Health inspection·June 18, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews, and review of the facility policy, the facility failed to conduct a thorough neglect investigation. This affected one (#44) of three residents reviewed for neglect. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, acute cystitis with hematuria, repeated falls, congestive obstructive pulmonary disease, mitral valve prolapse, atrial fibrillation, depression and anxiety. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was cognitively intact, had an indwelling Foley catheter (discontinued 05/03/24), was frequently incontinent of bowel and had no Range of Motion impairment in upper and lower extremities. Resident #44 required moderate assistance with eating and oral hygiene, maximal assistance with personal hygiene and bed mobility, and dependent for toileting, bathing, dressing and transfers. Review of a SRI dated 05/19/24 revealed Resident #44 reported she was forcefully administered Morphine orally via a syringe by an Agency Licensed Practical Nurse (LPN) #9 after Resident #44 stated she did not want the Morphine because of the way it made her feel. The SRI was initiated by the facility Administrator on 05/22/24 alleging neglect and was substantiated by the facility Administrator on 05/27/24. Review of the SRI facility investigation file revealed an interview with Resident #44 was completed by the Administrator. Review of the investigation filed revealed a one-time questionnaire was administered by facility staff to 15 Residents (#37, #38, #39, #41, #42, #45, #46, #47, #48, #49, #50, #52, #53, #54 and #55) and one family member. Further review of the SRI facility investigation file revealed Agency LPN #9 was the name of the alleged perpetrator on an Addendum Documents and Notes dated 05/28/24 however, there is no documentation indicating attempts were made to contact the alleged perpetrator. Review of the SRI facility investigation file revealed no documentation of attempts to identify and interview others who might have knowledge of the incident. Interview on 06/14/24 at 1:15 P.M. with the Administrator confirmed the facility did not complete a thorough investigation of the SRI dated 05/22/24 involving Agency LPN #9 and Resident #44. The Administrator further confirmed the facility did not attempt to contact the perpetrator, identify and interview any other individuals who may have knowledge of the incident, or provide complete and thorough documentation of the investigation as stated in the facility's policy titled Abuse, Neglect and Exploitation, dated 10/24/22. The Administrator confirmed the facility substantiated the SRI based on Page 1 of 2 365014 365014 06/18/2024 Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331

F 0610 the interview with Resident #44. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Abuse, Neglect and Exploitation dated 10/24/22 states on page 4, Section V. Investigation of Alleged Abuse, Neglect and Exploitation, B. Written procedures for investigations include: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00154258. 365014 Page 2 of 2