Failure to Immediately Report Resident’s Allegations of Rough Care and Possible Abuse
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property were reported immediately, and no later than two hours after the allegation was made, to the administrator and appropriate state officials. One resident with metabolic encephalopathy, Alzheimer’s dementia, anxiety, multiple vertebral compression fractures, pain, and bipolar disorder, who was cognitively intact per a BIMS score of 14, alleged that two CNAs were rough during a bed bath, twisted her leg, and jumped on her bed and legs. The resident’s care plan noted impaired cognitive function/dementia and later documented verbal behavior symptoms directed toward others, including allegations that staff attacked her, followed by expressions of affection for the same staff. The facility’s investigation identified the incident date as early in the month when two CNAs provided a bed bath, and the facility documented that it did not become aware of the allegation until later in the month, at which time the allegation was reported to the state. According to staff interviews and statements, the resident first voiced concerns about rough care on a date several days after the bed bath, when a medication aide (MA A) reported that the resident said a CNA was rough with her. MA A stated she told the resident she did not think the CNA would be rough, then continued passing medications and did not immediately report the allegation to the administrator or clearly to the charge nurse, DON, ADON, or other leadership, despite acknowledging that rough treatment could constitute abuse and that such allegations were to be reported immediately. Multiple nurses (LVN F, LVN G, and the ADON) stated that MA A did not report this allegation to them on that date, and each indicated that they would have reported any such allegation to the administrator immediately. The facility’s abuse protocol required any person observing or suspecting abuse to immediately report to the charge nurse, who must then immediately examine the patient and notify the Abuse Prevention Coordinator. Several days later, the resident again reported to another medication aide (MA E) that a CNA and another aide were rough during care and that her legs hurt because the aides were jumping up and down on her legs. MA E acknowledged that she did not report this allegation directly and immediately to the LVN or administrator, but instead informed the implicated CNA, who then reported the allegation to the LVN on duty (LVN D). LVN D stated that upon being informed by the CNA, she attempted to contact the administrator and then informed the ADON. The administrator reported that she first became aware of the allegation at approximately 4:40 p.m. on that later date, and the facility’s investigation form reflected that the incident had occurred many days earlier. Staff interviews and time card reviews confirmed the dates the CNAs worked and the timing of the bath relative to the resident’s subsequent complaints. The failure of MA A and MA E to follow the facility’s abuse protocol and immediately report the resident’s allegations to the charge nurse and administrator resulted in a delay in the facility’s awareness and reporting of the alleged abuse. In their statements, the CNAs involved (CNA B and CNA C) described providing a routine bed bath to the resident, noting that she complained of being wet and cold but did not complain of pain during the bath, and they denied hurting her or jumping on her bed or legs. They also stated that they were not informed of any complaint until many days after the bath. The resident, when interviewed later, reiterated that the aides were rough, twisted her leg, and jumped on the bed, and said she did not want them providing her care, although she could not recall the exact date or which staff member she initially told. The administrator, LVN D, CNAs, and medication aides all acknowledged in interviews that rough treatment could be considered abuse and that allegations of abuse must be reported immediately. Despite this, the facility’s own records and staff accounts showed that the initial allegation made to MA A and the subsequent allegation made to MA E were not promptly reported through the required chain, resulting in the facility not becoming aware of and not reporting the allegation to the state survey agency within the required timeframe.
Penalty
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A cognitively intact resident with a history of vertebral compression fracture, repeated falls, and bipolar disorder alleged that an RN hurt his back while assisting him to sit up during a medication pass, becoming combative and stating he was injured. Witnesses confirmed the interaction and noted the resident’s agitation and dislike of the nurse. The DON acknowledged the resident’s ongoing issues with certain nursing staff, and the Ombudsman reported notifying the Administrator that the resident had alleged physical abuse by staff. Despite this, the Administrator did not submit a required self-reported incident to the State agency, contrary to facility policy mandating timely reporting of all abuse allegations.
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse policy. A resident with multiple chronic conditions and intact cognition had elected video monitoring in the room. Video review showed an LPN shouting at the resident and using foul language, and a family member later submitted a written concern about the LPN’s behavior. The conduct was documented as disrespectful, abusive, and unprofessional, and the IDON confirmed it met criteria for a self-reportable incident. The HR director identified the affected resident, but the Administrator acknowledged that the incident was never reported to the state agency, contrary to the facility’s requirement to report abuse allegations within specified timeframes.
The facility failed to self-report multiple resident-to-resident physical altercations as allegations of abuse to the State Agency, despite having internal documentation and an abuse policy requiring such reporting. In several separate events, cognitively impaired residents with known histories of aggressive behaviors hit or punched other cognitively impaired residents in the abdomen, head, face, or chest. Nursing staff and CNAs documented the incidents, assessed the involved residents, and noted that no visible injuries were present, although one resident reported pain. The Administrator, DON, and other clinical leadership acknowledged that internal investigations were completed but stated that no Self-Reported Incidents were submitted because they believed there was no injury and that the residents lacked intent to harm or cause mental anguish, contrary to the facility’s written abuse policy and abuse flow sheet, which defined physical abuse to include hitting and required timely reporting of alleged violations involving abuse.
A resident with severe cognitive impairment and multiple comorbidities, who depended on staff for most care, was found by a family member to have a light purple bruise on the right cheek while being assisted with lunch. The RN on duty had not previously noticed the discoloration and notified the DON, who suggested it might have resulted from contact with a bedrail during incontinence care, though staff interviews did not confirm any such contact. The incident report lacked a clear description of the event, no skin assessment or medical record entry was completed for that day, the bruise was not logged on the incident/accident log, and no self-reported incident was submitted to the State Survey Agency, despite facility policy requiring timely reporting of suspected abuse or injuries of unknown origin.
A resident with severe cognitive impairment and multiple comorbidities alleged that a male CNA attempted to force sexual contact during personal care, identifying him by name and description. A social worker designee and the HR director interviewed the resident, confirmed the description matched a CNA on duty, and notified the Administrator by phone, but the incident was not documented in the medical record and was not promptly reported to the state as a sexual abuse allegation per facility policy. The internal investigation for that day lacked detailed witness statements from key staff and concluded no abuse occurred, relying in part on the resident’s son’s belief that no investigation was needed. When an SRI was later submitted, it was entered as physical abuse rather than sexual abuse, and a subsequent police report reflected conflicting information about when the facility became aware of the allegation.
A cognitively intact resident with multiple psychiatric and medical diagnoses reported to a provider that an LPN became angry, yelled, and used profanity toward them. This allegation of verbal abuse was documented in the medical record but was not entered into the facility’s SRI system, and the Administrator was not informed, so no timely reporting or investigation occurred as required by the facility’s abuse policy and federal timeframes.
Failure to Report Resident’s Allegation of Staff Abuse to State Agency
Penalty
Summary
Failure to timely report a resident’s allegation of staff-to-resident abuse to the State agency occurred after a cognitively intact resident with a history of wedge compression fracture of the T7-T8 vertebra, repeated falls, and bipolar disorder alleged that a nurse hurt his back while assisting him to sit up in bed. On the morning in question, a CPT RN entered the resident’s room to administer medications and, according to witness statements, the resident asked for help to sit up. The nurse assisted by holding the resident’s wrists/hands while he moved to a sitting position. Witness statements documented that the resident became combative, abusive, and agitated during the interaction, and that he did not like the nurse or new staff. The nurse later reported that the resident stated she had hurt him, which she denied. The DON reported that the resident had problems with Nigerian nursing staff and specifically with the CPT RN involved. The Administrator stated that the resident did not report abuse, but rather that the nurse pulled his hands to help him up and he felt it hurt his back, and confirmed that no Self-Reported Incident (SRI) was filed with the State agency. An Ombudsman reported calling the Administrator and relaying that the resident had alleged physical abuse by nursing staff, yet an SRI was still not submitted. This inaction occurred despite the facility’s abuse, neglect, and misappropriation policy requiring that alleged violations involving abuse be reported to the State Survey Agency and other authorities within specified time frames.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse, neglect and exploitation policy. Resident #65, who had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, was admitted on 07/23/25 and discharged on 03/02/26, with a quarterly MDS dated 01/28/26 indicating intact cognition. The resident’s care plan, initiated 07/29/25 and revised 08/12/25, documented that the resident elected to have video monitoring in his room. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. Review of LPN #221’s personnel file on 03/26/26 revealed a Corrective Action Report (CAR) signed 01/01/26 for incidents on 12/01/25 and 12/22/25, citing violations of rules of conduct and behavior. The CAR documented that on 12/01/25, LPN #221 was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described this behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the described behavior met criteria for a self-reportable incident. The Human Resources Director confirmed that Resident #65 was the resident involved. The Administrator later confirmed that the incident was not reported to the state agency, despite the facility’s policy requiring immediate reporting, but no later than two hours after an allegation of abuse is made. This deficiency was identified incidentally during a complaint survey completed on 03/26/26.
Failure to Self-Report Resident-to-Resident Physical Altercations as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely self-report multiple resident-to-resident physical altercations to the State Agency (SA) as allegations of abuse, in accordance with federal requirements and the facility’s own Abuse, Neglect and Exploitation policy. For one incident, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, and obesity, who had a documented history of verbal and physical aggression, pushed and struck another cognitively impaired resident in the abdomen after the second resident slammed a dining room chair into a table and attempted to push the first resident’s wheelchair. The second resident then struck the first resident on the back of the head. Nursing notes and internal incident reports documented the altercation, assessments, and that no injuries were observed. The Administrator and DON acknowledged that an internal investigation was conducted but confirmed that no Self-Reported Incident (SRI) was filed because there was no injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s abuse flow sheet indicating that the reasonable person concept should be applied to such physical altercations. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst. They found the cognitively impaired resident who had a history of aggressive behaviors sitting on the other resident’s bed, while the room’s occupant, who had Alzheimer’s disease with late onset, psychosis, vascular dementia, and other psychiatric and behavioral diagnoses, was in a wheelchair eating dinner. The room’s occupant reported that the aggressive resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were separated and that no injuries were observed. The Administrator and DON again stated that an internal investigation was completed but that no SRI was submitted to the SA because there was no injury and they believed the residents involved did not have the ability to intend harm or cause mental anguish, even though the facility’s policy and abuse flow sheet defined physical abuse to include hitting and required reporting of alleged violations within specified timeframes. Another incident involved a resident with dementia and extensive behavioral symptoms, including exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, and other disruptive behaviors, striking a severely cognitively impaired resident with multiple medical conditions, including vascular dementia, chronic obstructive pulmonary disease, heart disease, and chronic kidney disease. According to the Incident Audit Report and a Physical Aggression Form, a CNA witnessed the aggressive resident hit the other resident in the left side of the chest with her hand in a common area and immediately redirected the aggressor. The nurse assessed the struck resident, documented no redness or bruising, and recorded vital signs within normal limits, though the resident stated that it hurt and did not know why she had been hit. The physician and family were notified, and monitoring for pain or bruising was ordered. The DON stated that no SRI was completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s Abuse, Neglect and Exploitation policy defining physical abuse as including hitting and requiring immediate reporting of alleged violations involving abuse to the SA within the required timeframe. Across these events, record review, interviews, and policy review showed that the facility consistently treated these resident-to-resident physical altercations as internal incidents without reporting them as allegations of abuse to the SA. The facility’s abuse policy and undated abuse flow sheet specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and that alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The abuse flow sheet also clarified that having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions and directed staff to use the reasonable person concept to determine psychosocial impact. Despite this, the Administrator, DON, and RN/VPOC acknowledged that SRIs were not filed for these incidents because they focused on the absence of observed injury and their belief that the residents lacked intent, rather than on the willful nature of the physical acts and the reasonable potential for injury or mental anguish as required by their own policy.
Failure to Report and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 00), protein calorie malnutrition, major depressive disorder, and chronic kidney disease was dependent on staff for most activities of daily living and required monitoring for skin concerns during care. On the date in question, the resident’s family member observed a light purple bruise or discoloration on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not previously noticed the area and then notified the DON. The DON assessed the area and suggested it could have been caused by the resident’s cheek resting on a side rail during incontinence care, but staff interviews revealed no evidence that the resident’s face had come into contact with the bed rail. Despite the family’s report and the DON’s stated intent to investigate, the incident was not fully documented or reported as required. The facility’s incident report did not specify the nature of the incident, and there was no skin assessment documented in the medical record on the date the bruise was identified. The bruise was not entered on the February incident/accident log, and review of the state’s Enhanced Information Dissemination Collection system showed no self-reported incident related to the resident’s facial discoloration for the relevant period. The DON confirmed that no self-reported incident was submitted regarding this injury of unknown origin, contrary to the facility’s abuse policy, which requires notification of the Ohio Department of Health within 24 hours and completion of an investigation within five days.
Failure to Timely Report and Properly Classify Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident sexual abuse to the state agency as required by policy. A resident with severe cognitive impairment, dementia, depression, and multiple medical conditions, who required extensive assistance of two staff for mobility and transfers, alleged that a male CNA attempted to put his genitalia in her mouth. The resident identified the alleged perpetrator by name and physical description, which matched a male CNA on duty. The social worker designee and the human resources director interviewed the resident the same morning, confirmed the description, and contacted the Administrator by phone while in the resident’s room, placing the Administrator on speaker so she could hear the interview and reported events. Despite the Administrator being made aware of the allegation on the same morning it occurred, the facility did not document the incident in the resident’s medical record and did not report the allegation of sexual abuse to the state agency at that time. The internal investigation file for that date contained only brief, non-witness statements from staff attesting generally to the CNA’s behavior, with no detailed statements from the social worker designee, the human resources director, the LPN caring for the resident, or the CNA accused. The investigation summary concluded that the resident was confused and combative during personal care and that no abuse occurred, and the facility relied in part on the resident’s son’s opinion that an investigation was not needed and that the resident might have a urinary tract infection. Subsequently, when an SRI was entered into the state’s reporting system, it was categorized as physical abuse rather than sexual abuse, and there was no SRI entered for the original date of the allegation. A police report later documented that the Administrator reported the incident as sexual in nature and stated that the facility was not made aware of the allegation until the resident’s son reported concerns, which conflicted with staff interviews confirming the Administrator’s awareness on the date of the incident. The facility’s own abuse policy required that any allegation or suspicion of all types of abuse be reported to the state agency prior to investigation, but the allegation of staff-to-resident sexual abuse was not reported as such when initially known, and the investigation was incomplete and poorly documented.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and initiate an investigation in accordance with its abuse reporting policy and federal requirements. Resident #23, admitted on 02/02/26 with diagnoses including bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder (single episode, severe, without psychotic features), and hypertension, was documented as cognitively intact on the admission MDS. The MDS also showed the resident required supervision for toileting, bathing, dressing, and transfers, setup assistance for oral and personal hygiene, and was independent with eating and bed mobility. On 02/16/26, a provider visit note signed by Former Nurse Practitioner #175 documented that Resident #23 reported an incident in which a staff member, identified as LPN #94, became angry, yelled, and used profanity toward the resident. Review of the facility’s electronic Self-Reported Incidents (SRI) system from 02/16/26 to 03/11/26 showed no alleged incidents involving this resident had been entered. During an interview on 03/11/26, the Administrator stated she had not been informed of any abuse allegation involving LPN #94 and Resident #23 and indicated she would have reported and investigated the allegation if she had been made aware. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 04/2021, showed the facility was required to investigate and report any allegations within federally required timeframes; this did not occur for the allegation involving Resident #23.
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