Inspection·April 12, 2019

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 review and interview, the facility failed to prevent Resident #32's narcotics from misappropriation. This affected one of one resident reviewed for misappropriation. Residents Affected - Few Findings include: Review of Resident #32's medical record revealed an admission date of 09/15/16. Diagnoses include primary generalized osteoarthritis and Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert, oriented and cognitively intact. Review of the March 2019 physician's order revealed Resident #32 had an active order, effective 01/20/19, for Norco Tablet 5-325 milligram (a narcotic medication for pain), one tablet by mouth every six hours as needed for severe pain with a rating of 8 to 10 on a scale of zero to 10. Review of the care plan dated 09/16/16 for pain related to arthritis (osteoarthritis/rheumatoid) and chronic pain included an intervention for nursing staff to administer pain medication as ordered. Interview on 04/09/19 at 11:16 A.M. was conducted with Resident #32. She stated she remembered she was told her pain medication wasn't available and they told her they had to give to her the pain medication from the emergency stock. Resident #32 stated she had no concerns with getting her pain medication except she would prefer to have the medication routinely scheduled. Review of the facility Self Reported Incident (SRI) submitted 03/08/19 revealed on 03/07/19, Resident #32 asked for her Norco 5-325 mg pain medication and the nurse couldn't find her medication card in the narcotic drawer. All medications were searched and all nurses interviewed. All nursing staff were drug screened except one nurse who did a no call and no show, which means the nurse did not call off from work and did not report to work. All nurses that were drug tested were negative. The local police department was contacted and a detective was assigned to the case. Licensed Practical Nurse (LPN) #500 was the nurse who did not show up to be drug tested and did not respond to phone calls from the facility. Review of Registered Nurse (RN) #442's statement dated 03/07/19 revealed she was asked by Resident #32 for her Norco pain medication at 2:00 P.M. The nurse went to pull the medication from the medication cart and found no Norco medication card and no corresponding controlled substance sign out log in the narcotic drawer. The narcotic medication was not signed out. RN #442 re-counted the narcotics and reported the missing medication to the Director of Nursing (DON). Review of a statement to the local police by the Administrator dated 03/8/19 at 3:00 P.M. revealed RN #442's went into the medication cart and the Norco medication card was missing along with the controlled substance log from the narcotic book. The DON and the Administrator were notified. An investigation was started including interviews with all the nurses who worked from that medication cart. Review of the narcotic count dated 03/04/19 revealed Resident #32 had 60 Norco 5-325 mg tablets with a refill date of 3/19/19. Review of the Medication Administration Record (MAR) from 03/01/19 through 03/31/19 revealed Resident #34 received the Norco pain medication three times a day between 03/01/19 and 03/06/19, except on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 2 of 4 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0602 03/06/19, she only received it twice that day. Level of Harm - Minimal harm or potential for actual harm Interview on 04/11/19 at 10:59 A.M. with the DON revealed Resident #32's nurse, RN #442, informed her the Norco 5-325 mg medication and controlled substance log sheet were missing. The DON stated she talked with all the nurses who had worked from that medication cart. The DON stated she talked with LPN #500, who was the night shift nurse, and had asked if she had given Resident #32 any Norco pain medication. The DON stated LPN #500 initially stated Resident #32 didn't ask for this pain medication. The DON then asked if she had counted the narcotics during shift change prior to leaving her shift and LPN #500 stated she had not. The DON stated she then informed LPN #500 that all the nurses were going to be drug tested. The DON stated LPN #500 did not show up for the drug test and did not report back to work as she was scheduled. The DON stated she and the Human Resources Director attempted to contact LPN #500 without success. Residents Affected - Few Interview on 04/11/19 at 11:17 A.M. with the Administrator revealed the SRI was substantiated as Resident #32's narcotic pain medication was missing. The Administrator stated she had reported it to the board of nursing and said they were still investigating LPN #500. The Administrator stated the misappropriation occurred somewhere. Review of the facility's undated policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident property, revealed misappropriation was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident ' s belonging or money without the resident ' s consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 3 of 4 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #60's Medication Administration Record (MAR) was accurate and complete. This affected one resident of 19 residents reviewed for complete and accurate medical records. Findings include: Record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including diabetes. Resident #60's 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was alert. oriented and cognitively intact. During an interview on 04/09/19 at 3:48 P.M., Resident #60 stated she had not received all her medications, specifically her medications for diabetes, on 03/29/19 and that no one had checked her blood glucose levels that day. Review of Resident #60's MAR revealed on 03/29/19 not all medications were documented as having been administered. There was missing documentation two times on 03/29/19 for Metformin, an oral medication for diabetes, to indicated it had been given. There was missing documentation three times on 03/29/19 that the resident's standard dose of insulin had been administered. There was missing documentation four times on 03/29/19 that blood glucose levels and a corresponding dose of insulin was injected as needed. Review of the progress notes for 03/29/19 did not reveal any documentation regarding medication administration. A telephone interview on 04/12/19 at 11:07 A.M. with Licensed Practical Nurse (LPN) #456 and she stated Resident #60 received all her medications on 03/29/19. LPN #456 also stated she took the blood glucose levels. The LPN remembered talking with the resident about them. LPN #456 stated she usually wrote the medication information down on paper and transferred it the MAR later, she said she must have forgotten to transfer the information on that day. On 04/12/19 at 11:34 A.M. the DON verified Resident #60's MAR had missing documentation on 03/29/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 4 of 4