Ohio Veterans Home

Penalty

No penalty information released

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 deficiency involves the facility’s failure to implement its abuse policies by not providing timely interventions and required notifications after an allegation of staff-to-resident verbal abuse. A resident with Alzheimer’s disease, dementia, anxiety, hypertension, dysphagia, and severe cognitive impairment, admitted in late August 2024, was the subject of a substantiated verbal abuse allegation involving a CNA who was observed speaking inappropriately to the resident. The incident was self-reported by the facility, and the resident’s family was notified of the allegation on the day it occurred. However, review of the medical record and facility documentation from the date of the incident through early February 2026 showed no evidence that the physician, social worker, or psychiatric services were notified in a timely manner, despite facility policy requiring such notifications and follow-up. Progress notes lacked documentation of any psychosocial assessment or psychiatric follow-up after the alleged abuse. Interviews with the DON, ADON, and LSW confirmed that social services and psychiatric services were not promptly informed and that psychiatric services were notified only several days later, contrary to facility policy that calls for immediate protection of the resident, examination for injury or psychosocial needs, and provision of emotional support and counseling as needed.

Penalty

No penalty information released

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 deficiency involves the facility’s failure to timely report and thoroughly investigate multiple allegations of staff-to-resident abuse, including verbal abuse, physical abuse, and force feeding, and to make required notifications to authorities and clinical team members. A self-reported incident documented that a CNA verbally abused a severely cognitively impaired resident during a lunch meal, leading to the CNA’s removal from duty and a substantiated finding of verbal abuse. However, the investigation did not include interviews with all staff present in the dining room at the time, and nurses’ notes for the involved resident showed no documentation of physician notification, social services follow-up, or timely psychiatric referral despite an intervention being listed. The facility’s own policies required immediate reporting of all alleged violations of abuse, comprehensive interviews of all involved persons, and documentation of actions taken in the medical record, which were not followed. During the investigation of the verbal abuse incident, multiple staff witness statements described additional, prior and ongoing allegations of abuse by the same CNA toward several residents, including residents with dementia, Alzheimer’s disease, severe cognitive impairment, dysphagia, and dependence on staff for feeding. Witnesses reported that the CNA yelled at residents, cursed at them to wake up and eat, was not compliant with diet orders, and force fed residents by pushing food into their mouths when they resisted. Staff also reported that the CNA awakened residents during meals using sternal rubs. These concerns were said to have been reported to various nurses, the ADON, the DON, and a nursing supervisor, yet there was no documentation that these additional allegations were investigated, no self-reported incidents were submitted for these residents, and no corresponding entries were found in the residents’ medical records regarding abuse allegations. Interviews with nursing and dietary staff further demonstrated that significant information about alleged abuse was not escalated or acted upon in accordance with facility policy. Some CNAs stated they had reported force feeding and yelling incidents to LPNs and supervisory nurses, while the LPNs denied receiving such reports or stated they did not report them because the CNA was already on administrative leave. A dietary staff member and dietary supervisor described prior reports to a nursing supervisor about the CNA being mean to residents and yelling at them, but no statements had been taken regarding those earlier incidents. The DON acknowledged she had not reviewed the witness statements, was not notified of force feeding allegations, and confirmed that no additional self-reported incidents were completed for the new allegations uncovered during the investigation. The social worker reported not being informed of the verbal abuse allegation until much later, and the ADON confirmed that required notifications to social services, physicians, and psychiatric services were delayed or not completed for residents with abuse allegations, contrary to facility policy. Additional residents identified in the witness statements, including those with dementia, aphasia, severe cognitive impairment, and dependence on staff for feeding, had no documentation in their nurse’s notes of any abuse allegations during the review period, and no SRIs were found for them. The ADON acknowledged awareness of an allegation that one resident had been force fed but stated she relied on the resident’s wife’s denial and did not report or further investigate the allegation. A nursing supervisor admitted awareness of force feeding allegations but did not report them because the CNA was already off work. Overall, the facility failed to identify, document, investigate, and report multiple allegations of abuse involving several residents, and failed to ensure required notifications and assessments were completed, despite clear policy directives to do so.

Penalty

No penalty information released

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 deficiency involves the facility’s failure to thoroughly investigate multiple allegations of staff-to-resident abuse, primarily related to one CNA, and to ensure required notifications and documentation occurred. For one resident with Alzheimer’s disease, dementia, anxiety, hypertension, and dysphagia, staff reported an allegation of verbal abuse by a CNA during a lunch meal. The CNA was observed by another CNA and dietary staff cursing and yelling at the resident to wake up and eat while the resident was sleeping in the dining room. Although the facility substantiated verbal abuse for this resident, the investigation did not include interviews with all staff present in the dining room, including the registered dietitian who was on the unit at the time. Nurse’s notes for this resident showed family notification of the verbal abuse allegation, but there was no documentation of physician notification, no follow-up with social services, and no documented contact with psychiatric services despite an intervention for a psychiatric consult being implemented. Additional allegations of abuse involving the same CNA and several other residents were reported by staff but were not fully investigated or documented. Multiple witness statements described the CNA force feeding residents and using sternal rubs to wake residents during meals. One CNA reported that the CNA had force fed two residents by forcing a spoon into their mouths when they resisted and had awakened two other residents during meals with sternal rubs; these incidents were reportedly told to two LPNs. Another CNA reported witnessing the CNA yelling at a resident and force feeding another resident, and stated he reported this to an LPN who then reported it to the ADON. Dietary staff reported that the CNA had cursed at residents and told residents to sit down and shut up or get their heads off the table, and that these concerns had been reported to a nursing supervisor. Despite these reports, there was no documentation that these additional allegations were investigated, no Self-Reported Incidents were submitted for the other residents named, and the involved CNA was not questioned about the additional abuse allegations. Review of medical records for several residents identified in staff statements showed no documentation of abuse allegations, no related nursing notes, and no SRIs for staff-to-resident abuse for those residents. Interviews with nursing staff and supervisors revealed inconsistent awareness and follow-through on the reported concerns. One nursing supervisor acknowledged being aware of force-feeding allegations but did not report them because the CNA was already on administrative leave. The DON stated she had not reviewed the witness statements, had not been notified of force-feeding allegations, and confirmed that additional allegations discovered during the investigation were not reported or investigated and that required notifications and assessments were not completed. The facility’s own policies required immediate reporting of all alleged abuse, identification and interviewing of all involved persons and witnesses, notification of the Administrator, physician, family/legal representative, and police department as applicable, and thorough documentation of investigations and resident monitoring, but these steps were not carried out for the multiple allegations that arose during and around the initial verbal abuse incident. Video surveillance of the lunch meal where the initial verbal abuse allegation occurred showed the presence of multiple staff, including the CNA accused of abuse, other CNAs, an LPN, the speech therapist, the registered dietitian, and dietary staff, but the dietitian was never interviewed. Staff interviews further showed that some nurses denied receiving reports of abuse that CNAs stated they had made, and that social services and psychiatric services were not promptly notified of the verbal abuse allegation involving the cognitively impaired resident. The licensed social worker reported she was not informed of the allegation until much later, despite the expectation that she be notified of abuse allegations. The ADON acknowledged awareness of a force-feeding allegation involving a former resident but confirmed it was neither reported nor further investigated. Collectively, these actions and omissions demonstrate that the facility did not follow its abuse reporting and investigation policies, did not fully investigate all reported allegations, and did not ensure appropriate documentation and notifications for the residents involved. The facility’s written policies on Reporting Allegation of Abuse/Neglect/Exploitation and Abuse, Neglect, Exploitation required that all alleged violations of abuse be reported immediately, that all involved persons and witnesses be identified and interviewed, that the alleged victim be examined and monitored, and that complete and thorough documentation be maintained. The policies also required notification of the Administrator, facility police department, physician, and resident’s family or legal representative, as well as psychosocial assessment and emotional support as needed. In this case, the facility did not adhere to these requirements for the multiple allegations that surfaced, including those related to verbal abuse, force feeding, and inappropriate use of sternal rubs, resulting in an incomplete and insufficient investigation of alleged staff-to-resident abuse affecting multiple residents on the unit.

Penalty

No penalty information released

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 ensure that food items were provided according to physician-ordered diet textures for a resident with dysphagia and severe cognitive impairment. The resident had multiple diagnoses including hemiplegia, dementia, type 2 diabetes mellitus, chronic kidney disease, and dysphagia, and was care planned for a high-protein, pureed diet with nectar-thick liquids, along with direct 1:1 supervision, small bites, slowed rate of intake, and alternating food and fluids every few bites. Physician orders specified a high-protein, pureed texture diet with nectar consistency and direct one-to-one supervision during intake due to a history of suspected aspiration/penetration episodes. Despite these orders and care plan interventions, a CNA provided the resident with a whole banana, which did not conform to the ordered pureed texture and was given without the required direct supervision by the speech therapist. Multiple staff statements and interviews confirmed that the CNA had a pattern of serving residents food items not consistent with their diet orders and that she had given this resident a whole banana. The CNA reported she believed she had approval from the speech therapist to provide such items if the resident was awake and alert, but the speech therapist denied ever authorizing the resident to receive a banana without his direct supervision. The speech therapist acknowledged he did not assess the resident after learning of the incident and only reported it to a nursing supervisor. Further review of the medical record and nursing documentation showed there was no respiratory assessment completed for the resident after receiving the incorrect food texture. The facility’s dysphagia policy required food service and nursing staff to follow written diet and fluid consistency orders, but this was not followed in this case.

Penalty

No penalty information released

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

Facility staff failed to protect a resident from staff-to-resident verbal and physical abuse. An LPN was observed by a CNA aggressively pushing a resident in a wheelchair out of his room, swearing at him, and continuing to push him toward the nurses' station while the resident attempted to resist by reaching out his arms, placing his feet on the ground, and yelling 'no.' The LPN hit the resident's arm, pulled on the back of his shirt, and then forcefully pushed the resident in his wheelchair into a recliner, causing the resident to fly forward, hit the recliner, and land on the floor. While the resident was on the floor, the LPN attempted to pick him up by the back of his pants, and later kicked the back of the resident's right leg while sitting in the resident's wheelchair next to him. The CNA who witnessed the incident did not intervene to protect the resident or call for additional help. The LPN continued to work on the Memory Care Unit after the incident until the CNA reported the abuse to the RN Supervisor. During this time, the resident was agitated and upset, attempting to get away from the LPN. The resident sustained three skin tears to the bilateral upper extremities. The failure to immediately remove the LPN from the unit placed all residents on the Memory Care Unit at risk for abuse. The resident involved had a history of Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder, with severe cognitive impairment and frequent incontinence. The care plan indicated the resident could be non-compliant and resistive to care, and required substantial assistance with activities of daily living. The incident was substantiated by video surveillance, staff statements, and medical record review, confirming the occurrence of both verbal and physical abuse by the LPN and the lack of timely intervention by other staff.

Removal Plan

• CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700.
• Off duty RN Supervisor #772 called to report the allegation of abuse to the police department.
• RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor.
• Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse.
• ADON #549 notified the DON of the allegation of abuse.
• RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse.
• RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit.
• RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed.
• Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400.
• The DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately.
• LPN #602 was also informed to report to the Police Department for questioning and interviewing.
• RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment.
• RN #740 emailed a request for psychiatric services to evaluate Resident #241.
• ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit.
• LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before.
• RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift nursing staff.
• ADON #549 notified Resident #241's guardian of the allegation of abuse.
• ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241.
• The Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457.
• Psychiatric services responded to an email indicating they would evaluate Resident #241; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention.
• ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education.
• LPN #602 reported to the police department and was interviewed by Lieutenant #457.
• The Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse.
• Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241.
• Resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks.
• Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit.
• Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required.
• Resident Safety Monitoring was completed for five residents.
• Education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed.
• The QAPI Committee met via TEAMS to discuss this allegation of abuse and the mitigation items put into place.
• Psychiatric services evaluated Resident #241 with no new recommendations.
• The Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy.
• Interviews with 15 staff verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge.

Penalty

No penalty information released

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

A deficiency occurred when a resident, who was severely cognitively impaired and required extensive assistance of two staff members for all activities of daily living, including transfers, was transferred by a single staff member using a mechanical lift. The resident's care plan and physician orders specifically required two-person assistance for all transfers, and facility policy mandated two staff for all full body mechanical lift transfers. Despite these clear directives, the staff member performed the transfer alone. The incident was discovered after the resident was observed with signs of pain, bruising, and a deformity to the right knee. Subsequent assessment and x-rays confirmed a supracondylar femur fracture. The resident was unable to communicate how the injury occurred due to severe cognitive impairment. Video footage and investigation confirmed that the staff member entered the resident's room alone with the lift and completed the transfer without assistance, directly violating the care plan, physician orders, and facility policy. The staff member involved had previously been deemed capable of performing resident transfers according to her skills checklist. However, interviews and investigation findings established that she failed to follow required procedures, resulting in actual harm to the resident. The deficiency affected one of three residents reviewed for accidents in a facility with a census of 223.

Penalty

No penalty information released

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 protect residents from verbal and physical abuse, as evidenced by multiple incidents involving a certified nurse aide (CNA). One resident with severe cognitive impairment and multiple diagnoses, including dementia and depression, was subjected to deliberate agitation by a CNA during a shower, resulting in the resident spitting at the CNA, who then retaliated by throwing a towel at the resident's face and head. This incident was substantiated through staff witness reports and facility investigation. Additional incidents involved the same CNA exhaling vapor from a nicotine vaping pen into the face of another severely cognitively impaired resident during incontinence care, and verbally abusing a third resident by telling them to "go find a bridge to jump off of" when the resident expressed confusion in the hallway. These actions were reported by another CNA and confirmed through interviews and investigation. The facility's policy prohibits abuse, neglect, and exploitation, but these events demonstrated a failure to ensure residents were free from such mistreatment.

Penalty

No penalty information released

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

A deficiency occurred when a resident, who was cognitively intact and required hands-on assistance for activities of daily living, reported a significant amount of money missing from their wallet. The resident alleged that the theft was committed by a nurse aide from a staffing agency. The facility became aware of the claim and initiated an investigation, which included interviews with the resident and all staff present at the time of the alleged incident, as well as a review of medical records. During the investigation, a certified nurse aide confessed to taking the resident's money from the wallet that was hanging on the resident's wheelchair while in the room. Further investigation by the facility's police force led to the discovery of a bag containing the stolen money in the nurse aide's vehicle. The aide admitted to taking the funds, and this confession was documented in a statement by the facility's police department. The incident was also reported in local news, and the aide was subsequently charged with theft from the elderly. The facility's policy prohibits and aims to prevent abuse, neglect, exploitation, and misappropriation of resident property, but in this instance, the policy was not effectively upheld, resulting in the misappropriation of the resident's funds.

Penalty

No penalty information released

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

A deficiency occurred when the facility failed to timely report an allegation of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, and depression. The incident involved a Certified Nurse Aide (CNA) who, after being spit on by the resident during a shower, retaliated by throwing a towel at the resident, striking the resident in the face and head area. The event was witnessed by staff and documented in a self-reported incident (SRI) and investigation documents. Despite the facility's policy requiring immediate reporting of abuse allegations to the State Survey Agency and other authorities, the incident was not reported until more than a month after it occurred. An interview with the current Administrator confirmed that the previous Administrator did not fulfill the obligation to report the incident in a timely manner, as required by facility policy and state law.

Penalty

No penalty information released

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 adequately assess a resident for unsupervised smoking and did not adhere to its smoking policy, which led to a fire incident. The resident in question, who had a history of paranoid schizophrenia, cognitive impairment, and other medical conditions, was allowed to smoke unsupervised. Despite having a physician's order for oxygen use, the resident was assessed as a safe smoker without considering his medical and mental health conditions. The smoking assessment form used by the facility did not require evaluation of these critical factors, leading to the resident being classified as an unsupervised smoker. On the day of the incident, the resident was observed on video surveillance entering an auditorium, where he started a fire using tissues and a lighter. The fire was quickly extinguished by staff, and the resident was found with cigarettes and a lighter in his possession. Despite the resident's cognitive impairment and history of hallucinations, the facility's smoking assessment did not account for these issues, allowing the resident to maintain smoking materials unsupervised. Interviews with staff revealed inconsistencies in the smoking assessment process and a lack of clarity in the smoking policy. The facility's policy did not provide clear guidelines on evaluating medical conditions, mental health symptoms, or cognition when determining a resident's supervision level for smoking. This oversight contributed to the incident, as the resident's cognitive and mental health status were not adequately considered in the assessment process.