Health inspection·June 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to treat Resident #17 with dignity and respect by completing a urinary drug test without consent or physician's orders. This affected one (Resident #17) of three residents reviewed for dignity and respect. The facility census was 25. Findings included: Review of Resident #17's medical record revealed an admission date of 04/25/23. Diagnoses included paraplegia, chronic obstructive pulmonary disease, bipolar disease, and diabetes mellitus. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent upon staff for transfers. Review of Resident #17's most recent care plan revealed the resident was prescribed antidepressant medications. There was no care plan regarding drug addiction. Further review of Resident #17's medical record revealed a urine drug test was completed on 05/17/23 by the Director of Nursing (DON). The test was recorded on a hand-written form and revealed the resident tested positive for amphetamines, cocaine, and opiates. Review of Resident #17's physician's orders revealed there was no order for the urine drug test completed on 05/17/23. Review of the urine drug test form dated 05/17/23 revealed the DON completed the form that came with the test kit. The resident information and results were handwritten, which included being positive for amphetamines, cocaine, and opiates. The urine sample was taken from a Foley catheter bag and was between 90 and 100 degrees Fahrenheit. The drug test was completed due to Resident #17's behavior was very tired, snoring, and difficult to arouse. Review of Resident #17's medical record revealed a serum blood drug test was ordered by the physician per the resident's request. Review of the serum blood drug test dated 05/18/23 revealed the results were negative for drugs. Review of the blood serum drug test completed on 05/18/23 revealed the physician ordered test was negative for drugs. Interview on 06/22/23 at 8:56 A.M. with Resident #17 revealed on 05/17/23, the DON informed the resident that a urine test was needed and drew a urine sample out of the resident's Foley catheter bag. (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 3 Event ID: 366002 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 366002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827 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)