Failure to Report and Investigate Injury of Unknown Origin Involving Shoulder Dislocation
Summary
The deficiency involves the facility’s failure to report an injury of unknown source to the Department in accordance with its abuse prohibition policy and state and federal reporting requirements. A resident with significant medical conditions, including subarachnoid hemorrhage, traumatic brain injury, and hypertension, had a Minimum Data Set (MDS) indicating a Brief Interview for Mental Status (BIMS) score of 00, reflecting severe cognitive impairment, and was totally dependent on others for all care needs. On one afternoon, the resident’s responsible party (RP) informed nursing staff that the resident appeared unwell, pointed to the resident’s left shoulder, and stated that something was wrong and that the resident had a bad shoulder. The nurse documented that the resident appeared to be in some discomfort, administered PRN pain medication, notified the MD, and arranged for a left shoulder x-ray. Later that evening, the x-ray was performed and showed a left anterior shoulder dislocation with no acute fractures. In the early morning hours following the x-ray, nursing notes documented that the x-ray results revealed a significant finding of a left anterior shoulder dislocation, that the MD was called, and that the resident was sent to the emergency department for treatment, with the RP notified. During an interview, the RP stated that she had requested the x-ray after noticing the resident grimace when she touched his shoulder and that staff had told her the resident had recently been cleaned and repositioned after incontinent care. The RP confirmed that the x-ray showed the resident’s left shoulder was dislocated. In subsequent interviews, the DON confirmed that the resident’s left shoulder injury met the definition of an injury of unknown origin and acknowledged that it was not reported to the Department as required. The Administrator stated that he spoke with the RP a day or so after the injury was discovered; the RP denied any fall or observed trauma and suggested the injury was due to contractures, and the Administrator did not document this conversation. The Administrator stated he followed the RP’s lead and did not suspect abuse, despite acknowledging that the resident was under the facility’s care and that the cause of the shoulder dislocation was unknown. Both the Administrator and the DON acknowledged that the injury of unknown origin should have been investigated to rule out abuse and reported in accordance with the facility’s Abuse Prohibition Policy and Procedure, which requires prompt investigation and reporting of injuries of unknown source, especially those involving serious bodily injury.
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The facility failed to report multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia, anxiety disorder, and chronic respiratory failure. Emails from the resident’s daughter to facility staff and the state agency described an LPN allegedly giving Tramadol doses too close together, intimidating the resident, not administering ordered meds, falsely documenting refusals, and ignoring incontinence care requests, as well as a CNA allegedly disrespecting belongings and speaking to the resident like a small child, another aide allegedly yelling at the resident, and a theft of socks. These concerns were not documented in the resident’s record or concern log, and only one self-reported incident related to the resident appeared on the state website. The Administrator, DON, ADON, and Regional Nurse denied knowledge of the emailed allegations and confirmed they were not investigated or reported, despite facility policy requiring timely reporting of all such allegations to the state agency.
Two cognitively impaired residents were found in a male resident’s bed with both of their pants down, with a CNA observing the male on top of the female and immediately separating them and notifying an LPN and the DON. The female resident had Alzheimer’s disease with a BIMS score indicating severe impairment, and the male resident had dementia, hepatitis C, antisocial personality disorder, and a documented high-risk heterosexual behavior diagnosis, yet neither had any documented assessment of capacity to consent to sexual activity in their records or care plans. Facility leadership and clinical staff confirmed the physical circumstances of the incident, acknowledged that both residents were considered unable to consent based on BIMS scores, and confirmed that no report was made to the state survey agency, no SRI was filed, law enforcement was not contacted, and the male resident’s guardian was not consulted about police involvement. Review of facility policies showed requirements to evaluate capacity to consent when there is reason to suspect a resident may lack such capacity and to report alleged abuse and investigation results to the state survey agency within specified timeframes, which were not followed in this case.
A cognitively impaired, wheelchair-dependent resident with multiple chronic conditions developed new, red, quarter-sized, symmetrical discoloration on both cheeks, identified during a skin assessment by an RN after prior documentation that the resident would not open her mouth for medications. The RN notified the DON, hospice, and the resident’s family, but no self-reported incident was filed and no investigation or report to the State Survey Agency was made. The DON stated she assumed the discoloration was self-inflicted based on the resident’s history of flailing, and the incident was not treated as an injury of unknown origin, contrary to the facility’s abuse prevention policy requiring such injuries to be reported and investigated.
The facility failed to timely report multiple instances of misappropriation of resident trust funds, where several cognitively impaired and cognitively intact residents had unauthorized online purchases made from their accounts by former business office, activities, and social services staff. Items such as clothing, electronics, personal care products, snack foods, and dementia activity supplies were ordered without resident or representative consent, often without required documentation or signatures, and some items were never received by the residents and were instead found in the activities department. An activities staff member observed large quantities of goods ordered under resident accounts being stored and used in the activities area, suspected misappropriation, but did not report these concerns to the Administrator, DON, or corporate office, contributing to delayed reporting of these abuse allegations to the state agency as required by facility policy.
A resident with NASH, diabetes, ascites, obesity, and intact cognition was care planned as full code with interventions for CPR, 911 activation, and Q2H turning and repositioning. During a night shift, an agency CNA assigned to the resident was frequently unavailable and reported by staff as not tending to residents’ needs or following up on care requests. The CNA stated he last checked the resident between midnight and 1:00 A.M. and did not check again before an LPN found the resident unresponsive, cool to touch, and without vital signs during morning med pass, later verified by an RN. Staff interviews confirmed an expectation for resident checks every 1–2 hours, and the DON acknowledged the resident was not checked or cared for in a timely manner and that an extended period without checks would be considered neglect. Despite this, no self-reported incident of suspected neglect related to the resident’s death was submitted to the State agency, contrary to facility policy requiring immediate reporting and investigation of alleged abuse or neglect.
A dependent, cognitively impaired resident with multiple comorbidities was found on the floor of her room, after which family, the CNP, and the DON were notified and x‑rays were obtained that initially showed no fractures despite ongoing pain. Subsequent imaging revealed a cortical breach of the femoral neck and later a CT confirmed a nondisplaced right intertrochanteric femur fracture, with the DON unable to determine whether it was related to the fall or occurred during routine care and acknowledging it was an injury of unknown origin. The DON confirmed that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency as required by facility policy and federal regulations.
Failure to Report Multiple Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and misappropriation involving one resident to the State Agency as required by its abuse policy and state regulations. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026, and the resident concern log for the past year contained no concerns related to her. Review of the Ohio Department of Health (ODH) Certification and Licensure website showed only one self-reported incident (SRI) involving this resident within the last six months, dated 03/09/26, related to alleged neglect and mistreatment by an LPN and a CNA. However, record review of emails sent by the resident’s daughter to verified facility staff email addresses and ODH showed multiple unreported allegations. These included claims that an LPN administered Tramadol doses too close together, displayed animosity and hatred, intimidated the resident, failed to give medications as ordered, falsely documented refusals of care, and ignored calls for incontinence care after turning off the call light for several hours. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a pair of cabin socks was stolen. In interviews, the Administrator, DON, ADON, and Regional Nurse denied knowledge of these allegations and confirmed that no SRI investigations or reports to ODH had been completed for them, despite facility policy requiring all allegations of abuse, neglect, and exploitation to be reported to the state agency within specified time frames.
Failure to Report Alleged Sexual Abuse and Assess Residents’ Capacity to Consent
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the state survey agency and/or local law enforcement, and failure to evaluate and document the residents’ capacity to consent to sexual activity as required by facility policy. One resident, identified as having Alzheimer’s disease, hypertension, and major depression, was admitted in early June and had a BIMS score of 0 on her admission MDS, indicating severe cognitive impairment. Her care plan documented impaired cognition and thought processes related to Alzheimer’s disease, with interventions focused on yes/no questions, cueing, reorientation, supervision, and maintaining a consistent routine. There was no documentation in her medical record or care plan regarding an assessment of her capacity to consent to sexual activity, either before or after the incident. On a date in late July, prior to dinner, an agency CNA reported that she was looking for this cognitively impaired resident and, upon entering a male resident’s room, observed the male resident on top of her in his bed, with both residents’ pants down and no clothing below the waist. The CNA immediately separated the residents and notified an agency LPN, who then contacted the DON. Witness statements from the CNA and LPN consistently described the male resident on top of the female resident with both of their pants down. A subsequent assessment by the Infection Control/ADON documented a full body and vaginal assessment of the female resident, noting no blood, bruising, abrasions, lacerations, or signs of penetration, and that when asked if she was having pain or if it hurt, the resident only smiled. The male resident later told the former Administrator and an RN that the female resident had come into his room, sat on his bed, that he rubbed her leg, and that both of their pants were on, denying kissing and sexual contact. The male resident involved had dementia, viral hepatitis C, antisocial personality disorder, and a diagnosis of high-risk heterosexual behavior added shortly after the incident. He had a court-appointed legal guardian, but there was no documentation in his record or care plan regarding an evaluation of his capacity to consent to sexual activity. His quarterly MDS showed a BIMS score of 11, indicating cognitive impairment, and his care plan noted impaired cognition related to dementia. Interviews with regional leadership and the Infection Control/ADON confirmed that the male resident was on top of the female resident in his bed with both residents’ pants down, that the male resident had hepatitis C, and that lab testing was ordered for the female resident as a precaution. They also confirmed that the police were not contacted, there was no documentation that the male resident’s guardian was consulted about police involvement, and that no self-reported incident was filed with the state agency; only an internal investigation was completed. Further interviews with the DON and Infection Control/ADON revealed that no formal assessment of either resident’s capacity to consent to sexual activity was completed before or after the incident, that the facility relied solely on BIMS scores (with a threshold of 12) to determine consent capacity, and that they believed both residents could not consent based on their BIMS scores. Review of the state survey agency’s SRI database showed no SRI filed for this incident, and review of facility policies showed that the facility was required to evaluate capacity to consent when there was reason to suspect a resident might lack such capacity and to report alleged violations and investigation results to the state survey agency within required timeframes, which did not occur in this case. Additionally, interviews with staff and the primary care provider further underscored the lack of reporting and capacity assessment. The agency CNA who discovered the incident stated she no longer worked at the facility because the incident was disturbing and "just was not right," and reiterated that she found the male resident on top of the female resident with no clothing below the waist and that she was unsure if sexual activity had occurred because the male resident jumped up quickly when she yelled. The primary care provider for both residents stated she was aware of a potential sexual encounter and uncertainty about penetration, which led her to order hepatitis C testing for the female resident due to the male resident’s hepatitis C diagnosis. She stated that the female resident could not give informed consent, as the resident only gave a blank stare and did not communicate when questioned, while she believed the male resident could verbalize a desire for sex and give consent. Despite these observations and the facility’s own policies defining sexual abuse as non-consensual sexual conduct and requiring evaluation of capacity to consent and reporting of alleged abuse to the state survey agency, the facility did not complete or document a capacity-to-consent evaluation for either resident and did not report the allegation to the state survey agency or law enforcement. Review of the facility’s policies "Identifying Types of Abuse" and "Residents Right to Freedom from Abuse, Neglect, and Exploitation" showed that sexual abuse includes non-consensual sexual conduct of any type, including unwanted intimate touching and all types of sexual assault or battery, and that sexual contact is non-consensual if a resident appears to want the contact but lacks cognitive ability to consent. The policies state that when there is reason to suspect a resident may not have capacity to consent to sexual activity, the facility must take steps to protect the resident from abuse, including evaluating capacity to consent, and that when abuse is identified, the facility must report alleged violations and investigate within required timeframes, reporting investigation results to the Administrator and to officials including the state survey agency within five working days. In this incident, despite the female resident’s severe cognitive impairment, the male resident’s cognitive impairment and high-risk sexual behavior diagnosis, the observed physical positioning and state of undress of both residents, and staff and provider concerns, the facility did not perform the required capacity evaluations and did not report the allegation and investigation results to the state survey agency or law enforcement as required by its own policies and applicable regulations.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an injury of unknown origin to the State Survey Agency as required by its abuse prevention policy. A cognitively impaired resident with diagnoses including COPD, heart failure, anxiety, depression, type 2 diabetes mellitus, and dementia was dependent for ADLs, used a wheelchair, and required assistance for transfers and mobility. Progress notes documented that on one day the resident would not open her mouth to take medications during two separate medication administration attempts. The following day, a progress note indicated the resident was assessed for discoloration on both sides of her face. A skin assessment completed by an RN described new discoloration on the bilateral sides of the resident’s face, located under the cheekbones, red in color, symmetrical, and approximately the size of a quarter, with notifications made to the DON, hospice, and the resident’s family. The RN later confirmed these characteristics in interview. Review of self-reported incidents showed there was no investigation initiated or report made to the State Survey Agency regarding this new bilateral facial discoloration. In interview, the DON stated she assumed, based on the resident’s history of flailing herself, that the discoloration was self-inflicted due to behaviors, and confirmed it was not reported or investigated as an injury of unknown origin, despite facility policy stating that suspicious injuries of unknown origin must be reported and investigated.
Failure to Timely Report Misappropriation of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of misappropriation of resident funds to the proper authorities, despite multiple instances where resident trust accounts were used without authorization. For one resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed debits for online purchases that were not authorized by the resident’s representative. Items such as a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit, and a sweatshirt were charged to this resident’s account, and documentation of these purchases by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff was absent from the medical record. The resident later confirmed that items had been purchased using his funds and that he believed a television had been ordered but never received. Another resident, cognitively intact but requiring assistance with ADLs and diagnosed with type 2 diabetes mellitus, PTSD, and osteoarthritis, had large online purchases made in her name, including a tablet, tablet keyboard, clothing, personal care items, and other supplies totaling thousands of dollars. These purchases were made by former SS staff without authorization from the resident or her representative, and there was no documentation of these purchases in the progress notes. The resident reported that a cart of items was brought to her, including a tablet and clothing she had not requested, and that she sent the items back. The Administrator later verified that the purchase was made with the intent to withdraw the full amount from the resident’s account, even though the account had not yet been charged at the time of the initial internal review. Additional residents with varying levels of cognitive impairment and dependence for ADLs also had unauthorized online purchases made from their trust accounts. One moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had hearing aids and a television purchased without representative authorization, and the television could not be located. Another severely cognitively impaired resident with epilepsy, end-stage renal disease, and aphasia had multiple clothing and personal items ordered without authorization, with some items not found in his room. A further severely cognitively impaired resident with Alzheimer’s disease, congestive heart failure, and diabetes had numerous items such as cologne, boys’ pajamas, slippers, socks, snack foods, televisions, a record player, dementia activity items, and other products purchased without authorization, with some items missing and some found in the activities department. Interviews with former BOM and AD staff revealed that they used resident funds, including for Medicaid residents over the $2000 resource limit, to order items via an online retailer, and that some items purchased under resident accounts were kept and used in the activities department rather than being provided to the residents. An activities staff member reported she suspected misappropriation when large quantities of items ordered under resident accounts were stored in the activities room and not delivered, but she did not report these suspicions to the Administrator, DON, or corporate office, contributing to the facility’s failure to timely report the misappropriation allegations as required by its abuse policy. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that misappropriation of resident property be reported to the state agency within required timeframes. Despite these policies, multiple residents’ accounts showed unauthorized debits for online purchases without the required signatures or documentation, and staff interviews confirmed that items were ordered and sometimes used for general activities rather than for the specific residents whose funds were charged. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because an activities staff member did not escalate her suspicions of misappropriation to facility leadership, resulting in delayed recognition and reporting of the misappropriation of resident funds.
Failure to Report Suspected Neglect Related to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report a concern of neglect related to a resident’s death to the State agency, as required by policy. The resident had diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and an MDS showing intact cognition with a BIMS score of 15. The resident’s care plan documented full code status with interventions to call 911, initiate CPR, and provide oxygen or ambu-bag breaths if the resident stopped breathing, as well as a plan for turning and repositioning every two hours due to risk for impaired skin integrity. Progress notes documented that during morning medication pass, an LPN found the resident unresponsive, cool to touch, and without measurable vital signs, which was verified by an RN. There was no documentation of any change in condition prior to death, nor documentation of when the resident was last checked, seen, or cared for. Staff interviews revealed that the agency CNA assigned to the resident on the night shift was frequently unavailable, sitting at the desk, or difficult to locate, and was reported as not tending to residents’ needs or following up timely with care requests. A CNA working that night stated that when informed of the resident being found unresponsive, she asked the assigned CNA when he last saw the resident, and he reported a time of 11:20 P.M. The DON confirmed that the agency CNA was the assigned aide for the resident and acknowledged that facility staff did not check on the resident timely and that it was unknown how long the resident had been unresponsive before being found at 5:30 A.M. The DON also stated that her expectation was that residents be checked at least every two hours with staff visually confirming their safety, and confirmed that the resident was not cared for and checked on in a timely manner. Additional interviews with other CNAs confirmed the expectation that residents be observed and checked every one to two hours, including on night shift. The agency CNA later stated he assumed care of the resident at 11:00 P.M., that the resident had been using the call light frequently for incontinence care, drinks, and repositioning, and that he last checked on her between midnight and 1:00 A.M., after which he did not check on her again before she was found unresponsive. An RN reported that the LPN had mentioned the agency CNA was making himself scarce and was hard to locate, and stated the outcome may have been different with more frequent monitoring. The DON acknowledged that not checking on a resident for an extended period would be considered neglect and confirmed that no self-reported incident had been initiated or reported to the State agency regarding the resident’s care the night of her death, despite facility policy requiring immediate reporting and thorough investigation of all allegations of abuse, neglect, or mistreatment, and reporting results to the State survey agency within five working days.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by its abuse, neglect, exploitation, and misappropriation prevention policy and federal requirements. A resident with COPD, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia, who had moderate cognitive impairment and was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, was found on the floor of her room with her back on the floor and head against the bedside stand. Following this fall, the nurse notified the resident’s family, CNP, and DON, and x‑rays were ordered. Initial x‑rays of the right arm and leg, and a subsequent right hip x‑ray, were negative for fracture, though they showed diffuse osteopenia. Further imaging on a later date showed a cortical breach with a small step deformity of the femoral neck on the right hip, and a CT scan later confirmed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain, that the resident initially refused a CT scan which was then rescheduled, and that the CT ultimately showed the fracture. The DON also stated the facility did not believe the fracture occurred from the original fall but could not identify the cause, acknowledged the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture occurred during routine care. The DON confirmed that, despite the fracture being an injury of unknown origin, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report it to the State Agency when it was identified, contrary to facility policy requiring identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment within required timeframes.
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