Inspection·January 31, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of Medication Administration policy and Insulin Storage recommendations the facility failed to ensure medications for Resident #96 were securely stored and Resident #55's and Resident #45's insulin were used before expiration dates This affected one (Resident #96) of 31 sampled residents and two (Residents #55 and #45) of two residents identified with expired medications during observation of four medication carts. Findings include: 1. Review of the medical record for Resident #96 revealed a date of birth as 03/13/65 and admission into the nursing facility on 07/22/16. The primary diagnosis for admission was cellulitis. Additional diagnoses included asthma, type II diabetes mellitus, depression, hypothyroidism, lymphedema, hypertension, obesity and fibromyalgia. Review of the comprehensive assessment (MDS 3.0) dated 01/15/19 revealed a brief interview for mental status (BIMS) was completed. Resident #96's score was 15 of a possible 15 and this indicated intact cognition. An interview was completed with Resident #96 on 01/28/19 at 3:20 P.M. at the bedside. During the interview a plastic basin was observed on the night stand located to the left of the resident. The contents of the basin included various lotions and hygienic products. Mixed amongst the items in the basin, were several prescription and over the counter medications. Observed in the plastic basin were the following medications: 1. Mupirocin cream (a prescription antibiotic) 2% with approximately one quarter of the cream left in the tube. 2. Coly-mycin S (prescription antibiotic ear drops) optic drops with most of the bottle used. 3. (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: 365771 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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)