Health inspection·August 22, 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 - Some Based on review of facility self-reported incidents, review of controlled substances signs out sheets, review of policy, and staff interviews, the facility failed to prevent diversion of residents narcotic medications. This potentially affected 31 residents (Resident #1, #2, #3, #4, #9, #10, #12, #16, #20, #22, #25, #32, #35, #37, #41, #44, #50, #52, #57, #58, #66, #67, #83, #85, #90, #93, #101, #105, #110, #111 and #112) who resided on the Rosewood unit. The facility census was 106. Findings include: Review of facility self-reported incidents (SRI) #237089, #237081, #237080, and #237077, were all dated [DATE], the reports indicated the facility identified concerns regarding potential diversion of narcotic medications. During the facility investigation, additional concerns were identified. Review of the controlled drug administration records for 31 residents (#1, #2, #3, #4, #9, #10, #12, #16, #20, #22, #25, #32, #35, #37, #41, #44, #50, #52, #57, #58, #66, #67, #83, #85, #90, #93, #101, #105, #110, #111 and #112), revealed the records identified suspicious narcotic medication sign outs. Interview on [DATE] at 10:12 A.M., with the Administrator and Director of Nursing (DON) revealed the facility pharmacy called the facility on [DATE] and identified concerns regarding missing narcotic medications (1- Oxycontin and 5- Percocet pills) from the Omni-cell (automated dispensing system). The interview identified the pharmacy had sent six narcotic replacement medications that were not properly scanned in. The interview identified the facility started an investigation regarding narcotics after the pharmacy called with their concerns. The DON identified she pulled all the controlled drug administration records for review. The review of the records identified Licensed Practical Nurse (LPN) #300 had multiple instances of unusual errors, administration of pain medications to residents who don't usually need them, and suspicious documentation. The DON and Administrator identified LPN #300 was from a staffing agency and had been working at the facility since [DATE]. The interview identified the only unit LPN #300 worked at in the facility was the Rosewood unit. The interview confirmed that is where they started their investigation. The interview identified during their investigation there was suspicious activities of LPN #302 and Registered Nurse (RN) #303 identified. Continued interview revealed the DON contacted LPN #300 for their investigation and LPN #300 wrote a statement. The DON identified she produced copies of the concerning Narcotic records to LPN #300 and originally, she denied any mis-doing; however later, confirmed she had diverted narcotics from residents. Page 1 of 5 365976 365976 08/22/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of an undated letter written by LPN #300 revealed the letter identified LPN #300 admitted to taking residents medications when she pulled medications for unidentified residents. The note stated, I have taken one for myself after giving one to my patient and I have self-reported myself to the board of nursing because I wish to get help. Interview on [DATE] at 11:39 A.M., with the Administrator and DON verified during the facility investigation, LPN #302 was also identified with suspicious controlled drug records. The interview confirmed the facility spoke with LPN #302 whom denied any wrongdoing and agreed to submit to a drug screen. However, LPN #302 never showed up to take the test. The interview confirmed LPN #302's last day of work at the facility was [DATE] and she was terminated on [DATE]. The interview confirmed LPN #302 was turned into the board of nursing on [DATE], based on the suspicious activities. Continued interview with the Administrator and DON identified a third nurse, RN #303, was signing off destruction of residents narcotics, who had expired or discharged without another person's presence or signature. The interview confirmed RN #303 was placed on suspension, pending the investigation, and never returned to work. The facility identified they additionally contacted the board of nursing regarding RN #303 on [DATE]. Review of the policy titled Controlled Substances, updated [DATE], revealed Upon receipt, the nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substance being delivered, both individuals sign the controlled substances record of receipt. Upon Administration, the nurse administering the medication is responsible for recording: the name of the resident, name strength and dose of the medication, time, method, and quantity of medication remaining with signature of nurse administering. Upon Disposition, waste and disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposal sheet. At the end of each shift, controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of Nursing services immediately. The DON investigates all discrepancies in controlled medication reconciliation to determine cause and identify any responsible parties and report the finding to the Administrator. The DON consults with the provider pharmacy and the Administrator to determine whether legal action is indicated. Policies and procedures for monitoring controlled medication to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the Director of Nursing and the consultant pharmacist. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE], Pharmscript Pharmacy (the facility pharmacy) reported to the facility the Omnicell replacement medications (Oxycodone/Oxycontin (5) total) were not placed into the Omnicell. The DON and Administrator initiated an investigation. 365976 Page 2 of 5 365976 08/22/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0602 • Level of Harm - Minimal harm or potential for actual harm On [DATE], the DON and Administrator began interviewing staff concerning the potential missing medications, the process of administering medications, the processes for medication storage, and destruction. The facility pharmacy and Corporate also consulted. The interviews concluded on [DATE]. Residents Affected - Some • On [DATE], The DON began education-ongoing on storage/destruction of medications with nursing staff. • On [DATE], the facility notified the local police to report misappropriation of narcotics (Incident report Number 23-7832). • On [DATE], Resident #112 reported she did not receive pain medication as requested to a State Tested Nurse Aide, who reported to DON. • On [DATE], LPN #300 provided a written statement and admitted to narcotic misappropriation. LPN #300 worked various shifts from [DATE] to [DATE]. LPN #300, self-reported to Ohio Board of Nursing. The facility made LPN #300 employing agency aware of the diversion at the facility. • On [DATE], State Reportable Incident filed with the Ohio Department of Health. All staff education to include Controlled Substance Administration & Accountability and Abuse, Neglect and Misappropriation of Resident Property provided. Agency staff educated upon beginning of shift. Thirty-one residents were identified as affected by the misappropriation. • On [DATE], the DON or designated nurse completed resident interviews and pain evaluations for all residents, with no concerns noted. Responsible parties, residents' physicians, medical director, local authorities, Ohio Department of Health Investigator and Ohio Board of Nursing were notified. • On [DATE] to [DATE], the investigation was ongoing., consulted with pharmacy and regional/corporate team on plan of action. The facility sets up access to Pharmscript Portal, controlled substance reports are emailed routinely from Pharmscript to Administrator/DON. Consulted with Medical Director, all residents medication regimen reviewed, changes were made as indicated. • 365976 Page 3 of 5 365976 08/22/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0602 Level of Harm - Minimal harm or potential for actual harm On [DATE], the facility completed auditing of minimally weekly audits of charting narcotics, on medication carts/storage/destruction-controlled substances, to ensure properly documented. This was completed by the Director of Nursing or designee through [DATE]. • Residents Affected - Some On [DATE] and [DATE], the facility spoke with LPN #302 and requested employee to submit for a drug screen, employee failed to show up at laboratory for test. Employee terminated on [DATE]. LPN #302 was reported to the Ohio Board of Nursing on [DATE]. • Beginning on [DATE], agency staff given personal logins to access Omnicell/PCC, after completing education. This is provided by DON or designee. • On [DATE], the facility began regularly disposing of controlled substances and logging destruction of controlled substance(s). • On [DATE] an Ad Hoc QAPI meeting completed, with Medical Director, pharmacy, and campus leadership time. Systems will continue to be reviewed monthly. • By [DATE], the facility installed cameras in all medication rooms. The footage will be available for up to 10 days and will be randomly reviewed by the Administrator or DON. • On [DATE], RN #303 was placed on suspension, pending the investigation, and never returned to work. RN #303 quit without notice, last day worked: [DATE]. RN #303 was reported to the Ohio Board of Nursing on [DATE]. • On [DATE], the MAR to Cart audit was completed by contracted pharmacy and showed no discrepancies. • Review of seven resident (#27, #47, #58, #59, #78, #79, and #105) records reviewed for narcotic misappropriation revealed no current concerns. • Review of in-servicing records revealed all nursing staff was educated on narcotic control dispensing, destroying, storing, and documenting per the facility policy. This education was provided by the 365976 Page 4 of 5 365976 08/22/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0602 DON or designee. Agency staff was educated upon starting shift by DON or designee. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Some Interviews on [DATE], with LPNs #216, #217, #218, #219, revealed they were able to verify education was provided and was able to verbalize facility policy for controlled substances. This deficiency represents non-compliance investigated under Complaint Number OH00145102 and Complaint OH00144995. 365976 Page 5 of 5