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F0609
D

Failure to Report Resident-to-Resident Verbal Abuse

Springfield, Ohio Survey Completed on 05-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of resident-to-resident verbal abuse to the Ohio Department of Health as required. Multiple staff members, including LPNs and a CNA, directly witnessed or were informed of incidents where one resident verbally abused other residents by using profane and offensive language. Despite these observations, staff did not report the incidents due to fear of retaliation or belief that management would not take action. The administrator confirmed a lack of awareness regarding these recent allegations and acknowledged that no self-reported incidents (SRIs) had been filed or investigations conducted for these events. Three residents with varying medical and cognitive conditions were affected by the unreported verbal abuse. One resident with schizophrenia, CHF, and diabetes was called profane names and reported feeling offended due to his religious beliefs. Another resident with cerebral infarction and major depressive disorder was subjected to cursing and derogatory remarks, while a third resident with COPD and alcohol-induced psychotic disorder experienced repeated verbal abuse and reported it to staff without any follow-up action. The resident responsible for the abuse had a documented history of behavioral problems, including yelling, inappropriate language, and aggression toward both staff and residents. Review of facility records, including care plans and physician orders, confirmed that interventions were in place to address behavioral issues, but these were not effectively implemented or followed up with required reporting. The facility's own policy mandates reporting allegations of abuse to the state agency, yet no SRIs were filed for the incidents in question, and no investigations were initiated. Staff interviews further corroborated that the abuse was ongoing and unaddressed, with multiple staff members admitting to witnessing or being aware of the incidents but failing to report them.

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