Health inspection·March 20, 2025

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy review and interview, the facility failed to ensure Resident #65's written discharge summary was accurate to reflect the amount of the medication, Oxycodone, provided to the resident at the time of discharge. This affected one resident (#65) of three residents reviewed for discharge. The facility census was 64. Findings include: Review of the closed medical record for Resident #65 revealed an admission date of 02/29/24 and a discharge date of 02/26/25. Resident #65 had diagnoses including paraplegia, chronic pain syndrome, and major depression. Review of a care plan dated 02/29/24 revealed Resident #65 had chronic complaints of pain. Interventions included to provide medications as ordered and monitor for effectiveness. Review of a physician order dated 01/07/25 revealed an order for the controlled substance Oxycodone 20 milligrams (mg) (opioid pain medication) by mouth four times a day. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. The assessment revealed Resident #65 required substantial/maximal (staff) assistance for all activities of daily living. Review of the Discharge summary dated [DATE] that was signed by Resident #65 revealed the resident would receive a thirty-day (30) supply of medication upon discharge. Review of a narcotic count sheet revealed the sheet was discontinued on 02/26/25 and 30 Oxycodone tablets were given to Resident #65. (30 tablets of the medication equaled a seven-and-a-half-day supply of the medication as the resident was ordered the medication four times per day). Review of the nurse's note dated 02/26/25 at 7:56 A.M. revealed Resident #65 was being discharged home at that time. All personal belongings were sent with him. The note included medications that were sent with Resident #65 including 30 Oxycodone tablets. Interview on 03/19/25 at 1:35 P.M. with Regional Nurse #502 verified when Resident #65 was discharged he was given 30 Oxycodone pills which would be seven days' worth of medication, not a 30-day supply that was stated in the written discharge summary. Regional Nurse #502 reported this was a clerical error. The regional nurse indicated in addition to the seven-day supply of Oxycodone, the facility Page 1 of 2 365972 365972 03/20/2025 Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few set up an appointment with a primary care physician for 02/28/25, two days after the resident's discharge at which time medications could be reviewed and/or refills ordered. Interview on 03/19/25 at 2:02 P.M. with the Director of Nursing (DON) confirmed the nurse who went over the discharge instructions with Resident #65 documented on 02/26/25 at 7:56 A.M. the resident was sent with a 30-day supply of his regular medications and 30 tablets of Oxycodone. During the interview, the DON confirmed the written discharge summary documented that the resident was provided with a 30-day supply of all medications; however, this was not accurate as he only received 30 Oxycodone tablets. Review of the undated facility policy titled Transfer and Discharge revealed reconciliation of all pre-discharge medications with the resident's post discharge medications would include prescribed/prescription medications and over the counter medications. This deficiency represents non-compliance investigated under Master Complaint Number OH000163758. 365972 Page 2 of 2