Health inspection·November 7, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy, the facility failed to ensure that Resident #33 was free from verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. This had the potential to affect all 30 residents that resided in the facility. The facility census was 30. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and discharged on 11/02/23. Review of the admission Minimum Data Set (MDS) 3.0 assessment was not completed. Review of the admission assessment dated [DATE] revealed Resident #33 was oriented to person, place, time, and orientation. Review of the concern form dated 11/02/23 revealed family of Resident #33 alleged that on 11/01/23 State Tested Nursing Assistant (STNA) #108 was a kind of rough and rude. The investigation portion of concern on the form revealed Director of Nursing (DON) met with STNA #108 and discussed the incident. STNA #108 confirmed that she had a bad day, didn't perform her best and admitted to being rude to staff and residents. Review of personnel record for STNA #108 revealed a hire date of 04/06/23 with no documentation of that a background check was completed. This was verified by the DON on 11/06/23 at 4:13 P.M. Further review of the personnel record for STNA #108 revealed that she received a 90-day evaluation on 10/03/23 that stated in the area of attitude, attitude and language on the floor needs improvement and in the area of social skills, can be careless with language on the floor around residents. DON verified the evaluation on 11/06/23 at 4:13 P.M. Review of the separation letter dated 11/03/23 for STNA #108 revealed that STNA was terminated due to multiple call offs and repeated negative language and attitude resulting in other staff complaints, unprofessionalism, and substandard work performance. DON verified that she terminated STNA #108 on 11/06/23 at 4:13 P.M. Review of facility policy dated 2023 titled, Abuse, Neglect and Exploitation, residents have the right to be free from verbal, physical and sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00147266. 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 4 Event ID: 366036 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 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 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)