Health inspection·August 3, 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, review of a facility self-reported incident (SRI), facility investigation, employee personnel file, facility policy review, and interview, the facility failed to ensure a resident was free from misappropriation of medications. This affected one resident (#8) of three residents reviewed for misappropriation. Findings include: Review of the medical record for the Resident #8 revealed an admission date of 05/29/18. Diagnoses included chronic kidney disease, chronic pain, chronic ulcer of the lower leg, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/23/23, revealed Resident #8 had intact cognition. The resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for dressing and personal hygiene. Review of Resident #8's physician order, dated 05/02/23, revealed the order for oxycodone HCL oral tablet, give 10 milligrams (mg) every six hours, as needed for pain. Review of the SRI tracking number 236961, dated 07/11/23, revealed on 07/10/23 at 8:40 P.M., as part of a facility Mock Survey being conducted by the Regional Director of Clinical Services, it was noted that documentation revealed Resident #8 received oxycodone 10 mg (narcotic pain medication) on 07/07/23 at 10:20 P.M., 07/08/23 at 8:34 P.M., 07/09/23 at 8:32 P.M., and 07/10/23 at 8:40 P.M. Each dose was signed as administered by Registered Nurse (RN) #201. Resident #8 was interviewed regarding her pain management and indicated that she had been doing well with her pain and stated that she had been taking the pain medication maybe once every two weeks. When asked what pain medication she was referring to, she replied, the oxycodone. When asked if she had taken any oxycodone the previous night, she said she had not, and when asked if she had taken any over the weekend, she said she had not. The Administrator was informed of the concern identified and an investigation initiated. Review of the facility investigation, dated 07/14/23, revealed the investigation included resident assessments, resident interviews, staff interviews, medical record reviews, narcotic record reviews, and hospital drug screen reviews. RN #201 was suspended immediately pending further investigation. RN #201 denied misappropriating any medications and consented to a drug screen which resulted positive for barbiturates and oxycodone. RN #201 did not have any prescribed medications that would result in a positive drug screen. RN #201 was terminated based on the evidence of the investigation. The allegation of misappropriation of narcotic medications was substantiated. (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 9 Event ID: 366253 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 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)