Inspection·November 24, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle, just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) about her findings, who in turn instructed her to call the DON immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two bottles to the unit manager and informed her that she had already called the DON. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with Resident #8's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. Resident #8's Morphine bottle was given to the Ohio Board of Pharmacy for review, as part of their investigation, when they arrived on-site on 11/19/25. The other resident's Morphine Sulfate bottle was provided for review as well. On 11/19/25 at 2:15 P.M., an observation of Resident #8's Morphine Sulfate 30 ml bottle that was in the Director of Nursing's (DON's) office and being examined by the State of Ohio Board of Pharmacy representatives (Agent and Compliance Specialist) revealed it had a puncture hole in the seal that was covering the top of the medication bottle. The amount of liquid in the bottle of Morphine Sulfate was below the 30 ml. line that would indicate a full bottle. It was confirmed by the representatives from the Ohio Board of Pharmacy that some of the medication solution had been removed from the bottle. On 11/19/25 at 2:55 P.M., a follow up interview with the DON confirmed it was determined that Resident #8 had approximately 3.5 ml of her liquid Morphine Sulfate removed from her bottle, when inspected by the Ohio Board of Pharmacy representatives. He further confirmed there was no documentation on the MAR's or on the Controlled Drug Receipt/ Record/ Disposition Form to show Resident #8 had been given any doses of her Morphine Sulfate liquid, since it had been ordered back in May 2025 to account for the amount of the medication that was missing. He reported the Ohio Board of Pharmacy representatives went ahead (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 2 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and removed the resident's liquid Morphine Sulfate bottle from the facility, after completing their on-site visit/ investigation earlier that day. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI following the Ohio Board of Pharmacy's determination that controlled medications were unaccounted for, but acknowledged was not in the time frame in which they should have been reported. 2 a.) Review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting his right dominant side following a stroke, malignant neoplasm of the prostate, and unspecified dementia. He was admitted under the care and services of hospice on 07/30/25. Review of standing orders to implement with a hospice admission revealed it included the use of Morphine Sulfate 20 mg/ ml with directions to administer 0.25 ml po every four hours for pain or shortness of breath. A written prescription must be obtained from the physician for that order. A verbal order had been obtained by a hospice nurse for the above on 07/29/25. Review of Resident #50's physician's orders revealed the standing order for the use of Morphine Sulfate solution was not carried over into his active physician's orders after the verbal order was given on 07/29/25. Due to it not being carried over into his active physician's orders, the use of the Morphine Sulfate was not included on the medication administration record as one of the resident's prn medications. There was no evidence on the MAR's as any doses of the Morphine Sulfate as having been used for the resident, since the standing order originated on 07/29/25. Review of Resident #50's Controlled Drug Receipt/ Record/ Disposition Form for his Morphine Sulfate that had been sent by the facility's contracted pharmacy revealed 30 ml of the liquid Morphine was filled by the pharmacy on 07/29/25. A nurse signed receipt of the 30 ml of Morphine Sulfate on 07/30/25. The form was left blank where the nurses were to chart each dose administered reflecting no evidence of the liquid Morphine Sulfate having been used for the resident, since it had been filled and received by the facility on 07/30/25. On 11/19/25 at 2:15 P.M., an observation was made of Resident #50's Morphine Sulfate liquid bottle. The controlled medication bottle was in the DON's office being evaluated by representatives from the Ohio Board of Pharmacy, who was present and conducting their own investigation into the possible tampering of the resident's liquid Morphine. The seal on the top of the bottle was intact but there was an obvious puncture hole in the seal covering the top end of the bottle. The hole was approximately the size of a hole an ink pen would make, if it was pushed through paper. It appeared to have the full amount of 30 ml of liquid Morphine Sulfate in the bottle. The representatives from the Ohio Board of Pharmacy was performing a concentration test of the contents in the liquid Morphine Sulfate from Resident #50's bottle. They reported the control concentration was 10.8 and the actual concentration of the liquid medication inside that bottle was only reading 4.4 showing evidence that some of the liquid Morphine had been removed and replaced with some other solution. On 11/19/25 at 2:55 P.M., an interview with the DON confirmed the Ohio Board of Pharmacy was able to determine that Resident #50's liquid Morphine Sulfate had been accessed, as evidenced by the puncture hole in the seal. They were also able to confirm some of the liquid Morphine Sulfate had been removed with another solution added to make it appear the bottle was full. He stated that liquid Morphine Sulfate bottle had been confiscated by the Ohio Board of Pharmacy and taken with them upon their departure from the facility. He denied there was any documented evidence to show that Resident #50 had received any doses of his Morphine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 3 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sulfate that was supposed to be ordered prn for pain or shortness of breath, based on his standing orders from hospice. He acknowledged the standing order was never included in his active physician's orders to be reflected on a MAR, and the controlled medication sheet for that controlled medication was blank showing no evidence of any doses administered. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency, as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI, following the Ohio Board of Pharmacy's determination that there were controlled medications unaccounted for, but acknowledged it was still not submitted in the time frame in which it should have been reported. 2 b.) Review of Resident #50's physician's orders revealed he had an order in place to receive Oxycodone HCL 5 mg po every six hours as needed for pain. The order originated on 03/25/25. Review of a facility investigation file for allegations/ suspicions of misappropriation of medications/ medication diversion revealed the facility completed an investigation pertaining to the potential tampering of Resident #50's Oxycodone dated 07/10/25. The investigation file included a personal witness statement from LPN #210 for an incident date of 07/10/25 that indicated the DON had called her over to his office and informed her that LPN #166 had left the her medication administration cart keys on top of the medication administration cart. The DON removed the locked controlled medication box from the medication administration cart to see how long it took the nurse to realize it was missing. LPN #210 went to his office to see it, when she noted there was something off with the controlled narcotic card in the front right slot. LPN #210 pulled the medication card out of the slot and noticed light peeking through the back of each bubble when there should not have been light coming through. She then flipped the medication blister card over and saw slits along the bottom of each bubble's backing. She then noticed that some of the pills were not like the others and brought it to the attention of the DON. The DON took the blister card and looked at them as well, confirming what LPN #210 was seeing. Review of an email that was included in the facility's investigation file from a pharmacist contracted by the facility to provide their pharmaceutical services to the DON dated 07/16/25 at 11:26 A.M. revealed the contracted pharmacist communicated to the DON that she identified 15 out of 30 Oxycodone tablets with Rx #1446246 (card #2) had been replaced with Loratadine 10 mg tablets by cuts on the bottom of the foil coverings. Only 15 tablets of the remaining 30 tablets, were actually Oxycodone tablets. She further identified 12 tablets of Oxycodone 5 mg tablets had been removed from Rx 1446247 (card #1) and replaced with Loratadine 10 mg tablets. At the time of her inspection, only six of the 18 remaining tablets in the blister card were actually Oxycodone 5 mg tablets. On 11/20/25 at 9:40 A.M., an interview with the DON confirmed he conducted an investigation back in July 2025 pertaining to the possible tampering of Resident #50's Oxycodone 5 mg tablets ordered on a prn basis. He further confirmed the situation was first identified on 07/10/25, when he removed the controlled medication locked box from the 400 hall medication administration cart, after a nurse had left her keys to the medication cart sitting on top of the cart and unattended. He indicated it was LPN #210 that noted the backing on Resident #50's Oxycodone had small slits in the back of it and not all the pills in the blister card looked the same. He reported he then looked at the pills closer and verified the pills in that card were not all the same. They involved their contracted pharmacist, who visited the facility on 07/16/25, and verified some of the Oxycodone HCL 5 mg tablets had been removed and replaced with Loratadine 10 mg tablets. Observation of the blister cards during the interview with the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 4 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete revealed blister card #1 was filled on 03/26/25 and blister card #2 was filled on 05/20/25. Each were to contain Resident #50's Oxycodone HCL 5 mg tablets. Blister card #1 had 12 pills that had been removed with 18 remaining. Of the 18 pills remaining, 12 of the bubbles had small slits in the backing at the bottom of the bubble in the packaging. The remaining pills in those bubbles were noted not to have the same imprints on all of the remaining tablets. Some of them had 10's imprinted on the round white tablets, while others had K/18. Blister card #2 had 30 tablets present with one tablet in each of the 30 bubbles. It too was noted to have small slits in the backing on the reverse side of the card near the bottom of those bubbles. There was a total of 15 different slits in the backing of those 30 bubbles. Per the facility's DON, who remained present while the blister cards were inspected, it was determined by their contracted pharmacist that those 15 tablets of Oxycodone HCL 5 mg tablets in the bubbles with the slits had been replaced with Loratadine 10 mg tablets. That was confirmed by the facility's pharmacist, when they came on-site to inspect the blister cards on 07/16/25. He confirmed he had a copy of that email from their pharmacist following that visit on 07/16/25 showing what was found and included it in the facility's investigation file. He denied that he was able to confirm misappropriation of the resident's medication had occurred, as their investigation was not able to prove who took it. He acknowledged they did not have to prove who took the medication to show evidence of misappropriation of a resident's medication had occurred, only that there were doses unaccounted for that had not been used by the resident. He denied he had submitted a selfreporting incident (SRI) to the state survey agency for the suspicion/ allegation of misappropriation/ medication diversion, as he did not feel his investigation was able to determine that misappropriation of medication had occurred. He further acknowledged some of Resident #50's Oxycodone had been replaced with Loratadine 10 mg tablets and those Oxycodone tablets that were missing and replaced with Loratadine 10 mg tablets were not used for the resident as they were intended to be. Review of the facility's Abuse Prohibition policy (not dated) revealed residents of the facility would not be subjected to the misappropriation of their property by anyone. Misappropriation of resident property was defined as depriving, defrauding, or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. It was also the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. All alleged violations concern abuse, neglect, and misappropriation of property were to be immediately reported to the Administrator or designee. Allegations that involve abuse or result in serious bodily injury would be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident was discovered. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the Ohio Department of Health within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number 2672468. Event ID: Facility ID: 366443 If continuation sheet Page 5 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility investigations, observations, interviews, and policy review, the facility failed to ensure all allegations/ suspicions of misappropriation of resident property was reported to the State Survey Agency as required. This affected two (#8 and #50) of three residents reviewed for misappropriation of medications. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, dysphagia (difficulty swallowing), amputation of the left leg below the knee, and osteoarthritis. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She was coded on the MDS assessment as having had pain in the past five days she rated as a 4 on a 1-10 scale. She received both scheduled and prn pain medication for her pain. The medication section of the MDS assessment (Section N.) did not indicate that she had received opioid medications during the seven day assessment period (11/09/25- 11/15/25). Review of Resident #8's physician's orders revealed the resident had an order to receive Morphine Sulfate 20 milligrams (mg)/ milliliter (ml) with directions to give 0.25 ml by mouth (po) every four hours as needed (prn) for pain or shortness of breath. The order originated on 05/19/25, after she was placed under the care and services of hospice on 05/16/25. Review of Resident #8's medication administration records (MAR's) from May 2025 through November 2025 revealed the resident's prn order to receive Morphine Sulfate was included on the MAR's each month during that seven month period. There was no documented evidence of any prn doses of Morphine Sulfate having been administered to the resident for any complaints of pain or shortness of breath, since the order originated on 05/19/25. Review of Resident #8's Controlled Drug Receipt/ Record/ Disposition Form for her Morphine Sulfate revealed 30 ml of the liquid Morphine was filled by the facility's contracted pharmacy on 05/28/25. The form was blank and did not show any doses of the Morphine Sulfate had been used for the resident, since it was filled by the pharmacy. Review of a facility investigation file pertaining to Resident #8's liquid Morphine Sulfate revealed the facility obtained personal witness statements and/ or conducted phone interviews with facility nurses regarding the resident's Morphine Sulfate. A hand written statement from Licensed Practical Nurse (LPN) #115 dated 11/14/25 revealed she was doing the controlled narcotic drawer count when she noted a discrepancy with a Morphine Sulfate bottle for Resident #8. The contents of the bottle was below the 30 ml (approximately 27-28 ml's) that it should have been. She asked two other nurses (LPN #166 and LPN #350) when they started giving Resident #8 Morphine Sulfate and both denied knowledge of the resident ever receiving it. The resident just had the bottle on hand in case she needed it. She then informed the two nurses the bottle was low and some of the medication had been removed. The bottle appeared to be sealed, but when turned upside down, a drop of the liquid Morphine formed at the top of the bottle on the seal. She then noticed a very small hole in the seal. The plunger top and syringe for the liquid Morphine Sulfate bottle were still in the plastic packaging and had not been used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle, just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) about her findings, who in turn instructed her to call the Director of Nursing (DON) immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 6 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bottles to the unit manager and informed her that she had already called the DON. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with Resident #8's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. Resident #8's Morphine bottle was given to the Ohio Board of Pharmacy for review, as part of their investigation, when they arrived on-site on 11/19/25. The other resident's Morphine Sulfate bottle was provided for review as well. On 11/19/25 at 2:15 P.M., an observation of Resident #8's Morphine Sulfate 30 ml bottle that was in the Director of Nursing's (DON's) office and being examined by the State of Ohio Board of Pharmacy representatives (Agent and Compliance Specialist) revealed it had a puncture hole in the seal that was covering the top of the medication bottle. The amount of liquid in the bottle of Morphine Sulfate was below the 30 ml. line that would indicate a full bottle. It was confirmed by the representatives from the Ohio Board of Pharmacy that some of the medication solution had been removed from the bottle. On 11/19/25 at 2:55 P.M., a follow up interview with the DON confirmed it was determined that Resident #8 had approximately 3.5 ml of her liquid Morphine Sulfate removed from her bottle, when inspected by the Ohio Board of Pharmacy representatives. He further confirmed there was no documentation on the MAR's or on the Controlled Drug Receipt/ Record/ Disposition Form to show Resident #8 had been given any doses of her Morphine Sulfate liquid, since it had been ordered back in May 2025 to account for the amount of the medication that was missing. He reported the Ohio Board of Pharmacy representatives went ahead and removed the resident's liquid Morphine Sulfate bottle from the facility, after completing their on-site visit/ investigation earlier that day. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI following the Ohio Board of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 7 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Pharmacy's determination that controlled medications were unaccounted for, but acknowledged was not in the time frame in which they should have been reported. 2 a.) Review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting his right dominant side following a stroke, malignant neoplasm of the prostate, and unspecified dementia. He was admitted under the care and services of hospice on 07/30/25. Review of standing orders to implement with a hospice admission revealed it included the use of Morphine Sulfate 20 mg/ ml with directions to administer 0.25 ml po every four hours for pain or shortness of breath. A written prescription must be obtained from the physician for that order. A verbal order had been obtained by a hospice nurse for the above on 07/29/25. Review of Resident #50's physician's orders revealed the standing order for the use of Morphine Sulfate solution was not carried over into his active physician's orders after the verbal order was given on 07/29/25. Due to it not being carried over into his active physician's orders, the use of the Morphine Sulfate was not included on the medication administration record as one of the resident's prn medications. There was no evidence on the MAR's as any doses of the Morphine Sulfate as having been used for the resident, since the standing order originated on 07/29/25. Review of Resident #50's Controlled Drug Receipt/ Record/ Disposition Form for his Morphine Sulfate that had been sent by the facility's contracted pharmacy revealed 30 ml of the liquid Morphine was filled by the pharmacy on 07/29/25. A nurse signed receipt of the 30 ml of Morphine Sulfate on 07/30/25. The form was left blank where the nurses were to chart each dose administered reflecting no evidence of the liquid Morphine Sulfate having been used for the resident, since it had been filled and received by the facility on 07/30/25. On 11/19/25 at 2:15 P.M., an observation was made of Resident #50's Morphine Sulfate liquid bottle. The controlled medication bottle was in the DON's office being evaluated by representatives from the Ohio Board of Pharmacy, who was present and conducting their own investigation into the possible tampering of the resident's liquid Morphine. The seal on the top of the bottle was intact but there was an obvious puncture hole in the seal covering the top end of the bottle. The hole was approximately the size of a hole an ink pen would make, if it was pushed through paper. It appeared to have the full amount of 30 ml of liquid Morphine Sulfate in the bottle. The representatives from the Ohio Board of Pharmacy was performing a concentration test of the contents in the liquid Morphine Sulfate from Resident #50's bottle. They reported the control concentration was 10.8 and the actual concentration of the liquid medication inside that bottle was only reading 4.4 showing evidence that some of the liquid Morphine had been removed and replaced with some other solution. On 11/19/25 at 2:55 P.M., an interview with the DON confirmed the Ohio Board of Pharmacy was able to determine that Resident #50's liquid Morphine Sulfate had been accessed, as evidenced by the puncture hole in the seal. They were also able to confirm some of the liquid Morphine Sulfate had been removed with another solution added to make it appear the bottle was full. He stated that liquid Morphine Sulfate bottle had been confiscated by the Ohio Board of Pharmacy and taken with them upon their departure from the facility. He denied there was any documented evidence to show that Resident #50 had received any doses of his Morphine Sulfate that was supposed to be ordered prn for pain or shortness of breath, based on his standing orders from hospice. He acknowledged the standing order was never included in his active physician's orders to be reflected on a MAR, and the controlled medication sheet for that controlled medication was blank showing no evidence of any doses administered. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency, as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 8 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI, following the Ohio Board of Pharmacy's determination that there were controlled medications unaccounted for, but acknowledged it was still not submitted in the time frame in which it should have been reported. 2 b.) Review of Resident #50's physician's orders revealed he had an order in place to receive Oxycodone HCL 5 mg po every six hours as needed for pain. The order originated on 03/25/25. Review of a facility investigation file for allegations/ suspicions of misappropriation of medications/ medication diversion revealed the facility completed an investigation pertaining to the potential tampering of Resident #50's Oxycodone dated 07/10/25. The investigation file included a personal witness statement from LPN #210 for an incident date of 07/10/25 that indicated the DON had called her over to his office and informed her that LPN #166 had left the her medication administration cart keys on top of the medication administration cart. The DON removed the locked controlled medication box from the medication administration cart to see how long it took the nurse to realize it was missing. LPN #210 went to his office to see it, when she noted there was something off with the controlled narcotic card in the front right slot. LPN #210 pulled the medication card out of the slot and noticed light peeking through the back of each bubble when there should not have been light coming through. She then flipped the medication blister card over and saw slits along the bottom of each bubble's backing. She then noticed that some of the pills were not like the others and brought it to the attention of the DON. The DON took the blister card and looked at them as well, confirming what LPN #210 was seeing. Review of an email that was included in the facility's investigation file from a pharmacist contracted by the facility to provide their pharmaceutical services to the DON dated 07/16/25 at 11:26 A.M. revealed the contracted pharmacist communicated to the DON that she identified 15 out of 30 Oxycodone tablets with Rx #1446246 (card #2) had been replaced with Loratadine 10 mg tablets by cuts on the bottom of the foil coverings. Only 15 tablets of the remaining 30 tablets, were actually Oxycodone tablets. She further identified 12 tablets of Oxycodone 5 mg tablets had been removed from Rx 1446247 (card #1) and replaced with Loratadine 10 mg tablets. At the time of her inspection, only six of the 18 remaining tablets in the blister card were actually Oxycodone 5 mg tablets. On 11/20/25 at 9:40 A.M., an interview with the DON confirmed he conducted an investigation back in July 2025 pertaining to the possible tampering of Resident #50's Oxycodone 5 mg tablets ordered on a prn basis. He further confirmed the situation was first identified on 07/10/25, when he removed the controlled medication locked box from the 400 hall medication administration cart, after a nurse had left her keys to the medication cart sitting on top of the cart and unattended. He indicated it was LPN #210 that noted the backing on Resident #50's Oxycodone had small slits in the back of it and not all the pills in the blister card looked the same. He reported he then looked at the pills closer and verified the pills in that card were not all the same. They involved their contracted pharmacist, who visited the facility on 07/16/25, and verified some of the Oxycodone HCL 5 mg tablets had been removed and replaced with Loratadine 10 mg tablets. Observation of the blister cards during the interview with the DON revealed blister card #1 was filled on 03/26/25 and blister card #2 was filled on 05/20/25. Each were to contain Resident #50's Oxycodone HCL 5 mg tablets. Blister card #1 had 12 pills that had been removed with 18 remaining. Of the 18 pills remaining, 12 of the bubbles had small slits in the backing at the bottom of the bubble in the packaging. The remaining pills in those bubbles were noted not to have the same imprints on all of the remaining tablets. Some of them had 10's imprinted on the round white tablets, while others had K/18. Blister card #2 had 30 tablets present with one tablet in each of the 30 bubbles. It too was noted to have small slits in the backing on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 9 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the reverse side of the card near the bottom of those bubbles. There was a total of 15 different slits in the backing of those 30 bubbles. Per the facility's DON, who remained present while the blister cards were inspected, it was determined by their contracted pharmacist that those 15 tablets of Oxycodone HCL 5 mg tablets in the bubbles with the slits had been replaced with Loratadine 10 mg tablets. That was confirmed by the facility's pharmacist, when they came on-site to inspect the blister cards on 07/16/25. He confirmed he had a copy of that email from their pharmacist following that visit on 07/16/25 showing what was found and included it in the facility's investigation file. He denied that he was able to confirm misappropriation of the resident's medication had occurred, as their investigation was not able to prove who took it. He acknowledged they did not have to prove who took the medication to show evidence of misappropriation of a resident's medication had occurred, only that there were doses unaccounted for that had not been used by the resident. He denied he had submitted a self- reporting incident (SRI) to the state survey agency for the suspicion/ allegation of misappropriation/ medication diversion, as he did not feel his investigation was able to determine that misappropriation of medication had occurred. He further acknowledged some of Resident #50's Oxycodone had been replaced with Loratadine 10 mg tablets and those Oxycodone tablets that were missing and replaced with Loratadine 10 mg tablets were not used for the resident as they were intended to be. Review of the facility's Abuse Prohibition policy (not dated) revealed residents of the facility would not be subjected to the misappropriation of their property by anyone. Misappropriation of resident property was defined as depriving, defrauding, or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. It was also the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. All alleged violations concern abuse, neglect, and misappropriation of property were to be immediately reported to the Administrator or designee. Allegations that involve abuse or result in serious bodily injury would be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident was discovered. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the Ohio Department of Health within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number 2672468. Event ID: Facility ID: 366443 If continuation sheet Page 10 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 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. Based on review of a facility investigation pertaining to an alleged/ suspected tampering of controlled narcotic medications, review of shift to shift controlled medication reconciliation sheets, staff interviews, and policy review, the facility failed to ensure proper pharmacy procedures were followed in regards to performing an appropriate reconciliation of all controlled medications each time keys to medication administration carts providing access to those controlled medications were exchanged between nurses. This affected two (#8 and #50) of three residents reviewed for the handling of controlled narcotic medications. Findings include: Review of a facility investigation file pertaining to the suspected tampering of Resident #8 and Resident #50's liquid Morphine Sulfate revealed an allegation of potential tampering of the controlled medication was reported to the facility's Director of Nursing (DON) on 11/14/25. As part of the facility's investigation, personal witness statements and/ or phone interviews were conducted with the facility's nurses regarding Resident #8's Morphine Sulfate. Review of a hand written statement provided by Licensed Practical Nurse (LPN) #115 on 11/14/25 revealed she was doing the controlled narcotic drawer count when she noted Resident #8's Morphine Sulfate bottle to be below 30 milliliters (ml), with approximately 27-28 ml present. She asked two other nurses (LPN #166 and LPN #350) when they started giving Resident #8 Morphine Sulfate and both denied knowledge of the resident ever receiving it. The resident just had the bottle on hand in case she needed it. She then informed the two nurses the bottle was low and some of the medication had been removed. The bottle appeared to be sealed, but when turned upside down, a drop of the liquid Morphine formed at the top of the bottle on the seal. She then noticed a very small hole in the seal. The plunger top and syringe for the liquid Morphine Sulfate bottle were still in the plastic packaging and had not been used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) to report her findings, who in turn instructed her to call the DON immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two bottles to the unit manager and informed her that she had already called the DON. Review of a personal witness statement from LPN #100 (not dated) revealed he verified count with LPN #185 on Thursday 11/13/25 at 6:00 P.M. (the conclusion of his shift) with no discrepancies noted. He denied that he visualized Resident #8's Morphine Sulfate bottle personally when he completed the reconciliation count of the controlled medication for the 400 hall, where Resident #8 resided. Review of a typed statement provided by LPN #185 dated 11/14/25 at 5:00 P.M. revealed she did count the 400 hall medication administration cart with LPN #100. She denied that she took the bottle of Morphine Sulfate out of Resident #8's box, as she indicated it had never been used by the resident according to the controlled medication disposition sheet. She then stated she took the keys from LPN #100 and sat them down at the computer to get caught up on her residents. LPN #210 came in before 7:00 P.M. and she handed LPN #210 the keys and LPN #210 then started the medication pass on the 400 hall. She denied that she recounted the controlled medications in the medication administration cart with LPN #210, as she had just counted them with LPN #100 and was never in the cart following that. Review of a personal witness statement from LPN #210 (not dated) for an incident date of 11/13/25 revealed she arrived to the facility per request to assist with the 400 hall medication pass. LPN #100 grabbed the keys off the nurses' station desk and handed them to her. She then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 11 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few took the keys from LPN #100, who informed her that he and LPN #185 had already counted the narcotic drawer prior to her arrival. LPN #210 then proceeded to chart and begin the 400 hall medication pass. After she completed the 400 hall medication pass, she then handed the keys to LPN #166 (night shift nurse), who was standing at the 100 hall medication administration cart. Review of a typed phone interview with LPN #166 on 11/14/25 at 4:40 P.M. (not indicating who completed the interview) revealed LPN #185 counted the 400 hall medication administration cart with LPN #100, prior to LPN #185 taking the medication administration cart keys from LPN #100. She denied she knew what had happened between LPN #210 and LPN #185, when LPN #210 arrived. She claimed she was standing at the 100 hall medication administration cart talking with another staff member, when LPN #210 walked up and dropped the keys on the medication administration cart and saying I'm done, and everything was fine. LPN #210 then walked away, got her stuff, and left. LPN #166 reported, after she was done talking with the other employee, she got LPN #300 and the counted the 400 hall medication cart in front of the camera. Review of a typed phone interview with LPN #300 dated 11/14/25 at 7:07 P.M. revealed LPN #166 came to her and told her LPN #210 had laid down the keys and report paper and just left. LPN #166 stated she was not going to take the 400 hall medication administration cart until it was counted. She responded to LPN #166 and said let's go count the cart. She denied that either nurse had inspected Resident #8's Morphine Sulfate bottle that was in the cart. Review of additional personal witness statements obtained from LPN #260 on 11/18/25 and LPN #400 on 11/18/25 revealed they provided statements to the facility for their investigation as they had recently had access to the 400 hall medication administration cart. LPN #260 reported she had the 400 hall medication administration cart on Wednesday 11/12/25. She reported she did not re-verify the count and had not taken Resident #8's Morphine out of the box. The statement provided by LPN #400 revealed she counted the 400 hall cart on 11/12/25 and pulled the Morphine bottle of Resident #8 out of the box, but did not remove the lid. She stated she now knew that it was a requirement to remove the lid and inspect the seals to liquid Morphine bottles to ensure they remained intact. Review of in-service education provided to facility nurses revealed the DON educated the nurses on the topic of narcotic counts. The date of the in-service was not identified, but was signed by 17 nurses. Four were in person and 13 were provided via phone. Included with the in-service education was a copy of the Ohio Administrative Code Rule 4729:5-9-03.2 Security, storage, and control of dangerous drugs in an institutional facility effective 01/23/23, a copy of the facility's Controlled Medication Storage policy from the Nursing Care Center Pharmacy Policy and Procedure Manual from the facility's contracted pharmacy with a copyright date of 2007, and additional information from the facility's contracted pharmacy under the topic of Controlled Substances: Preventing Diversion and Narcotic Documentation. Review of a Shift Change Controlled Substance Accountability form for the 400 hall medication administration cart dated 11/13/25 revealed the last documented controlled medication reconciliation completed between two nurses occurred on 11/13/25 at 6:00 A.M. Only one nurse (LPN #100) signed that a reconciliation of the controlled medications was performed for the 400 hall medication administration cart at 6:00 P.M. as the off nurse. The on nurse did not sign to provide evidence of a proper reconciliation of all controlled medications stored in that cart had been performed. LPN #166 was the next nurse to sign that a reconciliation of those controlled medications were completed and that was at 9:00 P.M. She did not have another nurse sign to indicate that the reconciliation count was completed in conjunction with another nurse. LPN #210's first name was hand written at the 9:00 P.M. time, but was not signed to provide evidence she participated in any reconciliation count of the controlled medications in that medication cart. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 12 of 13 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #8 and #50's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. They (Ohio Board of Pharmacy) concluded both Resident #8 and Resident #50's Morphine bottles had been tampered with. They could not account for 3.5 ml of Resident #8's 30 ml Morphine Sulfate bottle and Resident #50 had some of his Morphine Sulfate removed and replaced with another kind of solution to hide the amount that had been removed. He confirmed his investigation showed concerns with the facility's nurses to not perform appropriate reconciliation of controlled medications stored in the medication administration cart for the 400 hall on 11/13/25- 11/14/25 when keys exchanged hands. He confirmed a reconciliation count of all controlled medications should be conducted for that medication administration cart anytime keys were passed to another nurse and the prior nurse had access to those controlled medications. Review of the facility's policy on Controlled Medication Storage dated December 2012 revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. The DON and the consultant pharmacist monitored for compliance with federal and state laws and regulations in the handling of controlled medications. At each shift change, or when keys were transferred, a physical inventory of all scheduled II medications was to be conducted between two licensed nurses or per state regulations and was documented on the controlled substances accountability record or verification of controlled substances count report. This deficiency represents non-compliance investigated under Complaint Number 2672468. Event ID: Facility ID: 366443 If continuation sheet Page 13 of 13