Health inspection·March 7, 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, facility documentation review, and facility policy review, the facility failed to ensure an allegation of medication diversion was reported to the Administrator in a timely manner. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a facility document dated 02/19/24 revealed Licensed Practical Nurse (LPN) #324 took a chewable baby aspirin from the over the counter bottle located in the top drawer of medication cart. LPN #324 forgot to take morning aspirin before work. LPN #324 was talked to by the Director of Nursing (DON) as soon as the incident was reported and was instructed to not take over the counter medication off the medication cart again. Further review revealed LPN #324 was very sorry about this mistake and promised to never repeat the mistake again. LPN #324 did not think about how the act could be perceived, and LPN #324 was embarrassed and very sorry. The documented was signed by LPN #324. A telephone interview with LPN #324 on 03/07/24 at 10:37 A.M. stated on 02/19/24 at approximately 9:00 A.M., while preparing medications for Resident #71, she placed a chewable 81 milligram (mg) aspirin tablet in a medication cup and a second chewable aspirin tablet in a second medication cup. LPN #324 verified she proceeded to consume the 81 mg chewable aspirin at the medication cart. When taking the aspirin, Student Nurse (SN) #442 was exiting a resident room behind her and observed LPN #324 take the medication. As a result, later that morning, LPN #324 was counseled by the DON not to take over the counter medications from the medication cart for personal use. No further investigation was conducted and LPN #324 continued to work the remaining shift. Interview with the DON on 03/07/24 at 12:15 P.M. revealed on 02/19/24 an allegation of LPN #324 taking medication from the medication cart was reported to her by Clinical Nurse Instructor Registered Page 1 of 5 366060 366060 03/07/2024 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0609 Level of Harm - Minimal harm or potential for actual harm Nurse (CNIRN) #438. The DON interviewed LPN #324 on 02/19/24 and was informed by LPN #324 she took a chewable baby aspirin from the over the counter bottle in the top drawer of the medication cart. The DON instructed LPN #324 to not take over the counter medication off the medication cart again. The DON stated no further information was obtained regarding the incident, including an investigation. The DON verified the incident was not reported to the Administrator. Residents Affected - Few Interview with the Administrator on 03/07/24 at 12:17 P.M. revealed no knowledge of the incident on 02/19/24 between Resident #71 and LPN #324. A telephone interview with CNIRN #438 on 03/07/24 at 1:09 P.M. revealed on 02/19/24 at approximately 9:30 A.M., SN #442 reported observing LPN #324 place a pill in a medication cup for a resident and another pill into a second cup. LPN #324 was observed to consume the second cup of medication while standing at the cart. CNIRN #438 reported the incident to the DON and was informed the DON would look into the incident. CNIRN #438 stated no statements were obtained from CNIRN #438 or SN #442. CNIRN #438 also indicated SN #442 did not report the container from which the medication was taken from. No further interactions with the facility occurred regarding the incident. Review of the abuse, neglect, and exploitation policy, revised 01/10/2024, revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be use in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, providing complete and thorough documentation of the investigation, and reporting of alleged violations to the administrator within specified timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00151001. 366060 Page 2 of 5 366060 03/07/2024 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

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 medical record review, staff interview, facility documentation, and facility policy, the facility failed to ensure an allegation of medication diversion was thoroughly investigated. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a facility document dated 02/19/24 revealed Licensed Practical Nurse (LPN) #324 took a chewable baby aspirin from the over the counter bottle located in the top drawer of medication cart. LPN #324 forgot to take morning aspirin before work. LPN #324 was talked to by the Director of Nursing (DON) as soon as the incident was reported and was instructed to not take over the counter medication off the medication cart again. Further review revealed LPN #324 was very sorry about this mistake and promised to never repeat the mistake again. LPN #324 did not think about how the act could be perceived, and LPN #324 was embarrassed and very sorry. The documented was signed by LPN #324. A telephone interview with LPN #324 on 03/07/24 at 10:37 A.M. stated on 02/19/24 at approximately 9:00 A.M., while preparing medications for Resident #71, she placed a chewable 81 milligram (mg) aspirin tablet in a medication cup and a second chewable aspirin tablet in a second medication cup. LPN #324 verified she proceeded to consume the 81 mg chewable aspirin at the medication cart. When taking the aspirin, Student Nurse (SN) #442 was exiting a resident room behind her and observed LPN #324 take the medication. As a result, later that morning, LPN #324 was counseled by the DON not to take over the counter medications from the medication cart for personal use. No further investigation was conducted and LPN #324 continued to work the remaining shift. Interview with the DON on 03/07/24 at 12:15 P.M. revealed on 02/19/24 an allegation of LPN #324 taking medication from the medication cart was reported to her by Clinical Nurse Instructor Registered Nurse (CNIRN) #438. The DON interviewed LPN #324 on 02/19/24 and was informed by LPN #324 she took a chewable baby aspirin from the over the counter bottle in the top drawer of the medication cart. The DON instructed LPN #324 to not take over the counter medication off the medication cart again. The DON stated no further information was obtained regarding the incident, including an investigation. Interview with the Administrator on 03/07/24 at 12:17 P.M. revealed no knowledge of the incident on 02/19/24 between Resident #71 and LPN #324. A telephone interview with CNIRN #438 on 03/07/24 at 1:09 P.M. revealed on 02/19/24 at approximately 9:30 A.M., SN #442 reported observing LPN #324 place a pill in a medication cup for a resident and another pill into a second cup. LPN #324 was observed to consume the second cup of medication while 366060 Page 3 of 5 366060 03/07/2024 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few standing at the cart. CNIRN #438 reported the incident to the DON and was informed the DON would look into the incident. CNIRN #438 stated no statements were obtained from CNIRN #438 or SN #442. CNIRN #438 also indicated SN #442 did not report the container from which the medication was taken from. No further interactions with the facility occurred regarding the incident. Review of the abuse, neglect, and exploitation policy, revised 01/10/2024, revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be use in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, providing complete and thorough documentation of the investigation, and reporting of alleged violations to the administrator within specified timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00151001. 366060 Page 4 of 5 366060 03/07/2024 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure wound treatments were completed per physician order. This affected one (#24) of three residents reviewed for wounds. The facility census was 66. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #24 admitted to the facility on [DATE]. Diagnoses included hypertension, dementia, anemia, depression, dysphagia, and muscle weakness. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/16/24, revealed Resident #24 was cognitively intact. The resident required assistance from staff for activities of daily living. Review of an interdisciplinary team progress note dated 01/05/24 revealed the wound to the bridge of Resident #24's nose was an area that began as a small open area that the resident continually picked at. Review of Resident #24's physician orders revealed an order dated 08/28/23 through 03/05/24 to cleanse the bridge of the nose with saline, pat dry, and apply the antibiotic Troleandomycin (TAO) topically every day and evening shift. Review of Resident #24's treatment administration record (TAR) for December 2023 through February 2024 revealed the resident did not receive treatment to the bridge of the nose on the evening shift as indicated on 12/02/23, 12/03/23, 12/16/23, 12/17/23, 12/21/23, 12/26/23, 12/30/23, 01/01/24, 01/08/24, 01/09/24, 01/13/24, 01/14/24, 01/18/24, 01/19/24, 01/23/24, 01/27/24, 02/06/24, 02/10/24, 02/13/24, 02/15/24, 02/25/24, or 02/29/24. Interview on 03/07/24 between 11:00 A.M. and 12:30 P.M. with the Director of Nursing (DON) verified Resident #24's treatments were not completed to the bridge of the nose as ordered. The DON confirmed there was no other evidence the treatments were completed. The DON also verified any treatment refusals would have been documented on the TARs. Review of the facility policy titled, Wound Treatment Management, revised 10/26/23, revealed wound treatments would be provided in accordance with physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00151001. 366060 Page 5 of 5