F0609

D

Failure to Report Alleged Abuse, Neglect, and Injury of Unknown Origin

North Canton, Ohio Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse, neglect, and injury-of-unknown-origin reporting policy in multiple situations. One cognitively intact resident with significant cardiopulmonary diagnoses, including ischemic cardiomyopathy, acute respiratory failure with hypoxia, chronic atrial fibrillation, COPD with acute exacerbation, and diabetes, had an order for continuous oxygen via nasal cannula. The resident reported that, after falling asleep in his motorized wheelchair, his portable oxygen battery lost charge and he became short of breath. He stated that when he urgently requested help from a CNA to change the battery, she told him not to be rude, changed the battery but did not turn the oxygen machine back on, and then told him to turn it on himself when he asked her to do so. The resident reported he then sought help from other CNAs on another hall, who turned the oxygen on and assisted him, and that he felt the CNA’s actions were an act of abuse and attempted murder, leading him to call 911. He reported this allegation to a unit manager LPN, who acknowledged being told of the incident and the resident’s belief that it was attempted murder, but did not report it to the Administrator. The facility did not self-report this allegation to the State Agency, and there was no nursing progress note or respiratory assessment documenting the incident.

The deficiency also includes the facility’s failure to identify and report an injury of unknown origin for a resident with adult failure to thrive, paranoid schizophrenia, and dementia, who had severely impaired cognition. A nurse practitioner note shortly before the survey documented intact skin with no bruising, and the resident was not on anticoagulant or antiplatelet therapy. During observation, surveyors noted a purplish-red, circular bruise approximately the size of a half dollar on the resident’s right forearm, which the resident could not explain. A subsequent observation showed the bruise diminishing in size and color. The Director of Resident Services and Regional Director of Clinical Services confirmed the presence of the bruise and that staff had not documented it or completed an assessment. An LPN reported she had noticed the bruise but believed it was old, marked “no new skin issues” on the shower sheet, and did not report the bruise or complete any statements, despite the facility policy requiring investigation and reporting of injuries of unknown source.

A further component of the deficiency concerns staff concerns and alleged neglect of care for another resident receiving hospice services, who had severely impaired cognition, was dependent on staff for toileting, and was occasionally incontinent of bowel. The resident’s care plan required staff assistance with ADLs and specified that the resident would be kept clean and well groomed, with staff treating the resident respectfully during care. Undated photographs submitted via a complaint to the State Agency showed an unidentified male, identified in the complaint as this resident, naked and covered in dried brown feces. The Administrator and DON stated they were unaware of pictures taken by staff of this resident during care. One CNA reported that another CNA had spoken to him about taking pictures of the resident to send to the State Agency, but he did not report this to his supervisor or the DON, assuming nursing staff at the nurse’s station had heard the conversation. An LPN also reported hearing rumors that an aide took pictures and was sending them to the State regarding lack of care for residents, but she did not inform the DON. These events occurred despite a written facility policy requiring staff to immediately report all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source to the Administrator and the State Agency.