Inspection·October 31, 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** Based on record review, review of a facility self- reported incident (SRI), review of facility investigation, review of facility policy, and staff interview, the facility failed to prevent the misappropriation of Resident #130's prescribed narcotics. This affected one resident (#130) of three residents reviewed for misappropriation. The facility census was 153. Residents Affected - Few Findings include: Medical record review revealed Resident #130 was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes mellitus, bipolar disorder, anxiety disorder, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/24, revealed Resident #130 had moderately impaired cognition, was on a pain regimen, and was dependent for activities of daily living. Review of Resident #130's plan of care dated 04/26/16 with a revision on 06/01/17 revealed Resident #130 was at risk for pain/discomfort related to a history of stroke, chronic colitis, chronic pain, and right hip pain. Interventions included but were not limited to acknowledge presence of pain, administer pain medications as ordered, monitor and document for side effects of pain regimen, encourage non-medical interventions to control pain and decrease use of analgesic therapy. Review of the pharmacy packing slip dated 09/30/24 revealed that a total of 116 pills of oxycodone-acetaminophen 5-325 milligram (mg) (opioid analgesic) were delivered to the facility for Resident #130 and signed off by License Practical Nurse (LPN) #524. Review of the October 2024 physician orders revealed Resident #130 was ordered oxycodone-acetaminophen (opioid analgesic) tablet 10-325 milligrams (mg) to be given every six hours for chronic pain. Review of Resident #130's Medication Administration Record (MAR) from 10/01/24 through 10/28/24 revealed on 10/15/24, Resident #130 did not have any Percocet (oxycodone/acetaminophen) that could be administered and staff were waiting for the medication to arrive. Review of the medication administration note dated 10/15/24 timed 2:59 A.M. revealed Percocet oral tablet 10-325 mg was not given because medication was not available. Review of the medication administration note dated 10/16/24 timed 1:21 A.M. revealed Percocet oral tablet 10-325 mg was given from the stock in the Pyxis machine (an automated medication dispensing system). (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 5 Event ID: 365757 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 365757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadview Multi Care Center 5520 Broadview Rd Parma, OH 44134 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)