Health inspection·March 6, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure incontinence care was provided in a timely manner. This affected one resident (#21) of three observed for incontinence care. The facility census was 63. Findings include: Review of Resident #21's medical records revealed an admission date of 11/30/21. Diagnoses included dementia and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition and was incontinent of bowel and bladder. Review of the care plan dated 02/21/24 revealed Resident #21 was incontinent of bowel and bladder. Interventions included clean peri-area after each incontinence episode. Interviews on 02/28/24 from 4:15 A.M. to 4:47 A.M. with State Tested Nursing Assistant (STNA) #237 and STNA #231 revealed they observed residents who appeared to have been soiled in urine and feces for long periods of time. Observation of incontinence care on 03/04/24 at 9:15 A.M. with STNA #244 for Resident #21 revealed Resident #21 had been incontinent of a large amount of urine. The urine smelled stale and had soaked through Resident #21's incontinence brief and onto his sheets. STNA #244 stated she had not provided incontinence care for Resident #22 since she started her shift at 7:00 A.M. and did not know when Resident #22 had last received incontinence care. STNA #244 stated she observed residents who had been heavily saturated in urine when she began her shifts. An attempt to interview Resident #21 at the time of the observation was unsuccessful due to cognitive impairment. This deficiency represents non-compliance investigated under Complaint Number OH00151291. Page 1 of 8 365667 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, staff statement review, police report review, and text message review the facility failed to ensure a nurse showing signs of potential impairment was evaluated to ensure she was competent to provide direct resident care and/or was removed from direct resident care following suspicions of impaired behaviors by co-workers. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63. Findings include: Interview on 02/28/24 at 5:57 A.M. with State Tested Nursing Assistant (STNA) #236 revealed she worked on 02/17/24 from 11:00 P.M. until 12/18/24 at 7:00 A.M. During the shift, STNA #236 observed Registered Nurse (RN) #217 dancing in the halls, singing loudly and acting weird. STNA #236 stated it appeared that RN #217 may have been under the influence of something. RN #217 was moving very fast and she observed RN #217 taking something out of the narcotic box and throwing it in the medication room. STNA #236 then observed RN #217 enter the medication room where she remained for a while. RN #217 told STNA #236 she was a street preacher and she knew a drug king pin. STNA #236 revealed during the shift, Licensed Practical Nurse (LPN) #216 called the Administrator and Director of Nursing (DON) several times, with no answer and LPN #216 eventually called the police. Telephone interview on 02/28/24 at 7:17 A.M. with LPN #216 revealed on the evening of 02/17/24 at approximately 10:00 P.M. an agency nurse ( RN #217) arrived to work and LPN #216 noticed RN #217 was acting fidgety, pacing the hallways, and repeating questions. LPN #216 stated LPN #201 (the minimum data set [MDS] nurse) was also present when RN #217 arrived and she also witnessed the behaviors. LPN #216 reported she witnessed a telephone conversation between LPN #201 and the DON on 02/17/24 between 10:00 P.M. and 10:30 P.M. and overheard the DON tell LPN #201 she had worked with RN #217 at a previous facility and the DON had fired RN #217 because she had taken liquid morphine from a resident's morphine vial and replaced the medication with water. After the phone call between LPN #201 and the DON, she and LPN #201 went to the medication cart located on the memory care unit (400 hall) and removed a bottle of Roxinol (brand name of morphine). LPN #201 left the facility shortly after removing the Roxinol from the 400 hall medication cart. LPN #216 continued to witness RN #217 exhibit erratic behaviors including skipping in the hallways, dancing around the medication carts and talking of God and how God was the one who would tell her how and when to pass medications. LPN #216 stated she made several calls to the DON and the Administrator, with no answer. Other staff members approached LPN #216 voicing their concerns related to RN #217's behaviors. Two STNAs told LPN #216 they observed RN #217 taking something out of the narcotic box located within the medication cart although they could not identify what was removed. LPN #216 was worried for the safety of the residents to whom RN #217 was assigned and contacted the police sometime between 2:00 A.M. and 2:30 A.M. Three police officers arrived at the facility and informed her the situation was a management problem and not a police matter. LPN #216 sent text messages to LPN #201 (the nurse on call) beginning at approximately 3:00 A.M. informing her of the situation. LPN #201 arrived at the facility between 4:00 A.M. and 5:30 A.M. and took the keys to the medication carts from RN #217 and RN #217 exited the facility. Telephone interview on 02/28/24 at 10:05 A.M. with STNA #241 revealed she worked on 02/17/24 from 7:00 P.M. until 02/18/24 at 7:00 A.M. STNA #241 stated on 02/17/24 between 11:00 P.M. and 12:00 A.M. 365667 Page 2 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she observed RN #217 at a medication cart for a long period of time. RN #217 told STNA #241 she was organizing the cart. STNA #241 heard RN #217 yelling about God and that she was a Nigerian pastor. Interview on 02/28/24 at 12:09 P.M. with LPN #201 revealed she was at the facility on 02/17/24 until approximately 10:30 P.M. LPN #201 gave report to RN #217 and stated she did not observe any abnormal behaviors. LPN #201 stated on 02/18/24 at approximately 3:00 A.M. she received a text message from LPN #216 informing her of concerns related to RN #217's behaviors and that staff members reported they observed RN #217 taking medications out of the narcotic box. LPN #201 stated she arrived at the facility sometime between 4:00 A.M. and 4:30 A.M. and counted the narcotics with RN #217 and all were accounted for. LPN #201 took the keys to the medication carts from RN #217 and RN #217 exited the facility. Prior to exiting the facility RN #217 said she needed her money because there were starving pygmies in [NAME]. LPN #201 stated she read various resident progress notes authored by RN #217 and the progress notes included documentation about God and other ramblings. LPN #201 contacted the corporate office regarding the situation, and attempted to contact the DON without success. LPN #201 made the DON aware of the situation on the morning of 02/18/24. LPN #201 did not speak to LPN #216 about the situation after she arrived at the facility. LPN #201 said staff were supposed to complete written statements but LPN #201 was not aware if any statements had been obtained. Telephone interview on 02/28/24 at 12:41 P.M. with STNA #238 revealed she worked on 02/17/24 from 7:00 P.M. until 02/18/24 at 7:00 A.M. STNA #238 was assigned to work with RN #217. Shortly after RN #217's arrival on 02/17/28 at approximately 10:00 P.M., STNA #238 noticed RN #217's behavior seemed odd, she was constantly moving and dancing, and it appeared RN #217 was on something. STNA #238 observed RN #217 rummaging through the narcotics box and removing something then she observed RN #217 going outside several times and when she returned her behaviors were more erratic than before and she was even more energetic. STNA #238 told LPN #216 what she observed and LPN #216 called the police sometime around 2:00 A.M. LPN #201 arrived at the facility between 4:00 A.M. and 5:00 A.M. and took the keys to the medication carts from RN #217 and RN #217 exited the facility. Interview on 02/29/24 at 9:06 A.M. with the DON revealed she did not receive the phone calls on the evening of 02/18/24 because the ringer on her phone was on the [NAME]. The DON was made aware of the situation regarding RN #217 on the morning of 02/18/24 at approximately 7:00 A.M. The DON contacted the staffing agency RN #217 worked through to report the concerns and placed RN #217 on the facility do not return list. The DON stated she did speak with LPN #201 on the evening of 02/17/24 at approximately 11:00 P.M., however the conversation was not about any concerns related to RN #217. Review of the police report dated 02/18/24 timed 2:25 A.M. revealed LPN #216 contacted the police due to suspicions of RN #217 being under the influence of drugs. LPN #216 reported RN #217 was observed dancing around and saying strange things and was observed putting pills in her pockets. LPN #216 attempted to contact management, with no answer. The report revealed police officers interviewed RN #217 and did not believe RN #217 to be under the influence of drugs. Review of progress notes dated 02/18/24 authored by RN #217 for Residents #22, #24, #27, #57 and #59 revealed documentation that referenced God, Jesus, angels, other religious ramblings. The documentation provided no information regarding the residents, their care or their medications. Review of text messages dated 02/18/24 beginning at 12:49 A.M. revealed LPN #216 sent a text to LPN #201 that RN #217 was tweaking and saying she's an independent nurse only by God and that God tells her how to do her med pass. LPN #201 responded she was sorry and would stay but . 365667 Page 3 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0726 Level of Harm - Minimal harm or potential for actual harm Review of text messages dated 02/18/24 beginning at 3:21 A.M. revealed LPN #201 sent a text to LPN #216 indicating I called DON and told her it was an emergency and she needed to call because of it being questionable diversion. LPN #216 responded to LPN #201 indicating The Administrator answered and said this is in your hands. LPN #201 replied .I know this sounds bad but I'm gonna act like I dont know. Let them deal with it. Residents Affected - Some Review of the statement authored by STNA #236 dated 02/18/24 revealed she observed RN #217 walking around the medication cart, pulling out drawers and going back and forth to the medication room. STNA #236 observed RN #217 putting pills in a small cup in the top drawer of the medication cart. Per the employee's statement, RN #217 was slurring her words and not making sense. Review of an undated statement authored by STNA #248 revealed she observed RN #217 fidgeting around like she was high. RN #217 was observed dancing around the medication cart and was fidgeting around in the narcotic drawer and it appeared she had taken something out and hurried to put it in her pocket, then put on her coat and rushed outside. Review of the statement authored by RN #217 dated 02/18/24 revealed RN #217 had written My nursing foundation is on the solid rock of Jesus Christ, Amen. Interview with the staffing agency representative on 02/29/24 at 9:25 A.M. confirmed a complaint was made on 02/18/24 at 7:58 A.M. regarding RN #217's erratic and disruptive behaviors. The representative stated it was reported RN #217 went outside for smoke breaks and had come back in with erratic behaviors. Interview on 02/29/24 at 10:48 A.M. with the DON revealed the facility did not have a policy or procedure in place which would provide guidance to staff who had concerns or were working with a staff member who was exhibiting signs of being impaired. Review of the facility census sheet for 02/17/24 revealed Residents #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63 resided on the 300 and 400 units which were the units RN #217 was assigned to for the shift. This deficiency represents non-compliance investigated under Complaint Number OH00151401. 365667 Page 4 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and personnel file review the facility failed to complete state tested nurse aide registry verification prior to allowing an individual to serve as a STNA. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Interview on [DATE] between 4:15 A.M. and 4:47 A.M. with State Tested Nursing Assistant (STNA) #237 and STNA #231 revealed Dietary Aide (DA) #251 worked as an STNA without having a current certification. Review of DA #251's personnel files revealed an employment application dated [DATE] indicating the position being applied for was that of an STNA. DA # 251's personnel file had an STNA certification with an expiration date of [DATE]. Interview on [DATE] at 4:36 P.M. with the Director of Nursing (DON) confirmed DA #251's personnel file contained an expired STNA certificate. The DON stated DA #251 was currently working in the kitchen as a kitchen aide. Interview on [DATE] with DA #251 revealed he had been employed at the facility for about two years. DA #251 was not aware his STNA certification had expired until the previous Human Resource staff told him in [DATE]. At that time he was offered a position in the kitchen. Interview on [DATE] at 9:52 A.M. with the DON and Human Resource #252 revealed DA #251 had not been checked against the nurse aide registry. An audit was completed and all current staff were checked against the nurse aide registry. This deficiency represents non-compliance investigated under Complaint Number OH00151291. 365667 Page 5 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, staff statement review, and text message review the administration failed to timely respond to reports of a nurse showing signs of potential impairment. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63. Residents Affected - Some Findings include: Interview on 02/28/24 at 5:57 A.M. with State Tested Nursing Assistant (STNA) #236 revealed she worked on 02/17/24 from 11:00 P.M. until 12/18/24 at 7:00 A.M. During the shift, STNA #236 observed Registered Nurse (RN) #217 dancing in the halls, singing loudly and acting weird. STNA #236 stated it appeared that RN #217 may have been under the influence of something. RN #217 was moving very fast and she observed RN #217 taking something out of the narcotic box and throwing it in the medication room. STNA #236 then observed RN #217 enter the medication room where she remained for a while. RN #217 told STNA #236 she was a street preacher and she knew a drug king pin. STNA #236 revealed during the shift, Licensed Practical Nurse (LPN) #216 called the Administrator and Director of Nursing (DON) several times, with no answer and LPN #216 eventually called the police. Telephone interview on 02/28/24 at 7:17 A.M. with LPN #216 revealed on the evening of 02/17/24 at approximately 10:00 P.M. an agency nurse ( RN #217) arrived to work and LPN #216 noticed RN #217 was acting fidgety, pacing the hallways, and repeating questions. LPN #216 stated LPN #201 (the minimum data set [MDS] nurse) was also present when RN #217 arrived and she also witnessed the behaviors. LPN #216 reported she witnessed a telephone conversation between LPN #201 and the DON on 02/17/24 between 10:00 P.M. and 10:30 P.M. and overheard the DON tell LPN #201 she had worked with RN #217 at a previous facility and the DON had fired RN #217 because she had taken liquid morphine from a resident's morphine vial and replaced the medication with water. After the phone call between LPN #201 and the DON, she and LPN #201 went to the medication cart located on the memory care unit (400 hall) and removed a bottle of Roxinol (brand name of morphine). LPN #201 left the facility shortly after removing the Roxinol from the 400 hall medication cart. LPN #216 continued to witness RN #217 exhibit erratic behaviors including skipping in the hallways, dancing around the medication carts and talking of God and how God was the one who would tell her how and when to pass medications. LPN #216 stated she made several calls to the DON and the Administrator, with no answer. Other staff members approached LPN #216 voicing their concerns related to RN #217's behaviors. Two STNAs told LPN #216 they observed RN #217 taking something out of the narcotic box located within the medication cart although they could not identify what was removed. LPN #216 was worried for the safety of the residents to whom RN #217 was assigned and contacted the police sometime between 2:00 A.M. and 2:30 A.M. Three police officers arrived at the facility and informed her the situation was a management problem and not a police matter. LPN #216 sent text messages to LPN #201 (the nurse on call) beginning at approximately 3:00 A.M. informing her of the situation. LPN #201 arrived at the facility between 4:00 A.M. and 5:30 A.M. and took the keys to the medication carts from RN #217 and RN #217 exited the facility. Interview on 02/28/24 at 12:09 P.M. with LPN #201 revealed on 02/18/24 at approximately 3:00 A.M. she received a text message from LPN #216 informing her of concerns related to RN #217's behaviors and that staff members reported they observed RN #217 taking medications out of the narcotic box. LPN #201 arrived at the facility sometime between 4:00 A.M. and 4:30 A.M. and after counting narcotics 365667 Page 6 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0835 Level of Harm - Minimal harm or potential for actual harm with RN #217 she took the keys to the medication carts and RN #217 exited the facility. LPN #201 read various resident progress notes authored by RN #217 and the progress notes included documentation about God and other ramblings. LPN #201 contacted the corporate office regarding the situation, and attempted to contact the DON without success. LPN #201 made the DON aware of the situation on the morning of 02/18/24. Residents Affected - Some Telephone interview on 02/28/24 at 12:41 P.M. with STNA #238 revealed she worked on 02/17/24 from 7:00 P.M. until 02/18/24 at 7:00 A.M. STNA #238 was assigned to work with RN #217. Shortly after RN #217's arrival on 02/17/28 at approximately 10:00 P.M., STNA #238 noticed RN #217's behavior seemed odd, she was constantly moving and dancing, and it appeared RN #217 was on something. STNA #238 observed RN #217 rummaging through the narcotics box and removing something then she observed RN #217 going outside several times and when she returned her behaviors were more erratic than before and she was even more energetic. STNA #238 told LPN #216 what she observed and LPN #216 called the police sometime around 2:00 A.M. LPN #201 arrived at the facility between 4:00 A.M. and 5:00 A.M. and took the keys to the medication carts from RN #217 and RN #217 exited the facility. Interview on 02/29/24 at 9:06 A.M. with the DON revealed she did not receive the phone calls on the evening of 02/18/24 because the ringer on her phone was on the [NAME]. The DON was made aware of the situation regarding RN #217 on the morning of 02/18/24 at approximately 7:00 A.M. Review of the police report dated 02/18/24 timed 2:25 A.M. revealed LPN #216 contacted the police due to suspicions of RN #217 being under the influence of drugs. Review of progress notes dated 02/18/24 authored by RN #217 for Residents #22, #24, #27, #57 and #59 revealed documentation that referenced God, Jesus, angels, other religious ramblings. The documentation provided no information regarding the residents, their care or their medications. Review of text messages dated 02/18/24 beginning at 12:49 A.M. revealed LPN #216 sent a text to LPN #201 that RN #217 was tweaking and saying she's an independent nurse only by God and that God tells her how to do her med pass. LPN #201 responded she was sorry and would stay but . Review of text messages dated 02/18/24 beginning at 3:21 A.M. revealed LPN #201 sent a text to LPN #216 indicating I called DON and told her it was an emergency and she needed to call because of it being questionable diversion. LPN #216 responded to LPN #201 indicating The Administrator answered and said this is in your hands. LPN #201 replied .I know this sounds bad but I'm gonna act like I dont know. Let them deal with it. Review of the statement authored by STNA #236 dated 02/18/24 revealed she observed RN #217 walking around the medication cart, pulling out drawers and going back and forth to the medication room. STNA #236 observed RN #217 putting pills in a small cup in the top drawer of the medication cart. Per the employee's statement, RN #217 was slurring her words and not making sense. Review of an undated statement authored by STNA #248 revealed she observed RN #217 fidgeting around like she was high. RN #217 was observed dancing around the medication cart and was fidgeting around in the narcotic drawer and it appeared she had taken something out and hurried to put it in her pocket, then put on her coat and rushed outside. Interview on 02/29/24 at 10:48 A.M. with the DON revealed the facility did not have a policy or procedure in place which would provide guidance to staff who had concerns or were working with a staff 365667 Page 7 of 8 365667 03/06/2024 Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256

F 0835 member who was exhibiting signs of being impaired. Level of Harm - Minimal harm or potential for actual harm Review of the facility census sheet for 02/17/24 revealed Residents #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63 resided on the 300 and 400 units which were the units RN #217 was assigned to for the shift. Residents Affected - Some This deficiency represents non-compliance investigated under Complaint Number OH00151401. 365667 Page 8 of 8