Health inspection·July 18, 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** Based on record reviews, resident and staff interviews and policy review, the facility failed to ensure residents were free from misappropriation of medications. This affected two (#19 and #100) out of the four residents reviewed for medications. The facility census was 98. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #100 revealed an admission date of 11/17/22 with medical diagnoses of morbid obesity, diabetes mellitus, vascular dementia with behavioral disturbances, delusional disorder, schizoaffective disorder, and major depression. The medical record revealed Resident #100 discharged on 06/22/23. Review of the medical record for Resident #100 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #100 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. The MDS revealed Resident #100 complained of occasional moderate pain and received an opioid medication for seven days. Review of the medical record for Resident #100 revealed a physician order dated 04/24/23 for Percocet 7.5/325 milligrams (mg) one tablet by mouth three times per day for pain control. Review of the medical record for Resident #100 revealed the June 2023 Medication Administration Record (MAR) indicated Resident #100 was administered one Percocet 7.5/325 mg on 06/22/23 at 6:00 A.M. by Registered Nurse (RN) #262. Review of the MAR revealed that was the only time Resident #100 was administered a Percocet on 06/22/23. Review of the medical record for Resident #100 revealed a controlled drug record which indicated RN #262 had signed the record on 06/22/23 at 6:00 A.M. for one Percocet 7.5/325 mg tablet. Further review of the controlled drug record for Resident #100 revealed documentation on 06/22/23 at 7:00 A.M. that Licensed Practical Nurse (LPN) #334 had signed for one Percocet 7.5/325 mg tablet and documented that tablet was wasted. The documentation did not contain the signature of a second nurse to confirm the Percocet tablet was disposed of or destroyed properly. Review of the facility staff schedule for 06/22/23 revealed LPN #334 did not work on that day. Interview on 07/17/23 at 1:26 P.M. with Director of Nursing (DON) stated the facility did not have a policy for controlled substances. DON stated the facility procedure for controlled substances included for the licensed nurse to complete an assessment, document residents' pain, to administer the medication within 15 minutes of residents' request for pain medications, and to document Page 1 of 3 366035 366035 07/18/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration on the MAR and on the controlled substance record. DON stated the procedure for the destruction of a controlled substance required two licensed nurses' observation of the destruction of the medication and both licensed nurses' signatures on the controlled substance record. DON confirmed the signature for the Percocet on 06/22/23 at 7:00 A.M. was LPN #334. DON confirmed the controlled substance record for Resident #100 did not contain the signature of a second nurse to confirm the Percocet was destroyed properly. DON also confirmed LPN #334 did not work on 06/22/23, the day LPN #334 signed Resident #100's Percocet was wasted. 2. Review of the medical record for Resident #19 revealed an admission date of 07/06/22 with medical diagnoses of chronic kidney disease Stage III, polyneuropathy, spastic hemiplegia, and low back pain. Review of the medical record for Resident #19 revealed an annual MDS, dated [DATE], which indicated Resident #19 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. The MDS indicated Resident #19 complained of frequent pain and received an opioid medication for seven days. Review of the medical record for Resident #19 revealed a physician order dated 04/12/23 for Norco (hydrocodone-acetaminophen) tablet 5-325 mg one tablet by mouth every four hours as needed for pain. Review of the medical record for Resident #19 revealed the July 2023 MAR indicated Resident #19 was given one Norco tablet 5-325 mg on 07/15/23 at 7:30 A.M. and 11:30 A.M. Review of the medical record for Resident #19 revealed a controlled substance record which indicated as of 07/15/23 Resident #19 had 15 Norco 5-325 mg tablets available. The controlled substance record revealed LPN #334 signed for one Norco 5-325 mg tablet at 7:30 A.M. and one at 3:00 P.M. leaving 13 Norco 5-325 mg tablets available. The record did not contain documentation that LPN #334 signed for the Norco indicated as given at 11:30 A.M. per the MAR. Further review of the controlled substance record revealed LPN #334 signed for one Norco 5-325 mg tablet on 07/15/23 at 7:00 P.M. which resulted in 12 tablets left. A line was drawn through this entry with error wrote next to the line along with LPN #334's initials. The medical record did not contain documentation to support Resident #19 was given Norco 5-325 mg at 7:00 P.M. on 07/15/23. Continued review of the controlled substance record revealed on 07/16/23 at 8:00 A.M. an unidentified nurse signed for one Norco 5-325 mg tablet leaving Resident #19 with 11 Norco tablets available. Interview on 07/17/23 at 11:36 A.M. with Resident #19 stated he normally asked the staff for one Norco 5-325 mg tablet in the morning and one tablet in the evening for pain control. Resident #19 stated on 07/15/23 he did not receive one Norco tablet in the morning and did not receive one Norco until around 3:00 P.M. that day. Resident #19 stated he requested another Norco around 7:00 P.M. on 07/15/23 and LPN #334 administered the medication as requested. Resident #19 denied any negative outcomes from not receiving the Norco at 7:30 A.M. on 07/15/23. Interview on 07/17/23 at 1:26 P.M. with DON confirmed the nurse's signature on Resident #19's-controlled substance record was LPN #334 and confirmed the record did not contain the signature of a second nurse to confirm the Norco signed out at 7:00 P.M. had been destroyed properly or the entry was written and error. DON also confirmed the count for the number of Norco tablets available for Resident #19 did not add to the correct amount that should have been available. DON stated LPN #334 was suspended effective 07/17/23 pending an investigation into medication diversion. 366035 Page 2 of 3 366035 07/18/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0602 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse Prevention dated 08/20/21 revealed misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent. This deficiency represents non-compliance investigated under Complaint Number OH00144507. Residents Affected - Few 366035 Page 3 of 3