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F0610
E

Failure to Thoroughly Investigate Alleged Resident 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 conduct a complete and thorough investigation into possible resident neglect by a nurse who was reported to be intoxicated while on duty. On the night in question, a resident called 9-1-1 to report that her nurse was intoxicated and smelled of alcohol. Police arrived and observed the LPN with glossy eyes, slurred and abnormal speech, and behaving in a disorderly manner, including speaking loudly and using vulgar language in front of residents. The LPN was subsequently arrested for disorderly conduct and public intoxication. Facility records showed that the LPN was responsible for the care of 13 residents during this shift. Despite the seriousness of the allegations and the facility's policy requiring immediate and thorough investigation of suspected neglect, the facility only interviewed two residents and did not assess or interview all 13 residents assigned to the LPN. The Director of Nursing reviewed medical records and medication administration records for these residents and determined that no medication or care had been provided by the LPN during the shift. However, the lack of direct assessment or interviews with all potentially affected residents constituted a failure to follow the facility's own investigative procedures.

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