Inspection·March 5, 2024

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 medical record review, staff interview, review of written statements, review of self-reported incidents, and review of a facility policy, the facility failed to report an allegation of potential abuse to the State Survey Agency as required. This affected one (#74) of three residents reviewed for abuse. The facility census was 73. Findings include: Review of Resident #74's medical record identified admission to the facility occurred on 02/14/24 with medical diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, and history of methamphetamine withdraw. Review of Resident #74's medical record revealed on 02/28/24 at 6:17 P.M. the resident was noted with increased weakness and confusion. Further review of the progress notes 02/28/24 revealed Resident #74's confusion began on 02/27/24 following a fall. Resident #74 was sent to the hospital on [DATE] and was admitted with aspiration pneumonia. Resident #74 returned to the facility on [DATE], and review of hospital records revealed no evidence of the resident being provided medications he was not ordered. Thorough review of Resident #74's medical record revealed the resident had no order for the medication to treat narcotic dependence Suboxone. Interview with State Tested Nurse Aide (STNA) #98 on 03/04/24 at 12:51 P.M. stated, on the evening of 02/28/24, another STNA (#99) told her she gave Resident #74 Suboxone from STNA #99's own prescription. STNA #98 confirmed she reported the conversation with STNA #99 via text message to the Director of Nursing (DON) after she got home that evening. STNA #98 stated she was aware Resident #74 went to the hospital that evening and was worried it could have been the result of STNA #99 giving him Suboxone. STNA #98 confirmed she did not witness STNA #99 give Resident #74 any medications. Interview with the DON on 03/04/24 at 1:52 P.M. confirmed she received a text message from STNA #98 on 02/28/24 that she had a concern regarding STNA #99. The DON stated STNA #98 reported that STNA #99 told her she gave Resident #74 some of her Suboxone medication. The DON stated she contacted STNA #99 regarding the incident and indicated she did recommend Resident #74 get Suboxone because she thought the resident was going through withdrawals. The DON stated STNA #99 denied giving Resident #74 Suboxone on 02/28/24. The DON stated the facility started an investigation into the allegation made by STNA #98; however, the DON confirmed the allegation and investigation was not reported to the State Survey Agency. Review of a written statement from STNA #110 dated 03/01/24 revealed STNA #110 documented STNA #99 (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 6 Event ID: 365418 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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)