Health inspection·December 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of personnel records and facility policy review, the facility failed to ensure the integrity and security of controlled substances and failed to maintain accurate narcotic destruction records as required, when Licensed Practical Nurse (LPN) #694 forged LPN #677's signature on a controlled drug record for Residents #483. This affected one resident (#483) of three residents reviewed for controlled medications. The facility census was 68.Findings include:Review of Resident #483's medical record revealed an admission date of 09/26/25 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, presence of right artificial hip joint, malignant neoplasm of overlapping sites of colon, malignant neoplasm of pancreas, unspecified, type II diabetes mellitus with diabetic autonomic (poly)neuropathy, essential (primary) hypertension, mixed hyperlipidemia, other acute postprocedural pain, pain in right hip, neoplasm related pain (acute)(chronic),trigeminal neuralgia, major depressive disorder, recurrent, unspecified, generalized anxiety disorder, autonomic neuropathy in diseases classified elsewhere, history of falling, muscle weakness (generalized), personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, and personal history of other venous thrombosis and embolism, long term (current) use of anticoagulants.Review of Resident #483 progress notes dated 09/12/25 revealed Resident #483 began palliative services.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #483 had impaired cognition and functional limitation in range of motion (ROM) to one side in the lower extremities. Resident #483 was dependent on staff for mobility and frequently incontinent.Review of the September 2025 medication administration record (MAR) for Resident #483 revealed an order dated 09/12/25 (discontinued 09/26/25) for oxycodone w/acetaminophen (APAP) 5/325 milligrams (mg) (opioid pain medication) one tablet by mouth every four hours for pain.Review of the controlled drug record revealed on 09/16/25 an oxycodone w/APAP 5/325 was signed as wasted by LPN #694 and initialed by (LPN #677) as witnessing LPN #694 waste the medication. Interview on 12/04/25 at 11:42 A.M. with the Director of Nursing (DON) revealed on 09/16/25 LPN #694 signed that she wasted a narcotic forging another nurse's (LPN #677) initials as a witness. The DON was not made unaware of this until 09/19/25. At that time, LPN #694 was suspended and an investigation began. LPN #694 was suspended from 09/20/25 through 09/23/23. LPN #677 was on shift; was aware LPN #694 wasted narcotic and did not get back to station to witness the wasting of the narcotic and initial as a witness in the controlled drug record with LPN #694. LPN #677 was disciplined for medication wasting policy and was written up and educated on 10/08/25. One-on-one education and competencies were completed with all nurses.Interview on 12/04/25 at 12:37 P.M. via telephone with LPN #694 revealed she wasted a narcotic for a resident (Resident #483) on 09/16/25 and asked another nurse, LPN #677, to waste it with her. LPN #677 said, just put my initials, I trust you. LPN #694 indicated she put LPN Page 1 of 2 365822 365822 12/04/2025 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #677's initials and wasted the narcotic in the shred box. LPN #694 indicated this was the only incident. Review of personnel records for LPN #694 revealed a disciplinary form dated 09/24/25, stating LPN #694 did not follow the facility's medication administration and wasting policy. LPN #694 was placed off duty during the investigation and was suspended from 09/20/25 through 09/23/25 and returned on 09/24/25 after a negative drug test. Review of personnel records for LPN #677 revealed a disciplinary form dated 10/08/25, stating LPN #677 did not follow the facility's medication administration and wasting policy. LPN #677 was given a written warning.Review of the facility's medication administration policy, dated 03/20/19, revealed the DON, nurse, and/or pharmacist witnessing the destruction ensures the following information entered on the individual controlled substance accountability record book to include date of destruction, resident's name, name and strength of medication, prescription number, amount of medication destroyed, and signatures of witness.This deficiency represents noncompliance investigated under Complaint Number 2639628. 365822 Page 2 of 2