Failure to properly substantiate neglect allegations: A resident reported being left wet overnight, and three other residents on the same assignment reported delayed call light response and missed or late incontinence/ADL care. The IDT unsubstantiated the allegation based on no skin impairments and residents denying distress, even though resident statements described delayed care and being left wet.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to fully implement staff education following a fall in which a resident sustained a hematoma to the scalp, complained of knee pain, and was later found to have fractures of the shoulder/collarbone and scapula after ER evaluation. Although the investigation identified the injuries and the need for safe resident handling education, only two CNAs received training, and no additional staff were educated, indicating the facility did not use the investigation results to ensure comprehensive staff education.
Failure to Report and Thoroughly Investigate Alleged Neglect: A resident alleged that after wetting the bed, he was not cleaned up for several hours and that staff turned off his call light and left. The grievance investigation was inconclusive and relied on typed aide statements and a skin assessment, but the allegation was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to investigate allegations of abuse: A surveyor found a typed statement in an investigation file describing repeated verbal abuse and unprofessional conduct by two NAs toward residents, including name-calling, rude comments during care, and shutting off call lights. The writer of the statement was not identified, and the Administrator stated the allegations in the statement had not been previously investigated.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident on an Alzheimer’s unit was physically abused when an LPN smacked the resident’s hand and made a remark about how it felt to be smacked, with staff observing temporary discoloration of the hand and video evidence confirming the event. The facility’s investigation substantiated the abuse and its policy required analysis of the incident, staff training on abuse/neglect, and reporting licensed staff suspected of abuse to their licensing board. However, the facility did not provide the mandated abuse training before allowing the LPN to return to work and did not report the LPN to the licensing board, while the LPN remained employed on the unit.
The facility failed to document that the 5-day follow-up investigation for a Facility Reported Incident was sent to OHFLAC. A resident removed a toilet seat, broke a mirror, and displayed verbal behaviors toward staff; staff secured the area, removed sharp objects, and the physician ordered IM Haldol and Benadryl. Although the follow-up investigation was completed, there was no fax or email receipt confirming submission, and the DON and Administrator confirmed the missing documentation.
The facility failed to complete and submit required five-day investigation reports to state and other officials following multiple incidents, including a fall with a femur fracture during a CNA-assisted transfer and an allegation by a cognitively intact resident that another resident entered her room, hit her, and took items. In these cases, the DON could not produce initial reportables or five-day follow-ups, resident care planning was not updated after falls, and no grievance or reportable documentation existed for the resident-on-resident incident. In another facility-reported incident, there was no evidence that the mandated five-day follow-up to the state agency was completed, as the former NHA who handled FRIs had not done so.
Failure to submit required five-day follow-up investigation reports: The facility had FRI files for multiple incidents involving residents, but there was no proof the DON or other staff submitted the follow-up investigations to the State Agency within the required timeframe. One incident involved a resident struck in the arm by another resident; the victim had a BIMS of 15 and capacity, and the other resident had capacity and was later diagnosed with a UTI. Staff confirmed there was no evidence the reports were sent.
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