Belpre Landing Nursing And Rehabilitation

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet