Helen Purcell Home

Based on record review and interview, the facility failed to prohibit staff from working after a positive drug screen. This had the potential to affect all residents. The facility census was 49.

Findings include:

A review of facility self reported incident (SRI), dated 07/19/25, revealed Licensed Practical Nurse (LPN) #619, #618, #621, #627, and #807 were sent for rapid drug screens when the facility controlled substance counts were not accurate. The SRI indicated all drug screens were negative and results were confirmed by lab analysis. The LPNs were all given final written warnings for not following the facility controlled substance policy.

Review of a form titled Notice of Corrective Action Written Reprimand dated and signed by former executive director on 07/18/25 revealed LPN #807 did not sign this form and was terminated, with no signature on this form.

Review of a document titled Time Card dated 07/01/25-07/31/25 for LPN #807 revealed the LPN worked six shifts after being drug tested, and three of those shifts were after the facility had received the results of the drug test, which was positive for marijuana. The LPN worked 07/18/25 from 2:00 P.M. to 7:45 A.M., 07/21/25 from 10:15 A.M. to 11:15 A.M. and 11:00 P.M. to 7:30 A.M., 07/22/25 from 11:00 P.M. to 8:15 A.M., 07/26/25 from 11:00 P.M. to 8:00 A.M., 07/27/25 from 11:00 P.M. to 8:00 A.M., and 7/30/25 from 11:00 P.M. to 7:45 A.M. This was confirmed by the Deputy Executive Director (DED) on 02/04/26 at 12:00 P.M.

Review of a form titled Results of Controlled Substance Testing, dated 07/18/25, for LPN #807 revealed LPN #807 tested positive for marijuana. This result was forward to the facility on 07/24/25.

Review of a form titled Notice of Corrective Action Written Reprimand dated 07/31/25, and signed by both the former Executive Director and LPN #807 revealed LPN #807 was terminated on 07/31/25 for failing a drug screen from incident relating to 07/15 investigation.

On 02/04/26 at 12:00 P.M., during interview with the Deputy Executive Director (DED) reported she knew there was going to be an issue with Licensed Practical Nurse (LPN) #807's drug test. If a drug test was negative, as it had been for all of the other nurses who tested the same day, the results were received within 24 hours. When it had not come back when all of the others had, that usually indicated the laboratory would have to repeat the testing which took a couple days longer. The entire nursing staff had been sent for drug testing, therefore the DED and Executive Director did not feel they were able to send all nurses home pending drug test results because they would not have had any nurses to care for the residents. The DED confirmed LPN #807 had taken a drug test on 07/18/25. She was not removed from the schedule. LPN #807's drug test results were positive for marijuana. The DED had advised the former Executive Director if the LPN was positive for marijuana she had to be terminated. He did not agree and went back and forth with me about what we should do. She confirmed the nurse worked six shifts from 07/18/25 through 07/30/25. LPN #807 was terminated on 07/31/25, not 07/18/25 as the initial disciplinary action indicated.

On 02/04/26 at 9:40 A.M., an interview with the Deputy Executive Director (DED) revealed prior to 07/19/25 the facility did not have a policy for the use and managing of controlled substances. The policy was created on 07/19/25 by the former Executive Director (ED) as a result of an investigation into inaccurate narcotic counts. A policy regarding drug diversion investigations was added by the ED on that same date. She confirmed the nurses had not been provided with a policy or procedure on managing controlled substances prior to 07/19/25.

A review of an undated facility policy titled Drug and Alcohol Testing revealed the facility drug tested all staff pre-employment. For facility purposes, the policy indicated the use of marijuana was not acceptable, even under the advice of a physician. If there were circumstances which were suspect for drug diversion, employees could be randomly tested. If positive, the employee could not return to work until disciplinary decisions were made between the employee and the administration, which could include treatment options and/or termination. As a condition of employment, employees must acknowledge the facility drug policy.

This violation represents non-compliance investigated under Complaint Number OH00168899

Based on observation, record review and interview, the facility failed to provide a variety of activities which would stimulate, improve, or enrich the lives of the residents. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

On 02/02/26 at 11:15 A.M., an observation of the Shinnick Center (a unit of the facility where residents had cognitive issues but was not considered a specialty unit) revealed several residents walking or self-propelling wheelchairs aimlessly in the hallway. No staff was observed interacting with the residents.

Review of a February 2026 Activity calendar revealed there were no activities scheduled for residents on the weekends. On Monday through Friday of the calendar, the 9:30 A.M. activity was Artistic Expression in Shinnick and the 10:15 A.M. activity was MOVE IT!! In Shinnick Center. The last activity every day was scheduled for 1:30 P.M. On 02/12/26 and 02/19/26 there were no 9:30 A.M. activities.

On 02/02/26 at 11:05 A.M., an interview with Resident #125 revealed she did not have anything to do. She reported she would probably just find someone to talk to. She liked activities where they played games and listened to music, but sometimes people did not like the activities, so they wouldn't come.

On 02/04/26 at 2:20 P.M., an interview with the daughter of Resident #45 revealed she felt the facility activities were not meeting the needs of the residents. She reported there was never anything to do on the weekends, and residents would just roam around or stay in bed, because there was nothing to get them moving. Her mother had been at the facility for about a year and a half, and she felt the activities for residents had just gone downhill since she had been there. Her mother would often tell her she was bored, or they would find her napping instead of out of bed in the middle of the day.

On 02/02/26 at 1:15 P.M., an interview with Activity Associate (AA) #631 revealed there were no separate activities for the residents with cognitive issues and all other residents. She reported the facility was trying to get back to that, but right now there was only the one calendar. She confirmed there were no activities scheduled after 1:30 P.M. Monday through Friday and there were no activities on the weekends.

On 02/04/26 at 8:15 A.M., an interview with the Activities Director (AD) revealed she felt the activities in the facility were lacking, but not for lack of trying, and it was her top priority to increase her staff to meet the needs of the residents. She indicated she needed to double the size of her staff, which at the time of survey included one Monday through Friday employee, and two employees who worked two days during the week. There was no one scheduled for activities on the weekends. The last scheduled activity through the week was at 1:30 P.M. She confirmed there were no activities for residents on the weekends. During the week, the activity staff was responsible for all resident transportation as well. She further indicated that until 02/25 they operated with two calendars. One was for the unit identified as the Shinnick Center, which held residents with more cognitive functioning issues, and the other was for the rest of the building. She lost a large number of staff at that time, and had to cut the schedule and has not been able to find or keep what she called quality staff.

This violation represents non-compliance investigated under Complaint Number OH00168899.

Based on observation, interview and record review, the facility failed to use proper hand hygiene to reduce and prevent the risk of infection during medication administration. This affected five residents (#105, #125, #150, #155, and #160 observed during medication administration of 43 residents who receive medication administration from facility staff. The facility census was 49.

Findings include:

On 02/03/26 at 7:35 A.M. an observation of Licensed Practical Nurse (LPN) #618 revealed she did not perform hand hygiene with soap and water or an alcohol-based hand sanitizer before or after preparing medications for Resident #105. This was confirmed by LPN #618 on 02/03/26 at 8:08 A.M.

On 02/03/26 at 7:53 A.M., an observation of LPN #618 revealed she did not perform hand hygiene with soap and water or an alcohol-based hand sanitizer before or after preparing medications for Resident #125. This was confirmed by LPN #618 on 02/03/26 at 8:08 A.M.

On 02/03/26 at 7:56 A.M., an observation of LPN #618 revealed she did not perform hand hygiene with soap and water or an alcohol-based hand sanitizer before preparing medications for Resident #150. This was confirmed by LPN #618 on 02/03/26 at 8:08 A.M.

On 02/03/26 at 7:59 A.M., an observation of LPN #618 revealed she did not perform hand hygiene with soap and water or an alcohol-based hand sanitizer after preparing medications for Resident #155. This was confirmed by LPN #618 on 02/03/26 at 8:08 A.M.

On 02/03/26 at 8:00 A.M., an observation revealed LPN #618 preparing medication and administering oral medications and insulin for Resident #160. The LPN did not perform hand hygiene before applying gloves or after removing gloves prior to administering insulin. After administering insulin, the LPN used an alcohol pad, which she was holding with the paper wrapper to wipe the injection site. At that time, the wrapper was rubbed across the injection site as well. This was confirmed by LPN #618 on 02/03/26 at 8:08 A.M.

On 02/03/26 at 8:08 A.M., an interview with LPN #618 confirmed she had not performed hand hygiene correctly throughout medication pass with Residents #105, #125, #150, #155, and #160. She acknowledged she did not wash her hands prior to and after applying gloves, and kept the wrapper for the alcohol in her hand to keep it clean, however it had touched Resident #160's skin when she used it. She did have hand sanitizer available on her medication cart at the time of the medication pass.

Review of a facility policy titled Hand Hygiene Policy, dated 02/26/25, revealed it was the policy of the facility for appropriate hand hygiene to be performed by staff to prevent the spread of infection. Hand hygiene was the most important procedure for preventing healthcare associated infections. If hands were not visibly soiled, staff should use an alcohol-based hand rub for decontaminating hands in all clinical situations.

Review of a facility policy titled Infection Control Policy, dated 04/09/25, revealed standard precautions and infection control were important to help reduce the spread of communicable diseases. Good hand washing, use of gloves, disposing of used items and the cleaning of equipment after use would guard against the spread of germs/infection. This level of precautions should be used with all patient care unless a higher level of precaution was indicated.

The policy further indicated staff members should perform hand hygiene prior to having contact with residents, before putting on gloves, and before administering medications. Staff should perform hand hygiene after having contact with a resident's skin, having contact with resident's items such as dressings, laundry or trash, and after taking off gloves.

Based on record review and interview, the facility failed to establish and implement an effective water management program to identify hazardous conditions, and take steps to manage the risk of occurrence and transmission of waterborne pathogens, including but not limited to Legionella. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

Record review revealed no evidence of a water management program within the facility. This was confirmed by the Director of Resident Services on 02/04/26 at 4:00 P.M.

On 02/04/26 at 4:00 P.M., an interview with the Director of Resident Services (DRS) revealed the facility did not have a water management program to monitor and prevent the occurrence of water borne pathogens such as Legionella.

Based on record review and interview, the facility failed to properly evacuate all residents who were ambulatory during fire drills. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

Review of monthly fire drills for April 2025 through January 2026 failed to reveal the facility evacuated all residents who were ambulatory during two of three fire drills on each shift. There were no fire drills which indicated the residents were evacuated to the exterior of the building or moved to a safe location. This was confirmed on 02/04/26 at 4:00 P.M. by the Director of Resident Services (DRS).

On 02/04/26 at 4:00 P.M., an interview with the Director of Resident Services (DRS) revealed the facility had not evacuated all ambulatory residents or moved them to a safe location during fire drills from April 2025 through January 2026.

Based on observation and interview, the facility failed to post in a conspicuous place in each section or floor of the residential care facility a correctly oriented wall-specific floor plan designating room use, evacuation routes and exits, and flow of resident evacuation. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

On 02/02/26 at 11:30 A.M., an observation of a small bulletin board outside the ground floor dining room revealed an evacuation route sign which did not show a locator indicating You are here. The sign was partially covered by a Resident Bill of Rights booklet. This was the only evacuation plan sign found on the ground floor of the facility which contained a large formal dining room, a community room, multiple administrative offices, a public restroom, the kitchen and main resident dining room. This was confirmed at the time of the observation by the Deputy Executive Director (DED).

On 02/02/26 at 11:45 A.M., an observation of an evacuation plan sign located on a cabinet in the laundry room indicated two separate You are here locators with two separate evacuation routes. The sign was not in the proper orientation. This was confirmed by Laundry Staff #611 at the time of observation.

On 02/02/26 at 11:50 A.M., an observation of the first-floor bulletin board revealed an evacuation plan sign which did not have a locator icon. The sign was not in the proper orientation. This was confirmed by the Admissions and Activities Director (AA) on 02/02/26 at 1:10 P.M.

On 02/02/26 at 12:27 P.M., an observation of an evacuation plan sign located outside of Room 102 revealed there were three areas marked with a you are here locator, with three separate escape routes. The sign was not in the proper orientation. This was confirmed by Maintenance Staff #635 at the time of the observation.

On 02/02/26 at 1:00 P.M., an observation of the Straker Center, as well as the two restrooms and three offices contained within, failed to reveal any evacuation signage. This was confirmed by AA at the time of observation.

On 02/02/26 at 1:00 P.M., an interview with AA revealed the facility had been working on new emergency evacuation signs. She thought they were somewhere in the building, but was not sure where. She confirmed there was no signage in the Straker Center, as well as confirmed most of the evacuation signage within the building was either outdated, mislabeled, or in the incorrect orientation.

Based on record review and interview, the facility failed to conduct at least a monthly fire safety inspection which was recorded on forms provided by the Ohio Department of Health. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

Review of the facility form titled Self-Inspection Form-fire safety revealed the facility was not documenting on the current form provided. The form the facility was using was last revised 10/28/98. The accurate form to be used was revised 03/04/24. This was confirmed on 02/04/26 at 4:00 P.M. by the Director of Resident Services.

On 02/04/26 at 4:00 P.M., an interview with the Director of Resident Services (DRS) revealed the facility used the incorrect form to document the monthly fire self-inspections.

Based on record review and interview, the facility failed to maintain written transfer agreements with other facilities that would meet the needs of residents required transfer because their health and safety could be adversely affected by conditions in the facility. This had the potential to affect all residents of the facility. The facility census was 49.

Findings include:

Review of a facility form titled Transfer agreement dated 06/22 (no effective day noted), revealed a contract with the local hospital for timely admissions of patients who develop complications or require inpatient medical treatment. This agreement covered medically compromised residents and did not cover the transfer of facility residents in the event of an emergency at the facility which would require evacuation residents. This contract was confirmed by the Deputy Executive Director on 02/02/26 at 4:20 P.M.

Review of a facility document titled Evacuation Plans, dated 06/25, revealed the facility had an agreement with a local hospital which allowed residents who needed hospitalization from an emergency caused by an evacuation of the the facility to be transferred to the hospital. The home had informal arrangements with a local church in which to temporarily shelter evacuated residents.

On 02/02/26 at 4:20 P.M., an Interview with the Deputy Executive Director (DED) revealed the contract with Genesis Healthcare was the only transfer contract the facility currently had. Previously they had an agreement with another Residential Care Facility, however that company was purchased so the contract was no longer valid. The contract with Genesis was an agreement to take a sick resident who met acute inpatient criteria to be hospitalized. It did not include emergency shelter or placement for residents in the event of an emergency for the facility. At the time of survey, the facility had no other agreements or contractual arrangements for transfers of the residents in the event of an emergency.

Based on observation and interview, the facility failed to ensure the main elevator of the facility was safe to prevent resident injury and provided direction to residents in the case of an emergency. This had the potential to affect all residents within the facility. The facility census was 49.

Findings include:

On 02/02/26 at 11:00 A.M., an observation of the main elevator of the facility revealed there was no signage inside the elevator indicating what to do in the event of an emergency. The red emergency button had all wording on it rubbed off and could not be read and it appeared to be melted. The G (ground floor) button which was covered in plastic was broken with sharp plastic shards. The call button on the ground floor of the building was also broken. This was confirmed by Activity Associate #608 on 02/02/26 at 1:15 P.M.

On 02/02/26 at 1:15 P.M., an interview with Activity Associate #631 confirmed the elevator did not have any signage for emergencies. She could not tell what the red button would be for since the words were missing. She confirmed the G button on the elevator was broken and had sharp plastic pieces on it.

On 02/02/26 at 3:00 P.M., an interview with the Deputy Executive Director (DED) revealed she was aware the buttons on the elevator were broken. She did not realize there were no instructions for what to do in the event of an emergency within the elevator. The facility did not have any policies regarding the elevator or elevator maintenance. She indicated it was difficult to get the elevator repair company to the facility.

Based on review of policies and procedures and staff interview, the facility failed to develop written policies and procedure for homes infection prevention and control program, and failed to ensure infections were monitored. This had the potential to affect all 39 residents residing in the facility.

Findings include:

Review of the facility's policies and procedures revealed no evidence the facility had developed a written policy and procedure for the homes infection prevention and control program.

There was no documented evidence that the facility had been monitoring infections per the regulation.

Interview on 04/09/25 at 1:26 P.M., with the Executive Director (ED)/Infection Preventionist (IP) confirmed the facility had not developed or implemented written policies and procedures for the homes infection prevention and control program. The ED/IP confirmed the facility has not been monitoring infections, except she had reported COVID cases to the local health department. The ED reported she was just recently made aware of the regulation requirement last week.

Based on observation of puree meal preparation and interviews, the facility failed to ensure sanitary conditions were maintained during the puree preparation. This had the potential to affect five (#1, #4, #18, #38, and #39) of five residents who received pureed lunch meals.

Findings include:

1a. Observation on 04/09/25 10:41 A.M., of lunch puree preparation with Dietary Manger #100 and Dietary Cook #101 revealed the cook had used the robot coupe (food processor) to puree the beef, and then a dietary staff member took the bowl, lid wiper, and blade and ran them through the dishwasher to re-use for the next food item. The cook then used the robot coupe bowl, lid wiper, and blade to prepare the scalloped potatoes without letting the parts to air dry. The Cook and Dietary Manger placed one pureed serving of scalloped potatoes in five small bowl and placed a lid on the bowl and placed the five bowls in a pan on the steam table. After pureeing the scalloped potatoes, a dietary staff placed the bowl, lid wiper, and blade in the dishwasher to use for the next food item. The Cook began to pour the vegetables into the robot coupe bowl and the surveyor intervened and asked Cook #101 to observe the robot coupe bowl to see if she noticed anything. The Cook replied, no. The surveyor asked the cook if there was still water inside the robot coupe bowl, and she responded yes. The Cook then removed the bowl from the robot coupe and took a towel and dried out the side of the bowl. The surveyor asked the Cook if that was the proper way to dry the bowl and the Dietary Manger intervened and replied no the bowl should have air dried. The Cook reported she was unaware of the robot coupe had to air dry between users and she could not use a towel to dry it.

1b. An additional observation during lunch puree revealed Cook #101 had laid a scoop on a small paper tablet with writing on it that was lying on the prep table. The cook then picked up the scoop to scoop out the beef from the robot coup bowl. The surveyor intervened.

Interview with Cook #101 during the time of the observation confirmed she had laid the scoop on a contaminated surface (paper tablet) and was going to use the scoop out scalloped potatoes before the surveyor intervened.

1c. Cook #101 washed her hands in between the puree lunch meal preparation and dried her hand with a paper towel. The Cook then walked over to the puree prep table and used the same paper towel she used to dry her hands and wiped down the food prep area where she was preparing the puree meals. Findings confirmed the Cook #100 during observation.

Based on medical record review, observation, interviews and policy review, the facility failed to ensure water temperatures in resident rooms were maintained between 105-120 degrees Fahrenheit. This potentially affected all 14 residents (#1, #3, #4, #11, #18, #19, #20, #21 #22, #29, #31, #32, #38, and #39) of 14 residing on the Shinick Unit (unit with cognition impairment residents/elopement risk).

Findings included:

1. Observation on 04/07/25 at 1:03 P.M. of water temperature in resident rooms sinks with Maintenance #102 revealed the water temperature at point of service in unoccupied room 208 (at the end of the hall) was 83.0 degrees Fahrenheit, and Resident #31's (Room 209 at the end of the hallway) was 83.0 degrees Fahrenheit. Maintenance #102 confirmed findings during the observation. Maintenance #102 confirmed the two hot water tanks on the ground floor supplied hot water to the first-floor resident rooms and resident rooms 201-219 (Shinick Unit) on the second floor. Maintenance #102 confirmed the residents on Shinick had cognition impairment, and there were doors with a WanderGuard system (a system designed to protect at risk residents, often those with dementia, from wandering outside of a secure area) placed at the entrance of the unit; however, the doors were not locked.

Additional observation with Maintenance #102 of the hot water tanks on the ground floor revealed the two tanks were confected. Maintenance #102 used an infrared thermometer laser gun and pointed the gun to a black spot painted on the pipe to obtain the water temperature. The temperature ranges varied, and the gun was not able to provide an accurate temperature.

2. Medical record review revealed Residents #1, #3, #4, #11, #19, #20, #21, #38, and #39 had severe cognitive impairment. Residents #29, #31, and #32 had moderate cognitive impairment, and Residents #22 and #18's cognition was intact. Residents #1, #22, #31, #29, #21, #19, #32, #20, and #3 were ambulatory without staff assistance.

Observation on 04/09/25 at 8:48 A.M., of random water temperatures in resident bathroom sinks on the Shinick Unit with Maintenance #102 revealed room 218 was 124 degrees Fahrenheit, room 213 was 123 degrees Fahrenheit, room 202 was 123 degrees Fahrenheit, and the whirlpool room was 127 degrees Fahrenheit. Maintenance #102 reported that he did not have time to complete an audit of water temperatures on the second floor after concerns were identified on 04/07/25. The facility had adjusted the temperature on the hot water tanks on the ground floor, which fed water to the second floor.

The residents in rooms 218, 213, and 202 were not able to be interviewed due to severe cognitive impairment.

Interview on 04/08/25 at 8:48 A.M., with the Nurse Aide Supervision (NAS) #103 confirmed all the residents on the Shinick unit had cognitive impairment. The NAS reported all the residents showered in the whirlpool room (water temperature was 127 degrees Fahrenheit). The NAS reported she was unaware of any concerns related to water temperatures issues on the unit.

Interview on 04/09/25 at 9:54 A.M., with the Maintenance Director (MD) reported the water tanks temperatures were checked weekly at the pipe where the two water heaters were connected. The facility uses an infrared thermometer laser gun and points the gun to a black spot painted on the pipe to obtain the water temperature. The facility doesn't monitor water temperatures in resident rooms at the point of service. The MD confirmed the two hot water tanks feed water to the ground floor (office and dining room), the first-floor resident rooms, and resident rooms 201-219 on the second floor. The other section of the second floor is where resident rooms (249-253) have individual water tanks in the room. The MD reported he thought the issue was he had stopped using the circulatory pump a while ago and the water in pipes were not continuing circulating.

Review of the facility's policy titled Water Temperatures Policy dated 06/02/16 revealed it was the facility's policy to monitor water temperatures weekly. The water temperature would be checked at the tempering devices. The temperature would be adjusted as needed to reach the goal temperature of 119. Report to the resident service director if unable to maintain temperature.

Based on personnel file review and interview, the facility failed to ensure all staff were checked against the nurse aide registry for abuse. This had the potential to affect 37 of 37 residents residing in the facility.

Finding include:

1. Review of the personnel file for Licensed Practical Nurse (LPN) #113 revealed no evidence she was checked against the nurse aide registry.

2. Review of the personnel file for LPN #130 revealed no evidence she was checked against the nurse aide registry.

Interview on 01/28/25 at 11:21 A.M. with Deputy Executive Director (DED) #101 revealed she was unaware all staff had to be checked against the nurse aide registry.

This violation represents an incidental finding of non-compliance investigated under Complaint Number OH00161480.

Based on record review and interviews, the facility failed to ensure a resident was treated with dignity and respect at all times. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 37.

Findings include:

Record review revealed Resident #22 was admitted to the facility on 08/16/22 with diagnoses including seizures, hypertension, polymyalgia rheumatica, and dementia.

Review of a service plan completed on 09/03/24 revealed Resident #22 had mildly impaired cognition.

Review of a statement dated 01/03/25 by Nurse Aide Supervisor (NAS) #200 revealed Nurse Aide (NA) #203 approached her and stated Resident #22 told NA #203 someone was rough with her. NAS #200 spoke with Resident #22 who was a little confused but did state someone was rough during care. Resident #22 could not recall any details.

Review of a statement dated 01/03/25 by NA #203 revealed on 12/25/24 she was talking to Resident #22 who was seated in her recliner, shaking. Resident #22 was speaking quietly and stated, those two girls that worked last night. NA #203 asked what happened and Resident #22 informed her the aides were rough with care and tossed her on the bed, didn't change her clothes, and she slept in the same clothes she wore all day. A couple days later, Resident #22's family was visiting and expressed they did not feel like anyone was listening to their concerns.

Review of a statement from the director of nursing (DON) dated 01/07/25 revealed she had been informed Resident #22 had a skin tear from a nurse aide's ring. The DON spoke with the unspecified nurse aide, who removed the ring immediately.

Review of a statement dated 01/08/25 revealed NA #201 went into Resident #22's room and the resident stated evening shift had refused to put pajama pants on her because she would just wet them anyway. Resident #22 had been incontinent at the time of the interaction.

Review of a statement from the DON dated 01/09/25 revealed staff were informed Resident #22 should be assisted to her recliner after meals if requested.

Review of a statement from the DON dated 01/09/25 revealed staff were informed of the proper evening care each resident needed, including washing face, washing hands, washing peri-area, brushing teeth, and changing clothing. Additionally, if a resident is incontinent and gets changed in bed, they are to sleep in a hospital gown but if a resident is transferred to the toilet they can wear clothes of their choosing despite incontinence status.

Review of a statement from Deputy Executive Director (DED) #101 dated 01/09/25 revealed a meeting was held with Resident #22's family regarding an investigation into abuse towards the resident. Resident #22 was allegedly afraid to be at the facility. Family was informed there had to be evidence to substantiate a complaint of abuse and they were working on the investigation.

Review of a statement from Executive Director (ED) dated 01/09/25 revealed a meeting was held with Resident #22's family regarding concerns of potential abuse but informed the family they had second-hand information with no real evidence to substantiate claims, but the investigation was ongoing.

Review of an undated statement by NAS #200 revealed on 12/29/24, she went to the room of Resident #22 after the resident's daughter yelled at an aide. While in the room, Resident #22 stated staff were rough with her during transfers when they do not use the sit-to-stand lift. Resident #22 stated the staff hold her and sling her around and she is truly afraid when that happens. Resident #22 gave descriptions of the staff including one had dark hair and skin, and the other was heavy-set with short blonde hair.

Review of an educational posting dated 01/13/25 revealed nursing staff were not to leave medication unattended in resident rooms and should stay to watch the residents take their medicine.

Review of a statement dated 01/13/25 by DED #101 revealed after reviewing statements and speaking with Resident #22, who states she is happy with her care, the allegations of abuse were unsubstantiated.

Interview on 01/28/25 at 8:15 A.M. with DED #101 revealed there was a meeting with Resident #22's family regarding some incidents and a copy of the meeting minutes was provided. The minutes revealed there was an ongoing investigation into concerns of potential abuse.

Interview on 01/28/25 at 8:41 A.M. with DED #101 revealed abuse policy education to all staff had not been completed yet because they were trying to set up an all staff meeting for all educations at once so staff do not have to come in all the time. There was not a date set for education. DED #101 stated staff who were working at the time the allegations of abuse were made were immediately interviewed and educated, but there was no evidence of this education. When asked if the incident was reported to the Health Director, DED #101 stated Residential Care Facilities (RCFs) do not have to report allegations of abuse unless they are substantiated.

Interview on 01/28/25 at 10:35 A.M. with Resident #22 revealed she had no concerns with care, staff were not rough with her, and they treated her with dignity and respect.

Interview on 01/28/25 at 11:21 A.M. with DED #101 confirmed there was no evidence a resident assessment was completed, like residents were interviewed or assessed, and no evidence of the re-education on abuse policies.

Review of the facility Abuse policy (dated 03/18/16 and revised 06/01/22) revealed abuse is physically and emotionally harming or intentionally placing another in fear of harm. In the area of Investigate the policy revealed if any suspicious signs are found or verbal statements made by the resident or their responsible party concerning care, neglect, or misappropriation of property, an immediate report is to be made to the Charge Nurse. Both the reporting person and Charge Nurse then report to the Resident Health Director promptly and an investigation made. If a resident or their responsible party has raised a specific allegation that is not readily satisfied upon discussion with the Resident Health Director, the Executive Director is to be immediately notified. Upon clarification of the allegation with the resident/responsible party, the Executive Director will file a preliminary report with the Ohio Department of Health. In the area of Reporting the policy revealed if the investigation indicates the likelihood of abuse, the Resident Health Director should see that the Charge Nurse records this in the incident report. The Resident Health Director should report the incident to the Executive Director along with any additional findings. The Executive Director will file a report with the Ohio Department of Health. If a particular employee is suspected the Charge Nurse should assign someone else to the patient to ease the situation. The Resident Health Director will follow established resident grievance procedures after compiling all related investigative information.

This violation represents non-compliance investigated under Complaint Number OH00161480.