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F0609
D

Failure to Timely Report Staff-to-Resident Verbal Abuse

Grand Rapids, Ohio Survey Completed on 09-30-2025

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

Staff failed to timely report an allegation of staff-to-resident verbal abuse involving a resident with vascular dementia, generalized anxiety disorder, and a history of stroke. The resident, who had moderate cognitive impairment and required total assistance with activities of daily living, exhibited a range of challenging behaviors, including throwing objects, smearing stool, and moving between rooms without assistance. During a dining room incident, a certified nursing assistant (CNA) became frustrated with the resident's behaviors and directed inappropriate, explicit, and demeaning language toward the resident in front of others. Multiple witnesses, including another staff member and residents, confirmed that the CNA called the resident derogatory names, made fun of him, and forced him to apologize to the dining room. Despite the presence of staff and witnesses, the incident was not immediately reported to facility management as required by facility policy. The administrator only became aware of the incident two days later when a visitor who witnessed the event reported it. Interviews with staff and review of witness statements revealed that at least one staff member present felt uncomfortable with the CNA's conduct but did not report the incident. The facility's policy required immediate reporting of all allegations or suspicions of abuse to the administrator or abuse coordinator, but this protocol was not followed in this case, resulting in a delay in addressing the alleged abuse.

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