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 Page 1 of 3 366358 366358 06/17/2024 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care during the investigation. Staff present on shift interviewed and no family friends of Resident #10 were known to have visited. No family or friend visitors were able to be identified. Resident #10 had a diagnosis of anxiety and brief interview for mental status (BIMS) assessment for cognitive impairment score of six indicating Resident #10 was severely impaired. All staff were immediately educated on the facility policy related to abuse, neglect, misappropriation, and exploitation. Monitoring was to occur by additional resident interviews and additional interviews with Resident #10. The allegation was found to be unsubstantiated. Evidence revealed abuse, neglect or misappropriation did not occur. In addition, residents were re-interviewed, including Resident #10, and allowed time to express concerns. No findings were noted. All staff was educated on the facility's policy related to abuse and identifying abuse. Review of the facility's investigation revealed there was no indication STNA #204 was removed from the facility and put on leave during the investigation. Review of the Staffing Schedule for the time the SRI investigation was taking place 05/24/24 through 05/28/24 revealed the STNA #204 worked on 05/25/24 from 6:30 P.M. to 6:30 A.M., 05/26/27 from 6:30 P.M. to 6:30 A.M., 05/27/24 from 6:30 P.M. to 6:30 A.M., and 05/28/24 from 6:30 P.M. to 6:30 A.M. Interview on 06/17/24 at 12:15 P.M. with the Director of Nursing (DON) verified the Specified Perpetrator (STNA #204) in the self-reported incident was not removed from the facility nor taken off the schedule after the allegation of physical abuse. The DON reported STNA #204 was moved to the other building and worked under the nurse after the allegation of slapping. The DON stated Resident #10 accused STNA #204 and quickly changed her story stating a family member had slapped her. The DON reported had Resident #10 specifically identified STNA #204 she would have been removed from the facility and put on administrative leave. However, they did not feel Resident #10 had done so. Interview on 06/17/24 at 3:22 P.M. with the Administrator revealed STNA #204 was moved to another home during the investigation and the interview portion of the investigation was completed within a couple hours at which time they determined there was not an abuse concern. The 05/28/24 date was the date the facility completed all portions of the investigation and submitted the final report. Review of the facility policy title, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, revised 10/25/22, revealed the facility if a partner was accused or suspected of abuse the facility should immediately remove the partner from the facility and the schedule pending the outcome of the investigation. This non-compliance was indentified during the investigation of Complaint Number OH00153669. 366358 Page 2 of 3 366358 06/17/2024 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ in the first quarter of 2024. This had the potential to affect all residents. The facility census was 17. Findings include: Review of the PBJ Staffing Data Report revealed the facility triggered for not having licensed nursing coverage 24 hours a day in the first quarter of 2024. The specific days identified were Monday 01/01/24, Friday 01/05/24, Saturday 01/06/24, Sunday 01/07/24, Sunday 01/19/24, Sunday 01/21/24, Monday 01/29/24, Saturday 02/03/24, Sunday 02/04/24, Friday 02/09/24, Saturday 02/10/24, Sunday 02/11/24, Saturday 02/17/24, Sunday 02/18/24, Friday 02/23/24, Saturday 03/02/24, and Sunday 03/17/24. Review of the staffing schedule for the 17 days noted in the PBJ as having insufficient nursing coverage revealed the staff on the floor did not match the information entered into the PBJ. For the days identified as deficient in the PBJ the actual nurse coverage ranged from 24 hours of nurse coverage a day to 32 hours of nurse coverage. There was sufficient nurse staffing for 24 hours on each of the days identified as deficient in the PBJ. Reconciliation of the staffing time sheets for Monday 01/01/24, Friday 01/05/24, Saturday 01/06/24, Sunday 01/07/24, Sunday 01/19/24, Sunday 01/21/24, Monday 01/29/24, Saturday 02/03/24, Sunday 02/04/24, Friday 02/09/24, Saturday 02/10/24, Sunday 02/11/24, Saturday 02/17/24, Sunday 02/18/24, Friday 02/23/24, Saturday 03/02/24, and Sunday 03/17/24 revealed the staffing schedule matched the staffing times worked. Interview on 06/17/24 at 10:54 A.M. with the Administrator verified the data entered into the PBJ for the first quarter of 2024 was not entered accurately. The Administrator reported the corporate agency had taken over entering data into the PBJ and appears to have missed the data when agency nursing staff was used. Follow up interview on 06/17/24 at 2:37 P.M. with the Administrator reiterated the data entered into the PBJ was not correct and audit of all the facilities was being completed to ensure the issue was corrected. 366358 Page 3 of 3