Health inspection·May 9, 2024

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 medical record review, resident and staff interviews, review of self-reported incidents, and policy review, the facility failed to report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#79) of three residents reviewed for abuse. The facility census was 84. Findings include: Review of the medical record for Resident #79 revealed an admission date of 12/26/22. Diagnoses included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/26/24, revealed Resident #79 was cognitively intact. Interview on 05/09/24 at 10:15 A.M. with Resident #79 revealed he reported an allegation of abuse on 04/11/24 to the Administrator related to Licensed Practical Nurse (LPN) #203 sticking her finger in his face. Interview on 05/09/24 at 2:10 P.M. with LPN #203 verified Resident #79 did report to the Administrator an allegation of abuse, but stated the allegation was not true. Interview on 05/09/24 at 3:30 P.M. with the Administrator verified Resident #79 reported an allegation of abuse on 04/11/24 for LPN #203 sticking her finger in his face. The Administrator stated the facility chose not to report the incident to the State Survey Agency because they felt the incident did not occur. The Administrator stated witness statements were collected and the incident was investigated. Review of the facility's self-reported incidents (SRIs) reported to the State Survey Agency in 2024 revealed no reports were submitted regarding the allegation made by Resident #79 on 04/11/24. Interview on 05/09/24 at 4:50 P.M. with the Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to investigate the allegation and report it to the State Survey Agency. Review of the undated facility abuse policy revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. In the event an allegation is made, the facility will take measures to protect residents from harm during the investigation. Accurate and timely reporting of incidents, both alleged and (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: 365424 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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)