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F0609
E

Failure to Report Alleged Neglect by Impaired Nurse

Toledo, Ohio Survey Completed on 12-22-2025

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 an allegation of neglect involving a nurse to the State Survey Agency, Ohio Department of Health, as required by policy. On the night in question, an LPN arrived for work, received report, and then left the facility with another LPN and a CNA to go to a gas station, returning after approximately 15 minutes. During this shift, a resident called 9-1-1 to report that the nurse was intoxicated and smelled of alcohol. Upon police arrival, the LPN exhibited signs of impairment, including glossy eyes and slurred speech, and was subsequently arrested for disorderly conduct due to public intoxication. The police requested that the RN on duty contact a supervisor, and administrative staff were notified. Despite the incident and the facility's policy requiring all alleged violations to be reported to the Administrator, state agency, and other required agencies within specified timeframes, the facility did not file a Self-Reported Incident (SRI) for this event. Staff interviews confirmed that the CNA observed the LPN's intoxication and attempted to notify the Administrator and RN on duty. The LPN was responsible for 13 residents during the shift in question. The failure to report the allegation of neglect as required constitutes the identified deficiency.

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