Health inspection·November 13, 2023

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 NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, interview, review of Self-Reported Incident (SRI) tracking number (#)240669, review of a personnel file, and facility policy review the facility failed to prevent misappropriation of a narcotic medication for Resident #56. This affected one resident (#56) of one resident reviewed for misappropriation of property. The facility census was 60. Findings include: Review of the medical record for Resident #56 revealed an admission date of 12/07/17. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, chronic obstructive pulmonary disease, vascular dementia, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated moderate cognitive impairment. Review of the progress notes from October 2023 to November 2023 revealed due to aphasia Resident #56 had difficulty with communication but was able to make basic needs known. Review of Resident #56's physician orders effective November 2023 revealed pain monitoring every shift and oxycodone-acetaminophen 10-325 milligrams (mg) (narcotic pain medication) one tablet every six hours as needed for pain. Review of SRI tracking #240669 dated 10/30/23 revealed an allegation of misappropriation by an unknown perpetrator of Resident #56's property (narcotic pain medication). The incident report indicated a nurse (unnamed) placed a card of 30 oxycodone-acetaminophen 10-325 mg tablets at the nurse's station and upon going to the medication cart to lock the medication in the medication drawer, the controlled medication was missing. A facility search was completed without finding the medication. Resident #56 had another card of the same medication with enough remaining tablets available if needed for administration. The pharmacy was contacted, and a new card was sent at cost to the facility. The physician and medical director were notified, and a police report was filed. Staff were sent for drug screens. Review of the nursing schedule for 10/27/23 for night shift revealed the assigned nurse for Resident #56 was Licensed Practical Nurse (LPN) #315. Review of the witness statement dated 10/28/23 by LPN #315 indicated the pharmacy delivered the Page 1 of 4 365784 365784 11/13/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few controlled medications while LPN #315 was still passing medications during the shift. LPN #315 counted the controlled medications and signed the sheets to acknowledge receipt then placed the controlled medications and paperwork in a cubbyhole at the nurse's station. When LPN #315 unlocked the cart to put medications away, Resident #56's card of oxycodone-acetaminophen was missing. Residents were in the hallway nearby waiting for medications. All were questioned and denied taking it. Resident rooms were checked with no findings. Review of the pharmacy packing slip for controlled medication dated 10/27/23 revealed a card of 30 oxycodone-acetaminophen 10-325 mg tablets was delivered. Review of the controlled medication disposition form for oxycodone-acetaminophen 10-325 mg tablets received on 10/27/23 indicated Resident #56 had 30 tablets available in the medication card. LPN #315 signed to acknowledge receipt of the medication on 10/27/23. Review of the witness statement dated 10/28/23 by Director of Nursing (DON) indicated arriving to the facility at 9:30 A.M. on 10/28/23. Searches of resident rooms, nurse's station, and medication rooms were completed with no findings. A controlled medication audit was completed with no additional discrepancies found. Police report #23-23095 was filed, and the pharmacy was notified. Review of the witness statement dated 10/28/23 by the Administrator indicated arriving at the facility approximately 8:30 A.M. Resident room searches were completed with no findings. Review of the pain assessment completed on 10/28/23 revealed Resident #56 had pain present defined as a two on a one to ten pain scale. The as needed pain medication was administered. Review of the controlled medication disposition form for oxycodone-acetaminophen 10-325 mg tablets received on 10/11/23 indicated Resident #56 had additional tablets available for administration to address pain. Review of the QAPI (Quality Assurance and Performance Improvement) meeting notes dated 10/28/23 revealed a concern with narcotic storage. The failed system was improper medication storage with a plan of correction to include education on medication storage, narcotic storage, and misappropriation. Review of education provided by the Director of Nursing (DON) dated 10/28/23 for all staff included misappropriation and for all nursing staff included medication and narcotic storage. Review of pharmacy communication by email to the DON dated 10/30/23 at 12:40 P.M. revealed loss or theft of 30 oxycodone-acetaminophen 10-325 mg tablets for Resident #56. The medication in question arrived on the 10/27/23 delivery and was discovered missing on 10/28/23. The building and staff searched the medication carts and audits were completed. Police report #23-23095 was filed. The investigation was ongoing. Staff were interviewed and drug screen reports were pending. The pharmacy planned to report to the Board of Pharmacy and Drug Enforcement Agency. Review of the pharmacy visit report dated 11/01/23 revealed a controlled medication audit was completed with no discrepancies. Review of the personnel file for LPN #315 revealed a hire date of 01/26/23. The Written Disciplinary Action Report dated 10/28/23 indicated LPN #315 received a written warning for missing narcotics due to improper medication storage upon receipt from pharmacy. LPN #315 signed the disciplinary 365784 Page 2 of 4 365784 11/13/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0602 action on 10/28/23. Level of Harm - Minimal harm or potential for actual harm Review of the drug screen for LPN #315 dated 11/02/23 revealed no positive findings. Residents Affected - Few Interview on 11/13/23 at 11:22 A.M. with the Administrator and DON reported the pharmacy delivered narcotic medications on 10/27/23 and the night nurse LPN #315 set them behind the nurse's station in a cubbyhole which was not locked or secured. When LPN #315 turned to the nurse's cart to place the medications, Resident #56's medication card was missing. LPN #315 looked for the medication card and could not find anything. Drug testing was conducted with no positive results. LPN #315 signed the narcotic record to acknowledge delivery of the medication. The DON and Administrator confirmed LPN #315 improperly stored the controlled medications which led to the loss of Resident #56's card of oxycodone-acetaminophen 10-325 mg. The Board of Nursing was notified. Interview on 11/13/23 at 1:13 P.M. with President of Clinical Operations #384 verified LPN #315 improperly stored the controlled medications which caused the loss of Resident #56's card of oxycodone-acetaminophen 10-325 mg tablets. Review of the facility policy, Storage of Medications, revised November 2020, revealed controlled medications were stored in separately locked, permanently affixed compartments separate from access to non-controlled medications. Review of the facility policy, Abuse Prevention Program, revised December 2016, revealed residents have the right to be free from misappropriation of resident property and facility administration protected residents from abuse by anyone. The deficient practice was corrected on 10/30/23 when the facility implemented the following corrective actions: • The DON notified the medical director, pharmacy, and law enforcement of the incident on 10/28/23. • The DON notified the Board of Nursing of the incident on 10/30/23. • The pharmacy notified the Drug Enforcement Agency and Board of Pharmacy on 10/30/23. • An assessment of Resident #56 was completed by the DON on 10/28/23 to ensure pain was managed with no negative findings. • A thorough investigation by administration was initiated on 10/28/23 and completed by 11/01/23. 365784 Page 3 of 4 365784 11/13/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0602 • Level of Harm - Minimal harm or potential for actual harm A QAPI meeting was held on 10/28/23. The investigation analysis completed determined a root cause as improper narcotic storage. Residents Affected - Few • Administration instituted a new procedure on 10/28/23 for two nurse signatures upon receipt of controlled medications from pharmacy and to immediately secure the controlled medications as required. • Education was completed by the Administrator and DON for all staff on 10/28/23 regarding drug diversion and abuse, neglect, and misappropriation. • Education was completed by the DON for all nursing staff on 10/28/23 regarding drug storage. • Audits were completed for all residents to ensure accuracy of controlled medications on 10/28/23 by the DON with no negative findings. • LPN #315 was disciplined on 10/28/23 for improper storage of controlled medications. • The pharmacy completed an additional audit on random controlled medications on 11/01/23 with no negative findings. 365784 Page 4 of 4