Health inspection·April 25, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview and policy review, the facility failed to ensure an accurate reconciliation and accounting of all controlled substances. This affected one (#122) out of three reviewed for medication reconciliation. The facility census was 123. Findings include: Review of the medical record for Resident #122 revealed an admission date of 02/13/25 and a discharge date of 03/15/25. Diagnoses include non-pressure chronic ulcer of right heel and midfoot with unspecified severity, type 2 diabetes mellitus with foot ulcer, rheumatoid arthritis without rheumatoid factor, and spondylolisthesis. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #122 was independent with eating, required supervision assistance with oral hygiene, personal hygiene, and wheelchair mobility, required partial assistance with bed mobility, required substantial assistance with bathing, dressing, and transfers, and was dependent on staff assistance with toileting hygiene. Review of the physician order dated 02/13/25 revealed an order for Oxycontin Oral Tablet Extended Release (ER) 12 Hour Abuse-Deterrent 10 mg tab, give 1 tablet by mouth two times a day for chronic pain syndrome. Further review of the physician orders revealed an order dated 03/14/25 that resident may discharge home with Home Health for physical therapy, occupational therapy and nursing (PT/OT/NSG) services. Review of the care plan dated 02/13/25 revealed Resident #122 required assistance with all activities of daily living. Review of the pharmacy packing slip dated 03/05/25 revealed Oxycontin Oral Tablet Extended Release (ER) 12 Hour Abuse-Deterrent 10 mg tablets, 30 tablets were delivered to the facility on [DATE] for Resident #122. Further record review revealed Resident #122's Oxycontin 30 tablets delivered on 03/05/25 could not be accounted for. Review of Resident #122's progress noted dated 03/15/25 at 10:00 A.M. revealed resident discharged to home with his wife today at 10:00 A.M., resident sent with his medications for the rest of the weekend. Page 1 of 3 366301 366301 04/25/2025 Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/25/25 at 10:34 A.M. with Administrator #335 confirmed on 03/16/25, the day after Resident #122 discharged home, the facility discovered 30 tablets of Oxycontin 10 mg, a full skid, came up missing on 03/16/25. Interview with Administrator #335 also revealed that the facility completed a full investigation, and two nurses, Licensed Practical Nurse (LPN) #478 and Registered Nurse (RN) #479 were terminated for not following protocol of not giving the narcotic keys to another nurse without counting narcotics first. Administrator #335 confirmed the facility was unable to determine where the 30 tablets of Oxycontin 10 mg went. Review of the Controlled Drug Reconciliation policy, dated 04/2025 revealed all controlled medications (Schedule II, III, IV, V) are counted by licensed personnel. At every change of shift and hand-off of narcotic keys, a reconciliation is conducted by both the departing and incoming licensed health care professional responsible for the security and control of the drugs in the medication cart(s). The deficient practice was corrected on 03/19/25 when the facility implemented the following corrective actions: • On 03/16/25, the Director of Nursing (DON) was notified of an inconsistency with narcotic proof of use sheets and narcotic skids regarding Resident #122's medication. The DON reported a self-reported incident (SRI) to the Ohio Department of Health and began an investigation. The DON also notified Physician #12, Administrator, Medical Director and Police regarding Resident #122's missing medications. • On 03/16/25 at 9:00 P.M., LPN #478 and RN #479 were removed from the nursing schedule and a drug screen was completed. The results of the drug screen for LPN #478 and RN #479 were negative. However, at the conclusion of the facilities investigation, LPN #478 and RN #479 were terminated. • On 3/16/25 at 11:00 P.M., all facility medication carts were audited by the DON and another licensed nurse on duty to ensure verification of controlled substance counts. Additionally, current residents' narcotic proof of use sheets and shift count sheets were reviewed by DON. No other concerns were identified. • On 03/16/25 through 03/19/25, all licensed nurses were interviewed by the DON regarding medications and missing medications. There were no other concerns identified. • On 03/17/25, a Quality Assurance meeting was completed with the Medical Director. • On 03/18/25, licensed nurses on duty verified residents' controlled substances are available for 366301 Page 2 of 3 366301 04/25/2025 Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069

F 0755 administration. No concerns were identified. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Few By 03/19/25, the DON or designee completed an audit of current residents on opiates or controlled substances to verify medications are available for administration. No concerns were identified. • On 03/19/25, the DON completed in-service training with all licensed nurses on the abuse policy including misappropriation and controlled substance procedures. This deficiency represents non-compliance investigated under Complaint Number OH00164014. 366301 Page 3 of 3