Inspection·May 21, 2024

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on a facility self-reported incident (SRI) review, medical record review, policy review and staff interview the facility failed to ensure resident narcotic medication was not misappropriated by a staff member. This affected two (Resident #23 and #73) of two residents reviewed for misappropriation of resident property. The facility census was 72. Findings include: Review of Resident #73's closed medical record revealed an admission date of 09/26/23 with diagnoses that included spinal stenosis, dorsalgia, chronic obstructive pulmonary disease and congestive heart failure. The resident was prescribed the use of oxycodone 5 mg every eight hours as needed for pain relief. Review of Resident #23's medical record revealed an admission date of 09/11/20 with diagnoses that included end stage renal disease with hemodialysis and congestive heart failure. The resident was prescribed the use of primidone 50 mg three times daily for tremors. Review of the facility SRI #245842 revealed on 03/31/24 Registered Nurse (RN) #119 removed Resident #73's oxycodone (narcotic opioid analgesic) medication blister card from the medication cart after the resident had discharged home. Upon inspection of the medication blister card, she observed possible tampering of the medication card and medication. The facility administrator was notified immediately, who notified the facility pharmacist. The medication blister card was locked in the RN #119's secured lock box in her office for pharmacist review. On 04/01/24 the pharmacist verified that six oxycodone five milligram (mg) pills for Resident #73 were replaced with primidone (for control of tremors) 50 mg pills from Resident #23. Local police, the State Survey Agency, Pharmacy Board and Board of Nursing were notified at this time. Facility investigation identified Licensed Practical Nurse (LPN) #121 as staff member responsible for diversion of the narcotic medications (the LPN had been documenting an increase in resident narcotic use). LPN #121 was terminated. Review of RN #119 witness statement dated 03/31/24 verified discovery of diversion of six oxycodone 5 mg tablets for Resident #73 with six primidone 50 mg tablets from Resident #23. Review of the pharmacist statement dated 04/01/24 verified diversion of six oxycodone 5 mg tablets for Resident #73 with six primidone 50 mg tablets from Resident #23. On 05/21/24 at 2:25 P.M. interview with the Director of Nursing verified six oxycodone 5 mg tablets (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: 365494 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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)