Health inspection·June 17, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of the Self-Reported Incident (SRI), medical record review, staff interview and review of the facility policy, the facility failed to implement their policy and ensure staff accused of physical abuse were removed from the facility and put on leave during the investigation. This affected one (#10) of four residents reviewed for abuse. The facility census was 17. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 05/07/24. Diagnoses included symbolic disfunctions, edema, anxiety disorder, restlessness and agitation. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 05/11/24, revealed Resident #10 was severely cognitively impaired. Resident #10 required maximum assistance with toilet use and parts of dressing. Resident #10 required moderate assistance with bathing. Resident #10 had delusions during the review period and displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 05/29/24 revealed supports and interventions for self-care deficit, risk for falls, plan to discharge to prior level of care, impaired cognitive function, chronic pain, and anxiety. Review of Resident #10's progress notes revealed on 05/24/24 while Resident #10 was waiting to be toileted she reported the aid was mean to her and slapped her. The nurse was notified of Resident #10's accusation, who notified the nurse on duty to do a complete skin assessment. An assessment was completed, and no marks were found. The nurse asked Resident #10 the name of the aid and Resident #10 accused someone who she said was a family friend and could not give a specific date. On 05/28/24 an interview was held with Resident #10's daughter regarding the comment Resident #10 made to the nurse regarding a family friend potentially slapping her. Resident #10's daughter reported no knowledge of any visitors and was not aware of anything like this happening in the past. Review of the Self-Reported Incident (SRI) dated 05/24/24 and completed 05/28/24 revealed On 05/24/2024 Resident #10 verbally alleged to a nurse she was slapped. Resident #10 was unable to initially say who slapped her or when this occurred. Resident #10 then pointed to State Tested Nursing Assistant (STNA) #204 who was walking through unit and said Her. The nurse further reported moments later Resident #10 stated It was a family friend who slapped her. The nurse completed a head-to-toe skin assessment of Resident #10 with no adventitious findings noted. Resident #10's family and physician were notified. Resident #10's daughter reported it was likely Resident #10's anxiety was high. Anxiety medication was administered. All other residents were interviewed by the nurse with no complaints found. All residents interviewed report feeling safe and secure. STNA #204 was removed from providing (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: 366358 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 366358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440 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)