F0609

D

Failure to Report and Investigate Allegations of Neglect and Verbal Mistreatment

Gibsonburg, Ohio Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report allegations of resident neglect to the state agency and to document an investigation, as required by its abuse and neglect policy. The facility’s policy dated 2016 states that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source must be immediately reported to the administrator or designee, and that the administrator or designee will notify the state survey agency of all such alleged violations within 24 hours of the allegation being made known to staff. Despite this policy, the Human Resources Director acknowledged that written allegations submitted by an Activity Assistant regarding staff treatment of residents on the dementia unit were not reported to the state agency and that no written investigation was completed.

Resident #2, admitted on 10/28/25, had diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. The most recent MDS showed severe cognitive impairment, no behaviors, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcer without current skin breakdown. Progress notes from October 2025 through February 2026 contained no documentation of alleged incidents. In the Activity Assistant’s written statement, she reported that Resident #2, while seated at a table with other residents, repeatedly stated she needed to use the restroom over the course of about an hour. CNA #401 was assisting another resident, and CNA #400, who was on her phone, repeatedly told Resident #2 she had to wait, while Resident #2 repeatedly said she was going to soil herself and needed the bathroom immediately.

Resident #3, admitted on 09/01/25, had diagnoses including Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. The MDS indicated severe cognitive impairment, behaviors directed at others, dependence on staff for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development with no current skin breakdown. The Activity Assistant’s statement described multiple occasions where CNA #400 raised her voice at Resident #3, including telling her she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet from down the hall. On another occasion, when Resident #3 requested to use the restroom about 45 minutes after a prior toileting, CNA #400 questioned her in a demeaning tone, delayed responding for 5–10 minutes, then refused to take her when the lunch cart arrived, telling her in front of others that it was acceptable because she was wearing a brief. The statement also described CNA #400 and CNA #401 recounting as a joke an incident where CNA #401 threw Resident #3’s stuffed dog in front of her, telling her the dog grew wings, which caused the resident distress. These allegations were not documented in the residents’ progress notes, not reported to the state agency, and not formally investigated by the facility.