Health inspection·February 29, 2024

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, interview, and facility policy review the facility failed to ensure narcotic medications were removed from circulation when discontinued and accounted appropriately, resulting in one unaccounted oxycodone pill for Resident #94. This affected one resident (#94) of three residents reviewed for controlled medication administration. The facility census was 93. Findings Include: Record review of Resident #94 revealed the resident was admitted on [DATE] and discharged on 02/09/24. Diagnoses included atrial fibrillation, Crohn's disease, and anxiety disorder. The most recent order for oxycodone (a narcotic pain medication) was discontinued on 12/25/23. Review of the medication administration record revealed no evidence the medication was given after this date. Review of the facility investigation documentation revealed a photograph of a medication card including one rectangular pill in the pouch labeled '17'. The pills in all other visible pouches were round. No identifiers were visible in the photograph. The facility also furnished a photograph of a drug record sheet for Resident #94's oxycodone tablets. This sheet had one medication documented removed on 12/31/23 signed by what appeared to be Licensed Practical Nurse (LPN) #602, leaving 16 oxycodone pills remaining in the card. Interview with the Director of Nursing (DON) and Administrator on 02/27/24 at 8:57 A.M. revealed the facility performed an investigation regarding incorrect pills being taped into a medication card for a resident. The facility actual count of the medication matched the documentation of how many pills should remain, excluding the taped-in pill. Interview with Registered Nurse #301 on 02/27/24 revealed she conducted an investigation following report of an incorrect medication being taped into the medication card for Resident #94's oxycodone. She tried to question the last nurse to care for the resident (LPN #602) who did not return her calls. Due to this, the facility contacted her agency, informed them of the event, and asked that she not return to the facility. Registered Nurse #301 then audited narcotic storage with no other discrepancies detected. The alleged event occurred the night of 01/17/24. Interview with the DON on 02/27/24 at 3:32 P.M. revealed facility investigation revealed the actual count of remaining oxycodone pills for Resident #94 was correct, only the taped-in pill made it incorrect. LPN #602 had a habit of writing sloppily in the narcotic book; however, when the facility did narcotic counts, no discrepancies were noted. (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 2 Event ID: 365845 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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)