Health inspection·December 26, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the facility Self-Reported Incident (SRI), and policy review, the facility failed to prevent physical abuse for one resident (#10) of three residents reviewed. The facility census was 48. Findings include: Review of the medical record for Resident #10, revealed an admission date of 04/08/22. Diagnoses included but were not limited to unspecified dementia, anxiety disorder, major depressive disorder, muscle weakness, and mood disorder due to known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 indicating severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility, transfers and total dependence with toilet hygiene. This resident was also assessed to have skin tears under skin conditions. Review of the SRI dated 11/12/24 revealed an allegation of neglect that occurred on 11/11/24. A Certified Nurse Assistant (CNA) reported to the Assistant Director of Nursing (ADON) that the alleged perpetrator (CNA #100) had a conflict with Resident #10. Resident #10 became combative during care on the night shift. Resident #10 was noted to have a skin tear and bruising to both her hands. CNA #100 was removed from the schedule and an investigation occurred. Based on the investigation, CNA #100 was terminated. The facility substantiated the allegation of neglect. Review of a witness statement from CNA #343 dated 11/11/24 revealed she was getting report from CNA #100 when she reported her, and Resident #10 got in a fight. CNA #11 had stated that Resident #10 has had behaviors and was combative with her. When she was showering Resident #10 that day, she noticed the skin tear and bruising to both of her hands. Review of witness statement from CNA #344 dated 11/11/24 revealed during morning report, CNA #100 told her that Resident #10 and her had a fight, and she won. During morning rounds she observed bruises and a skin tear to Resident #10's hands. Review of witness statement from CNA #345 dated 11/13/23 revealed on 11/11/24 during report CNA #100 told her she and Resident #10 got in a fight, and she had won. Later in the morning, she noticed bruising to her hands. Page 1 of 2 365431 365431 12/26/2024 Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of witness statement from the Assistant Director of Nursing (ADON) dated 11/12/24 that on 11/11/24 CNA #100 had in report said that her and Resident #10 got into a fight, and she had won. She was also informed the resident had bruising and a skin tear noted to her hands. She then went check on Resident #10 and observed bilateral hand bruising and a skin tear to the left top hand. When interviewing Resident #10 she stated you know one of your girls did it and it's that girl that changes my diapers and gets me up early in the mornings. I didn't want to get up and she started pulling on my arms and scratched my hand. Investigation then was started. Review of the skin check dated 11/11/24 at 1:03 P.M. for Resident #10 revealed the following: a left dorsum hand ulnar location skin tear that measured 1.8 centimeters (CM) by 0.3 CM, a right dorsum right hand bruising and left dorsum left hand bruising. Interview on 12/26/24 at 12:01 P.M. with the Administrator confirmed the physical abuse occurred to Resident #10 per investigation from the ADON. Interview on 12/26/24 at 12:28 P.M. with CNA#343 revealed her statement was accurate and when she came on shift that morning CNA #100 was saying she won the fight with Resident #10. She told the nurse in charge and the ADON was notified. The ADON was unavailable for an interview. Review of the facility policy titled Abuse dated 04/25/18 revealed abuse is defined as the willful infliction of injury which results in physical harm. All residents have the right to be free from abuse, and to feel safe, cared for, and respected at all times. All allegations of abuse will be investigated and reported per policy This deficiency represents non-compliance investigated under Complaint Number OH00160291. 365431 Page 2 of 2