F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review, and facility policy review the facility failed to store medications
properly for Residents #5, #20, #22, and #55 in the medication cart on the South and Speret units. This
affected four residents (#5, #20, #22, and #55) of 12 residents (#4, #5, #8, #20, #22, #23, #24, #26, #32,
#55, #64, and #69) the South and Speret units who receive narcotic medications. The facility census was
72.
Findings include:
1. Review of the medical record for Resident #5 revealed an admission date of 03/16/20. Diagnoses
included Alzheimer's disease, antisocial behavior, and major depressive disorder.
Review of care plan for Resident #5 dated 06/14/22 revealed he had aggressive behaviors. Interventions
included administering medications as ordered and redirecting Resident #5 from unsafe situations.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had
severe cognitive impairment with a memory problem. Resident #5 required extensive one-person
assistance for bed mobility, dressing, transfers, toilet use, and personal hygiene; and supervision with
set-up help only for eating.
Review of a physician's order dated 10/26/23 revealed an order for Ativan (controlled antianxiety
medication) 0.5 milligram (mg) every two hours as needed for behaviors.
2. Review of the medical record for Resident #20 revealed an admission date of 03/14/23. Diagnoses
included dementia, hypothyroidism, and hypertension.
Review of physician's order dated 03/29/23 revealed an order for Resident #20 for Ativan 0.5 mg three
times daily.
Review of the care plan dated 03/30/23 for Resident #20 revealed she had anxiety. Interventions included
administering medications as ordered and encouraging her to participate in activities.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had severe cognitive
impairment. Resident #20 required cueing assistance for activities of daily living.
(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:
365402
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
365402
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare of Alliance Ctr for Rehab & NC Inc
11750 Klinger Avenue NE
Alliance, OH 44601
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. Review of the medical record for Resident #22 revealed an admission date of 10/22/10. Diagnoses
included Alzheimer's disease, anxiety disorder, and osteoarthritis.
Review of the care plan dated 08/09/19 revealed Resident #22 had a potential for an alteration in comfort.
Interventions included administering medications as ordered and offering nonpharmacological interventions
as needed.
Review of the physician's order dated 09/01/22 for Resident #22 revealed an order for tramadol (controlled
pain medication) 25 mg twice daily.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had moderate cognitive
impairment. Resident #22 required supervision with set up help only for bed mobility and eating;
supervision with one-person assistance for transfers; and extensive one-person assistance for dressing,
toileting, and personal hygiene.
4. Review of the medical record for Resident #55 revealed an admission date of 10/02/23. Diagnoses
included hypertension, anxiety disorder, and anemia.
Review of physician's order dated 10/02/23 revealed an order for Exelon (memory medication) 3 mg twice
daily.
Review of the care plan dated 10/02/23 revealed Resident #55 had impaired cognition. Interventions
included administering mediations as ordered and reporting any changes in his status to the physician.
Review of admission MDS assessment dated [DATE] revealed Resident #55 had severe cognitive
impairment. Functional abilities were not documented at the time of the assessment.
Observation on 10/27/23 at 8:15 A.M. during medication pass of the narcotic drug book on the medication
cart for the South and Speret units revealed Resident #22 was to have 26 tablets in her blister pack of
tramadol medication. When Licensed Practical Nurse (LPN) #502 removed the pack from the narcotic
drawer there were only 25 tablets in it. LPN #502 confirmed the discrepancy and popped a pill out leaving
24 tablets in the pack and administered the medication to Resident #22. When LPN #502 returned to the
cart she reported she had prefilled the medication at the beginning of her shift. LPN #502 then reached into
her narcotic drawer and removed four medication cups with pills in them for four different residents. LPN
#502 confirmed the pills were the tramadol for Resident #22, Exelon for Resident #55, Ativan for Resident
#20, and Ativan for Resident #5. Comparisons with the pills in the cups matched the medications inside
with packs for each resident. LPN #502 confirmed the medication cups were not listed with pill identification
or the resident names listed on them, and she had prefilled them at the beginning of her shift.
Review of the facility-controlled medication storage, dated May 2020, revealed controlled medication
accountability sheets are maintained in the designated book. All medications received must state the name
of the resident, prescription number, drug name, strength and dosage form of medication, and quantity
received.
Review of the undated facility policy guidelines for medication administration undated revealed medications
are administered at the time they are prepared. Medications are not pre-poured.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365402
If continuation sheet
Page 2 of 2
