #9, #17, and #23 revealed
they did use the refrigerator and microwave to store and heat up food.
This deficiency represents non-compliance investigated under Complaint Number OH00159111.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365401
If continuation sheet
Page 3 of 3
