Inspection·October 31, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospice provider self-reported incident review, review of a facility self-reported incident investigation, and staff interview, the facility failed to thoroughly investigate an allegation of missing narcotic medications. This affected one (Resident #8) of three residents reviewed for narcotic medication use. The facility census was 73 Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 12/27/23 with diagnoses that included rheumatoid arthritis, adult failure to thrive and hypertension. Further review of the medical record revealed on 04/19/24 Resident #8 was prescribed the use of morphine sulfate (Roxanol, opioid analgesic medication) 20 milligram (mg) per one milliliter (ml) 0.25 ml every two hours as needed for pain. Review of the Medication Administration Record (MAR) revealed a total of 31 doses of medication administered between 04/21/224 and 07/19/24. Thirty-one 0.25 ml doses from a 30 ml bottle would equal 22.25 ml remaining in the 30 ml bottle. Review of the controlled drug administration record for Resident #8's Roxanol revealed a 30 ml bottle was provided to the facility on [DATE] and 29 doses were documented as administered for a total of 22.25 ml remaining in the bottle. However, 29 doses (0.25 ml per dose) from a 30 ml bottle would equal 22.75 ml remaining in the 30 ml bottle. Review of the Hospice provider's self-reported incident (SRI) revealed on 10/17/24 a discrepancy was noted on the facility controlled drug administration record for Resident #8. The SRI revealed that the controlled drug administration records indicated a total of 22.5 milliliters (ml) of morphine sulfate was to be remaining in the medication bottle. The hospice employee observed only 16 ml of medication remaining in the medication bottle, which indicated a total of 6.5 ml unaccounted for. Review of the facility SRI Tracking Number 253102 with a created date of 10/18/24 indicated an allegation of missing Roxanol. Review of the facility investigation revealed eight doses of medication were not signed out by staff on the controlled drug administration record and three doses were not signed out on the Medication Administration Record (MAR). Further review of the facility investigation identified a total of eight doses were not documented on the controlled drug administration record. Eight 0.25 ml doses would equal two ml, which would not make up the difference in the actual 16 ml in the medication bottle and 22.5 ml on the controlled drug administration record. Observation of a picture of a Roxanol medication bottle, taken by the Director of Nursing, revealed approximately 16 ml of medication was remaining in the bottle. (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 4 Event ID: 365629 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 365629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dixon Healthcare Center 135 Reichart Avenue Wintersville, OH 43953 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)