Inspection·December 6, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review, the facility failed to report an allegation of abuse to the state agency as required for one resident (#65). This affected one (Resident #65) of one resident reviewed for abuse. The facility census was 63. Findings Include: Review of the medical record for the Resident #65 revealed an initial admission date of 11/07/23 with diagnoses including fracture of shaft of humerus, left arm, anemia, chronic kidney disease, obstructive sleep apnea, diabetes mellitus, hypertension, hyperlipidemia, gastro-esophageal reflux disease, dysphagia, generalized muscle weakness, history of falling, pain and secondary hyperparathyroidism of renal origin. The resident discharged against medical advice (AMA) on 11/11/23. Review of the resident's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others and rejected care. The resident was dependent on toileting and required substantial assistance with bed mobility, bathing, and personal hygiene. Review of the progress note dated 11/11/23 at 2:13 A.M. revealed the resident was heard yelling and the nurse went into his room to find out what was going on. Two aides were in the room trying to change the pads under the resident but the resident was verbally abusive. The nurse instructed the aides to leave the room and the resident reported he wet himself because a urinal was placed between his legs with the lid on. The nurse explained spills do occur while using a urinal in bed and offered to change the resident and also provide care for him the rest of the night. The resident refused to be changed and called his family to come and get him. The resident's family arrived at the facility at 1:30 A.M. An AMA form was given to the family to sign but they refused to sign and wrote complaints on the form. The resident and his family left the facility at 1:45 A.M. The Certified Nurse Practitioner (CNP) was notified as well as the on call nurse manager. Review of the resident's AMA Form dated 11/11/23 revealed the resident's signature and a hand written note stating Leaving due to patient abuse. Would not come when light was on to urinate, put urinal on didn't take the lid off, urinated in bed. Insulted with smart comments and was made fun of. Two nights of abuse, had enough. Review of the facility's Self-Reported Incidents (SRI) revealed no incident related to the allegation of abuse. (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 2 Event ID: 365399 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 365399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerwood Rehabilitation 5757 Ponderosa Drive Columbus, OH 43231 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)