Kauhale Centerville

Based on record review, incident/self-reported incident (SRI) investigation review, staff interviews, written staff statements, hospital documentation, facility policy and law enforcement case report, the facility failed to prevent physical abuse by a staff member. This affected one resident (Resident #10) of three residents reviewed for abuse. The facility census was 62.

Actual physical harm occurred to Resident #10 on 05/18/26 when Personal Care Assistant (PCA) #100 knocked Resident #10 down and dragged her across the floor resulting in the resident sustaining skin tears and bruising in the shape of finger and handprints and requiring evaluation and treatment at the hospital. Resident #10 was discharged from the hospital to her family home during the abuse investigation.

Findings include:

Review of the closed medical record for Resident #10 revealed an admission date of 01/15/26. Diagnoses included unspecified dementia, unspecified severity with other behavior disturbances, generalized anxiety disorder and hypertension. Resident #10 was sent to the emergency room on 05/18/26 and was discharged from the hospital with family.

The functional assessment dated 03/03/26 revealed the resident was alert to person and time, had socially inappropriate behaviors and occasionally needed redirection.

Review of the SRI revealed on 05/18/26 at approximately 3:04 A.M. the Director of Health and Wellness Director (DHW) #101 were called by Personal Care Assistant (PCA) #102 and informed Resident #10 had skin tears on her right arm and was actively bleeding. PCA #102 was instructed to call the Emergency Medical Services (EMS) and update Resident #10's Power of Attorney (POA). EMS arrived at the facility and transported Resident #10 to the hospital at approximately 3:22 A.M. At approximately 3:47 A.M. law enforcement arrived at the facility to question PCA #100 regarding an allegation she had struck Resident #10, knocked her down and dragged her across the floor. PCA #100 was detained based on the statements provided by Resident#10 to EMS and hospital personnel, as well as visible injuries observed on Resident #10's right forearm and bicep, including markings consistent with finger and/or handprints.

Review of the Hospital Emergency Department documentation dated 05/18/26 revealed a diagnosis of alleged assault and skin tear of arm without complication. The history and physical information documented Resident #10 alleged she had been assaulted by a staff member at the facility where she resided. The initial assessment of extremities documented the proximal right upper extremity revealed a well-demarcated region of ecchymosis somewhat consistent of a handprint; there were associated mild skin tears and similar findings about the right knee. The triage notes at 3:36 A.M. documented Resident #10 arrived with multiple skin tears on the right arm and a bruise to the right knee. Further documentation revealed the police were contacted regarding Resident #10's allegation of abuse. At 4:20 A.M., the note documented law enforcement were present taking photos of Resident #10's injuries.

Review of the law enforcement case report (#MC260004024-001) documented an aggravated assault charge against PCA #100 for patient abuse, neglect committed abuse of a resident or patient of the facility. The documentation revealed law enforcement was dispatched on 05/18/26 at approximately 3:47 A.M. in reference to an assault complaint. The officer arrived at the emergency department and was advised by the physician Resident #10's injuries appeared to be by someone's hand, who grabbed Resident #10 aggressively.

Review of the written statement of PCA #102 dated 05/18/26 documented he was in the middle of the hall when he observed Resident #10 come out of her room bleeding and stated PCA #100 had swung her around, grabbed her and hit her. PCA #100 then came out of a room and said Resident #10 had slipped and fell. PCA #101 questioned why PCA #100 had not assisted Resident #10 and contacted management due to Resident #10 bleeding and PCA #100 answered she was doing something else.

Three attempts on 05/21/26 at 11:19 A.M., 11:51 A.M. and 2:17 P.M. to contact PCA #102 by phone were unsuccessful.

During an interview on 05/21/26 at 10:14 A.M., the Executive Director (ED) stated she was notified on 05/18/26 at approximately 4:45 A.M. that Resident #10 had been sent to the hospital for skin tears and Resident #10 had alleged PCA #100 had abused her. The ED stated although Resident #10's story to PCA #101, EMS and the physician changed slightly it remained essentially the same and therefore it was deemed credible. The ED stated she came to the facility and law enforcement had already been there, questioned PCA #100 and took her in for further questioning. The ED called the detective and was informed PCA #100 had admitted to the allegation of physical abuse to Resident #10. The ED stated she was unaware of any previous concerns for resident care by PCA #100 by other staff, residents or families. Skin assessments were completed on all residents on PCA #100's assignment and no concerns were revealed. The ED stated other residents in the facility were not assessed and acknowledged it was possible PCA #100 could have provided care for other residents not on her assignment.

Review of the facility policy titled Abuse and Neglect dated 01/01/25 documented staff members were required to provide care with respect and professionalism. Any suspected or actual abuse would be investigated following legal and regulatory requirements.

This violation represents non-compliance investigated under Complaint Number OH00170712.

Based on employee personnel record review and staff interviews, the facility failed to ensure unlicensed Resident Aides (RA) were trained and signed off by a licensed nurse as required. This affected three (RA's #202, #239, and #243) of three reviewed for techniques and had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

1. Review of RA #202's personnel record revealed a hire date of 08/26/25. The record did not contain evidence that RA #202 received training by a licensed nurse prior to providing care services without supervision.

2. Review of RA #239's personnel record revealed a hire date of 08/26/25. The record did not contain evidence that RA #202 received training by a licensed nurse prior to providing care services without supervision.

3. Review of RA #243's personnel record revealed a hire date of 08/26/25. The record did not contain evidence that RA #202 received training by a licensed nurse prior to providing care services without supervision.

Interview with Director of Business Administration (BMA) #206 on 09/17/25 at 4:31 P.M. revealed since the facility came under new management in October 2024, they have not been provided a new skills training curriculum for RA's.

Interview with Director of Health and Wellness (DHW) #227 on 09/18/25 at 8:59 A.M. revealed new RA's are in classroom orientation for their first day and are scheduled for on the floor training for at least one week, or longer if needed. DHW #227 reported that RA's are trained by other RA's. DHW #227 reported she checks in with new RA's during their training, but their care techniques are not observed by her or other nurses in the facility.

Based on resident record review and staff interviews, the facility failed to complete an initial functional assessment and an initial fall risk assessment within 48 hours of admission. This affected one (#116) of five residents reviewed for initial health assessments. The facility census was 61.

Findings include:

Review of Resident #116's electronic medical record revealed an admission date of 05/05/25 with diagnoses including Alzheimer's disease and prostate cancer. Further record review revealed a complete functional assessment was completed on 05/09/25, and a fall assessment had not been completed.

Interview with Director of Health and Wellness (DHW) #227 on 09/18/25 at 8:58 A.M. confirmed the date of Resident #116's initial functional assessment was more than 48 hours from admission, and confirmed that no fall assessment was in the chart.

Based on medical record review, staff interviews, and facility policy reviews, the facility failed to investigate injuries of unknown origin. This affected one (#123) out of five residents reviewed during the survey. Additionally, the failed to maintain an accurate incident log. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of Resident #123's electronic medical record revealed an admission date of 10/01/20 with diagnoses including memory loss and hypertension. Review of a functional evaluation dated 01/16/25 revealed Resident 123 utilizes a manual wheelchair and is able to propel herself, no tactile deficits, and requires one-person assistance with transfers, ambulation, bathing, and toileting.

Review of nurse note on 04/12/25 revealed Resident #123 had several scratches on her left arm of unknown cause with no signs or symptoms of infection. It was not reported how many scratches were observed or how big. There were no other notes in the chart regarding this skin tear.

Review of nurse note on 04/13/25 revealed a skin tear of unknown size on Resident #123's right hip. The source of the scratch was unknown. The wound was cleansed and left open to air. There were no other notes in the chart regarding this skin tear.

Review of nurse note on 07/30/25 revealed Resident #123's right arm was bandaged due to a skin tear approximately three centimeters in length. Resident #123 did not voice pain or discomfort. Next nurse note on 08/03/25 revealed the bandage was removed from Resident #123's right arm, revealing a skin tear. The area was noted to be red, warm, and swollen, and the resident grimaced when the area was touched. The nurse called Resident #123's physician and received new orders to start the antibiotic Cipro 500 milligrams (mg) twice per day for seven days, and to clean the wound daily with a wound cleanser and apply an OptiFoam dressing until the wound healed. There were other notes in chart regarding this skin tear.

Review of incident log dated 10/24/24 to 09/17/25 revealed the skin tears were not included on the incident log. Further review revealed no falls or other incidents in a similar timeframe that would explain the injuries.

Interview with Director of Health and Wellness (DHW) #227 on 09/18/25 at 8:32 A.M. revealed the facility maintains the incident log under nurse notes in each resident's medical record. DHW #227 reported the incident log only contains falls with and without injuries and resident-to-resident altercations. DHW #227 reported that incidents of skin tears and injuries of unknown origin are charted in nurse notes. DHW #227 stated that it is difficult to investigate injuries because the residents are poor historians due to being diagnosed with dementia. DHW #227 revealed that one of Resident #123's behaviors include scratching herself. DHW #227 revealed Resident #123 had a stroke affecting her left side which is why she tends to have more scratches on her left side. An intervention was put in place to keep a body pillow under her left side while in bed to prevent her from scratching her left side. DHW #227 reported that Resident #123's skin tears were not further investigated.

Review of the policy titled Abuse/Neglect

Based on record review and staff interviews, the facility failed to establish and implement a tuberculosis (TB) control plan and complete a facility TB risk assessment. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of documents provided by the facility revealed there was no evidence the facility had established and implemented a TB control plan or completed a facility TB risk assessment as required.

Interviews with Director of Health and Wellness (DHW) #227 on 09/17/25 at 7:48 A.M. and 09/18/25 at 9:02 A.M. revealed the facility does not have a TB control plan or a facility TB risk assessment. DHW #227 reported that all staff have TB/Mantoux skin tests when hired and annually, but no other risk assessments are conducted by the facility.

Based on observations, staff interviews, and policy review, the facility failed to store, prepare, and distribute food in a manner to prevent contamination and spoilage. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Observations of the kitchen on 09/17/25 from 10:28 A.M. to 10:40 A.M. revealed three employees, Servers #230, #236, and #247, not wearing hair nets while moving throughout the kitchen. Observation of lunch preparation revealed a sheet of sandwiches stacked on top of another sheet of sandwiches without a barrier between the food on the bottom of the stack and the tray on top. Observations of the walk-in freezer and fridge revealed food debris on the floor, and multiple bottles of various sauces that were opened and unlabeled. Observations of the dry stock revealed food debris on the floor; open bags dry pasta, croutons, and potato chips that were opened and unlabeled; a large, open box of granulated sugar on the bottom shelf without a cover; and three jars of Nutella that were expired on 08/28/25.

Interview with Cook #203 on 09/17/25 at 10:31 A.M. revealed the stack of sandwiches did not need a protective cover or barrier between sheets as they were about to be toasted.

Interview with Server #230 on 09/17/25 at 10:40 A.M. confirmed food debris on the floor of the walk-in freezer and fridge, and the open and unlabeled sauces, dry stock, and sugar. Server #230 confirmed three jars of Nutella expired on 08/28/25. Server #230 confirmed that expired food is to be removed from the pantry.

Review of the policy titled Kitchen Sanitation & Food Safety

Based on record reviews and staff interviews, the facility failed to transmit a fire alarm signal for all fire drills as required. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of fire drills from the past 12 months revealed alarm transmission signals were not sent for fire drills conducted on 08/13/25 at 1:30 P.M., 07/22/25 at 5:00 A.M., 04/23/25 at 10:30 A.M., 01/28/25 at 12:30 A.M., 12/18/24 at 3:40 P.M., 11/04/24 at 11:00 A.M., 10/30/24 at 6:15 A.M., and 09/20/24 at 4:00 P.M.

Interview with Director of Sales and Marketing (DSM) #224 on 09/18/25 at 10:30 A.M. confirmed the facility did not complete alarm transmission signals to the alarm company for fire drills conducted on 08/13/25 at 1:30 P.M., 07/22/25 at 5:00 A.M., 04/23/25 at 10:30 A.M., 01/28/25 at 12:30 A.M., 12/18/24 at 3:40 P.M., 11/04/24 at 11:00 A.M., 10/30/24 at 6:15 A.M., and 09/20/24 at 4:00 P.M.

Based on record reviews and staff interviews, the facility failed to conduct monthly fire safety self-inspections using the Ohio Department of Health's (ODH) Fire Safety Self Inspection form. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of work history reports from the past 12 months revealed the facility conducted monthly fire safety self-inspections and recorded all findings on a form provided by Supply Company #12. Further review revealed the facility did not complete the monthly fire safety inspection and record the inspections on the forms provided by ODH.

Interview with Director of Sales and Marketing (DSM) #224 on 09/18/25 at 10:30 A.M. revealed all monthly fire safety self-inspections are recorded on Supply Company #12's form. DSM #224 reported the facility does not use the ODH Fire Safety Self Inspection form.

Based on record review and staff interviews, the facility failed to establish a grievance committee as required. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of documents provided by the facility revealed there was no evidence the facility had established a grievance committee as required.

Interviews with Director of Health and Wellness (DHW) #227 on 09/17/25 at 7:48 A.M. and 09/18/25 at 8:54 A.M. confirmed the facility does not have an established grievance committee.

Based on medical record review, staff interview, review of the facility incident log, and facility policy review, the facility failed to investigate incidents of skin tears and bruises of unknown source and failed to include incidents on incident and accident log. This affected one (#56) resident out of the three residents reviewed for injury of unknown origins. The facility census was 55.

Findings include:

Review of the medical record for Resident #56 revealed an admission date of 03/04/25 with medical diagnoses of dementia and hypothyroidism.

Review of Resident #56's functional assessment dated 03/07/25 revealed Resident #56 was oriented to person only, required two person assistance with transfers, one person assist for ambulation, and was a fall risk.

Review of Resident #56's nurses note revealed a note dated 04/22/25 at 10:17 P.M. which stated Resident #56 was found to have a skin tear to right back forearm of unknown source, a note dated 04/26/25 at 10:01 A.M. which stated Resident #56 was noted to have bruising to left flank of unknown source, and a note dated 05/01/25 at 1:20 P.M. which stated Resident #56 had bruising to left flank and buttock and was seen by Nurse Practitioner (NP) with no new orders.

Review of the NP note, dated 05/01/24, stated Resident #56 was seen per nurse request for evaluation for fall with bruising and skin tear. The note indicated Resident #56 had bruising to left low back, a skin tear to left shin, and ecchymosis to left lower extremity.

Review of the medical record for Resident #56 revealed a fall on 03/07/25 and two falls on 03/17/25. The medical record had no documentation to support Resident #56 had a fall on or around 05/01/25.

Review of the medical record for Resident #56 revealed a hospital note dated 05/11/25 which stated upon examination Resident #56 was noted to have erythema with multiple lesions across bilateral lower extremities.

Review of the facility incident and accident log revealed Resident #56 fell on 03/07/25 and had two falls on 03/17/25. No other falls were noted. Further review of the incident and accident log revealed no documentation to support the facility included the incidents of Resident #56's skin tears or bruising of unknown source on the incident and accident log.

Interview on 07/10/25 at 1:20 P.M. with Director of Nursing (DON) confirmed the facility did not investigate the cause of Resident #56's skin tears and bruising on 04/22/25, 04/26/25, or 05/01/25. DON stated Resident #56 was combative with cares at times and non-complaint with asking for assistance with transfers and would attempt to transfer self. DON stated Resident #56 did not sustain a fall on or around 05/01/25 and the NP note on 05/01/25 was incorrect. DON also confirmed the facility did not include Resident #56's incidents of skin tears and bruising of unknown source on the facility incident log.

Review of the facility policy titled, Abuse/Neglect