F0610

D

Failure to Investigate and Report Allegations of Neglect and Disrespectful Care

Gibsonburg, Ohio Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly act on and thoroughly investigate allegations of neglect and disrespectful treatment toward two cognitively impaired residents on the dementia unit. Resident #2, admitted with multiple diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, and hypertension, had a recent MDS showing severe cognitive impairment, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcers without current skin breakdown. Resident #3, admitted with Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder, had an MDS indicating severe cognitive impairment, behaviors directed at others, dependence for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development without current skin breakdown. Progress notes for both residents from October 2025 through February 2026 contained no documentation of any alleged incidents related to neglect or mistreatment.

According to a written statement dated 12/03/25 from Activity Assistant #300, CNA #400 repeatedly raised her voice at Resident #3, including telling the resident 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 while the resident was in her room. On another occasion, Resident #3 requested to use the restroom about 45 minutes after a prior toileting; CNA #400 responded in a demeaning tone, questioned whether the resident would actually go, and repeatedly told her to “hold on.” After five to ten minutes of continued requests, when the lunch cart arrived, CNA #400 told Resident #3 she could not be taken to the bathroom because it was lunch time and stated in front of others that it was okay because the resident was wearing a brief, leaving the resident clearly upset. AA #300 also reported that CNA #400 and CNA #401 recounted, as if humorous, an incident where CNA #401 took Resident #3’s stuffed dog (which the resident considers real), threw it in front of her, and told her the dog grew wings, causing the resident distress. AA #300 stated Resident #3 was regularly targeted and subjected to bullying and neglectful treatment.

AA #300 further reported that a few weeks prior, Resident #2, who was seated at a table with other residents, announced she needed to use the restroom. CNA #401 was assisting another resident, and CNA #400 told Resident #2 they would help her soon. Over the next hour, Resident #2 repeatedly asked to use the restroom while CNA #400, who was on her phone, continued to tell her she had to wait; Resident #2 repeatedly stated she was going to defecate in her pants and needed to go to the bathroom immediately. Despite these allegations, the Human Resources Director confirmed that when AA #300 submitted the written allegations on 12/03/25, no investigation was documented, the state survey agency was not notified, and the accused CNAs were not removed from the facility but instead reassigned to a different unit. This response was inconsistent with the facility’s Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, which requires immediate reporting to the administrator, notification of the state agency within 24 hours, removal of accused staff from the facility pending investigation, completion of an investigation within five working days, and documentation of resident assessment and notifications in the medical record.