Inspection·March 11, 2025

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 - Few Based on medical record reviews, reviews of a facility investigation, review of self-reported incidents (SRIs), and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected two (#4 and #47) of two residents reviewed for misappropriation. The facility census was 47. Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/24/23 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was unable to be interviewed and was dependent on staff for activities of daily living (ADLs). Review of the physician's orders for December 2024 revealed Oxycodone (narcotic pain medication) 20 milligrams (mg) given every six hours routinely and a as needed (PRN) order for five mg of Oxycodone every two hours. Review of the medical record for Resident #47 revealed an admission date of 07/14/17 with diagnoses including cerebral palsy, major depressive disorder, and generalized anxiety disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition and was dependent on staff for ADLs. Review of the physician's orders for December 2024 revealed Oxycodone five mg twice daily and a as needed (PRN) order for five mg of Oxycodone every four hours. Review of the SRI dated 01/09/25 revealed Licensed Practical Nurse (LPN) #108 signed out as needed (PRN) Oxycodone immediate release (IR) five milligrams (mg) for Resident #4 on 12/31/24 at 7:20 P.M. and 9:50 P.M. and on 01/01/24 at 4:00 A.M. on one narcotic count card and on another narcotic card for Resident #4 revealed Oxycodone IR 20 mg signed out at 7:20 P.M. on 12/31/24 as well as 12:00 A.M. and 5:00 A.M. on 01/01/25 in the narcotic count book. Resident #4's medication administration records (MARs) for December 2024 and January 2025 did not reveal that the PRN five mg. Oxycodone IR was administered to Resident #4 by LPN #108. Further review of the MARs for 12/31/24 and 01/01/25 revealed that they were not signed off and that Oxycodone IR 20 mg was not due at the times when taken from cart. Resident #4 was unable to verify she received it. Resident #4's habit was to sleep through the night and normally does not get the Oxycodone IR five mg at night. (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: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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)