Health inspection·December 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were treated in a respectful and dignified manner. This affected one (#51) of three residents reviewed for dignity. The facility census was 49. Finding include: Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic pain, and anxiety. The resident was discharged to the hospital on [DATE]. Review of nursing progress note, written by Registered Nurse (RN) #100, dated 11/17/23 at 10:25 P.M., revealed RN #100 entered Resident #51's room, and the resident asked where the nurse had been as she had been waiting on the nurse for some time. Further review revealed RN #100 informed Resident #51 her call light had come on 15 minutes earlier, the nurse aide was on break, and the nurse was assisting someone in another room. Resident #51 continued to insist that her call light was on for over an hour. RN #100 documented in the progress note, You're wrong and I'm not going to stand here and argue with you, I have your meds (medications). Resident #51 then asked RN #100 what medications he had, and RN #100 indicated he had Resident #51's morphine (narcotic pain medication) and gabapentin (nerve pain medication). RN #100 documented Resident #51 looked in the cup, and indicated she was not taking the medication, and RN #100 stated, That's fine, but I'm not the one in pain. RN #100 then let Resident #51 know he could just as easily get rid of the medication. Interview with the Administrator on 12/19/23 at 9:33 A.M., during review of Resident #51's progress notes, confirmed RN #100 documented speaking to Resident #51 in a undignified manner on 11/17/23. The interview confirmed the facility had started providing education with all the nursing staff regarding treating residents with dignity. This deficiency represents an incidental finding discovered during investigation under Complaint Number OH00149004. Page 1 of 3 365475 365475 12/19/2023 Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907

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, review of a police report, staff interview, review of self-reported incidents, and review of a facility policy, the facility failed to report allegations of abuse to the State Survey Agency as required. This affected one (#51) of three residents reviewed for abuse. The census was 49. Findings include: Review of Resident #51's medical record revealed admission to the facility on [DATE]. Diagnoses included end stage chronic obstructive pulmonary disease, chronic pain, and anxiety. Review of the record revealed on 11/18/23 Resident #51 called emergency medical services (EMS), demanded to go to the hospital, and was sent there. Review of a police report dated 11/30/23 revealed an incident classification of patient abuse and neglect was filed. Further review revealed Resident #51's son was contacted in reference to an assault, and the son provided written statements advising an unknown female staff person struck Resident #51 at the nursing home. Another police station contacted Resident #51 as she had moved to another nursing home, and Resident #51 reported the same unknown female worker struck her causing injuries while she was a resident in the nursing home. Review of facility self-reported incidents (SRIs) in the State Survey Agency reporting system revealed the facility did not report an allegation of abuse involving Resident #51. The last SRI submitted by the facility was dated August 2023. Interview with the facility Administrator on 12/19/23 at 9:33 A.M. stated a police officer came to the facility in the past week regarding bruising being reported to them as a potential abuse concern at the facility. The Administrator stated the police officer did not tell her who reported the allegation, but was notified the allegation involved Resident #51. The Administrator stated the officer asked for information of who was working during the time Resident #51 was in the facility. The Administrator verified the police officer notified her of an allegation of abuse regarding Resident #51 while in the facility, and verified the facility did not report the allegation of abuse to the State Survey Agency. Review of the facility abuse policy, dated November 2017, revealed all allegations of of abuse must be reported immediately to the Administrator and to the Ohio Department of Health (ODH). The policy further defined immediately to mean as soon as possible but ought not to exceed 24 hours after discovery of the incident. If there is an abuse allegation or serious resident injury, the incident will be reported to ODH with in two hours of discovery. This deficiency represents non-compliance investigated under Complaint Number OH00149004. 365475 Page 2 of 3 365475 12/19/2023 Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a police report, staff interview, and review of a facility policy, the facility failed to initiate an investigation into an allegation of abuse. This affected one (#51) of three residents reviewed for abuse. The census was 49. Residents Affected - Few Findings include: Review of Resident #51's medical record revealed admission to the facility on [DATE]. Diagnoses included end stage chronic obstructive pulmonary disease, chronic pain, and anxiety. Review of the record revealed on 11/18/23 Resident #51 called emergency medical services (EMS), demanded to go to the hospital, and was sent there. Review of a police report dated 11/30/23 revealed an incident classification of patient abuse and neglect was filed. Further review revealed Resident #51's son was contacted in reference to an assault, and the son provided written statements advising an unknown female staff person struck Resident #51 at the nursing home. Another police station contacted Resident #51 as she had moved to another nursing home, and Resident #51 reported the same unknown female worker struck her causing injuries while she was a resident in the nursing home. Interview with the facility Administrator on 12/19/23 at 9:33 A.M. stated a police officer came to the facility in the past week regarding bruising being reported to them as a potential abuse concern at the facility. The Administrator stated the police officer did not tell her who reported the allegation, but was notified the allegation involved Resident #51. The Administrator stated the officer asked for information of who was working during the time Resident #51 was in the facility. The Administrator verified the police officer notified her of an allegation of abuse regarding Resident #51 while in the facility, and verified the facility did not initiate an investigation into the allegation. Review of the facility abuse policy, dated November 2017, revealed the facility would investigate all allegations, suspicions, and incidents of abuse, mistreatment, neglect, the misappropriation of resident property, exploitation, and injuries sustained by its residents. This deficiency represents non-compliance investigated under Complaint Number OH00149004. 365475 Page 3 of 3