Inspection·April 24, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, staff interviews, review of facility policy, review of self-reported incidents (SRIs) and review of facility investigation, the facility failed to report an allegation of abuse to the state agency. This affected one resident (#30) out of three residents reviewed for abuse. The facility census was 83. Findings included: Review of the medical record for Resident #30 revealed an admission of 03/09/21. Diagnoses included dementia, type 2 diabetes mellitus, benign prostatic hypertrophy, gastroesophageal reflux disease, repeated falls, chronic obstructive pulmonary disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 04/06/23, revealed the resident was cognitively impaired. The resident had a brief interview for mental status (BIMS) score of 07. Review of the plan of care for Resident #30 dated 11/15/22, revealed the resident could be verbally inappropriate towards staff. Interventions included administering medications as ordered, discussing/exploring feeling of anger/anxiety with resident, and maintaining consistent caregivers as schedule would permit. Review of the witness statement written by LPN #107 regarding the incident with Resident #30 and his family revealed that on 04/11/23 at 3:30 P.M., the family of the resident requested that staff put Resident #30 in his wheelchair so they could take the resident outside. Licensed Practical Nurse (LPN) #107 stated that she was unable to locate State Tested Nursing Assistant (STNA) #183. At 3:45 P.M., STNA #183 arrived on the floor. The family of Resident #30 approached LPN #107 at 3:50 P.M. stating there was a problem. The family member alleged that STNA #183 was being rude to them and cussing at them. LPN #107 walked down the hallway with the family member to the Resident #30's room. STNA #183 was noted in the hallway spinning around in a rolling chair talking on her personal phone. LPN #107 asked STNA #183 to help her place the resident in his wheelchair. STNA #183 stated that she does not have time for this expletive. His expletive has been rude to me. The family of Resident #30 tried to apologize to STNA #183 stating that he is like this with everyone. STNA #183 responded by saying expletive this, I am not on this expletive. At this time, LPN #107 stated that she escorted STNA #183 off the floor asking her to leave and not return to the floor. Review of the facility investigation dated 04/13/23, regarding the incident that occurred with Resident #30's family on 04/11/23, revealed the facility stepped in when they recognized a bad situation. STNA #183 was asked to leave the floor immediately. Administrative Registered Nurse (RN) #100 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)