Health inspection·November 21, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4:45 P.M., and 5:30 P.M. This is 15 doses of the narcotic pain medication not documented as provided to the resident over these two days. Review of a facility self-reported incident dated 11/04/24, indicated during review of the Controlled Substance Record (CSR) it was discovered an agency nurse Registered Nurse (RN) #100 administered 19 doses of Oxycodone (opioid) five milligram (mg) on the CSR record for Resident #01 over two days. Only four of those 19 doses were recorded on the medication administration record (MAR) as provided to Resident #01. Resident #01 normally does not receive as needed doses of the medications. While reviewing cameras footage for a period of four hours, this nurse was not observed medicating Resident #01, despite the medication having been documented as having been administered. Attempts to contact RN #100 were unsuccessful as she failed to return any phone calls or calls from the staffing agency, who was her employer. Staff interviews revealed Resident #01 had no behaviors out of his ordinary over the time frame. Staff further stated they had not witnessed RN #100 medicate Resident #01. Staff interviewed further stated RN #100 would not be available at times during the three shifts, but none reported feeling she had been impaired. Review of the facility investigation revealed five like residents had been interviewed. None had any concerns with not receiving medications. The facility additionally interviewed two nurses and the two Certified Nursing Assistants (CNA) who had worked with RN #100, and all denied any knowledge of misappropriation. The [NAME] County Sheriff's office, the Ohio Board of Nursing, the facility pharmacy, and the staffing agency were all notified on 11/04/24 by the Administrator. Resident #01's physician was notified by the nurse who discovered the concern on 11/04/24. Review of Licensed Practical Nurse (LPN) #120's typed statement, dated 11/05/24, revealed on 11/02/24, while receiving report from RN #100, RN #100 appeared to be disorganized and unable to focus on anything for more than a few seconds. LPN #120 documented RN #100 kept reporting Resident #01 had been very combative with cares and stated Resident #01 had been hitting and kicking staff. After report the controlled substances were counted and RN #100 stated I hope I can stay awake long enough to drive home. When LPN #120 asked her why, she had stated she had been working a lot, in a defensive tone. LPN #120 reported she had told RN #100 to be careful and she would see her in the morning. LPN #120 reported RN #100 returned on 11/03/24 and during report kept trying to change the subject. LPN #120 reported she returned at 7:00 P.M. and once again RN #100 appeared very disorganized. When RN #100 reported on Resident #01 she stated she had contacted the provider as his medication was getting low and she had not wanted him to be without. RN #100 once again stated Resident #01 had been very combative with care during the day. After RN #100 left, LPN #120 asked the CNA if Resident #01 had been more combative throughout the day and she said, no more than normal. As LPN #120 was reviewing the documentation she noted Resident #01 had received the oxycodone every hour over the last two days. LPN #120 documented Resident #01 was alert and acting his normal behaviors. LPN #120 documented informing the Administrator and Director of Nursing of her concerns on 11/04/24. Review of the summary of investigation indicated the allegation of misappropriation by RN #100 towards Resident #01 was substantiated. Review of the Ohio Board of Nursing licensure verification revealed RN #100 held an active license as of 10/24/22. RN #100 was from a contracted staffing agency. Interview on 11/21/24 at 8:15 A.M. with the Administrator revealed RN #100 was never to return to the facility and no further incidents of misappropriation were discovered. The Administrator confirmed the facility conducted an investigation and substantiated that RN #100 misappropriated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 2 of 3 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 366125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Shane Hill 10731 State Route 118 Rockford, OH 45882 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)

F 0602 #01's medications. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Controlled Substance Administration & Accountability, undated, revealed the facility will have safeguards in place in order to prevent loss or diversion. The policy was followed in the events surrounding the misappropriation of Resident #01's narcotic medication by RN #100. Residents Affected - Few As a result of the incident, the facility took the following actions to correct the deficient practice by 11/21/24: • Immediate removal of RN #100 from the schedule on 11/04/24. • All resident narcotic records and Narcotic medications were audited on 11/04/24 with no deficient practice noted. • Five like residents were interviewed on 11/04/24 and had no concerns related to misappropriation. • Three staff members were interviewed on 11/04/24 and one on 11/05/24 and were not aware of any misappropriation occurring while working with RN #100. • All staff in the facility were in-serviced by the Administrator and the Director of Clinical Operations on the facility's abuse, neglect, and misappropriation policy by 11/21/24. • RN #100 has been placed on a Do Not Return list on 11/04/24. • All resident narcotic records continue to be audited weekly by the Director of Nursing and Unit Managers indefinitely. This deficiency represents non-compliance investigated under Complaint Number OH00159761. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 3 of 3