Health inspection·November 21, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on review of a facility self-reported incident (SRI), review of facility investigation, review of pharmacy packing slips, review of electronic medication storage (Cubex) sign in logs, staff interview, review of the policy, and review of corrective action, the facility failed to ensure controlled substances (narcotics) received in the facility were accurately recorded and stored according to policy. This had the potential to affect 20 of 20 residents who receive narcotics. The facility census was 118. Findings include: Review of a facility self-reported incident report dated 11/03/23, indicated the facility pharmacy notified the facility Director of Nursing (DON) that during a routine audit on 11/03/23, the pharmacist found there were four oxycodone five milligram (mg) tabs and one Ambien five mg tab unaccounted for in the in-house starter kit. The in-house starter kit is in the electronic Cubex (a locked cabinet with individual sections for each medication). The medications (oxycodone and Ambien) were signed for received on the pharmacy manifest on 10/27/23 by Licensed Practical Nurse (LPN) #259. Medications were to be used for facility stock medications. LPN #259 was suspended, and an in-house investigation was completed by DON. On 11/08/23, the investigation was completed. Based on the facility investigation, the facility was unable to substantiate that misappropriation occurred. Review of the facility investigation into the incident revealed LPN #259 went to the drug testing center and produced a negative drug screen. LPN #259 signed a statement (reviewed) dated 11/06/23 confirming she worked the night shift on 10/26/23 through 10/27/23. The statement stated LPN #259 signed for the pharmacy delivery at 2:00 A.M. LPN #259 revealed in the statement that she did not witness any ambien or oxycodone in the delivery and did not recall seeing any packets or cards with those specific medications. Three additional nurses who worked the night shift on 10/26/23 through 10/27/23 (LPN #229, #247, and #213) were also interviewed and made written statements revealing they also did not see the medication. The emergency supply of controlled substances was audited by the DON, and none were missing. Select residents were interviewed in regard to their experience receiving proper medication and timely medication, no unique findings were noted. Pharmacy noted they reported the missing medications to the pharmacy board. Review of the summary of investigation indicated the allegation of misappropriation was unsubstantiated. Review of the pharmacy packing slip included facility name and dated 10/26/23. The pharmacy packing slip also included Cubex four oxycodone tab five mg and one zolpidem (ambien) five mg. Below the (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 3 Event ID: 366180 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 366180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Pointe Care Center 9027 Columbia Road Olmsted Falls, OH 44138 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)