Inspection·July 22, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, facility self reported incident review, interview and policy review the facility failed to report an allegation of medication misappropriation to the Administrator and state survey agency. This affected one (Resident #18) of three residents reviewed for misappropriation. The facility census was 85. Findings include: Review of Resident #18's medical record revealed an admission date of 05/29/24 with admission diagnoses that included cervical radiculopathy, spinal stenosis and chronic pain. An admission Minimum Data Set (MDS) 3.0 assessment with a reference date of 06/05/24 indicated Resident #18 had an intact and independent cognition level. Review of the physician orders revealed the use of tramadol 50 mg every eight hours as needed for pain control. There was no evidence of a physician order for the use of cetirizine noted. Interview with Resident #18 on 07/22/24 at 10:01 A.M. revealed approximately one month ago a nurse provided him a different pill than his prescribed narcotic analgesic medication. Resident #18 further added that he kept the pill and advised the Assistant Director of Nursing, Registered Nurse (RN) #121 of the issue the following day. Resident #18 indicated the pill administered was cetirizine (allergy medication) 10 milligram (mg) rather than tramadol (narcotic analgesic) 50 mg. Interview with RN #121 on 07/22/24 at 10:17 A.M. revealed that last month she was notified Resident #18 had a concern with receiving the wrong medication. She and the unit co-coordinator went to talk with the resident and were provided the pill . RN #121 indicated the pill was identified as a cetirizine tablet. RN #121 indicated the Director of Nursing was on vacation and she did not inform or report the concern to anyone. RN #121 verified the allegation of misappropriation of medication was not investigated. Interview with the Director of Nursing on 07/22/24 at 10:30 A.M. revealed she had no knowledge of Resident #18's medication misappropriation allegation. Interview with the Administrator on 07/22/24 at 11:16 A.M. revealed he had no knowledge of Resident #18's medication misappropriation allegation. Interview with the Administrator and Director of Nursing on 07/22/24 at 11:35 A.M. verified staff failed to follow facility policy and report Resident #18's allegation of misappropriation of medication so an investigation could be initiated. (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: 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 07/22/2024 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)