Inspection·December 4, 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 record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported immediately to the state agency as required. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/08/20 with diagnoses including chronic systolic heart failure, type two diabetes mellitus, atrial fibrillation, hypertension, and anxiety disorder and a discharge date of 11/20/24. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/17/24 revealed the resident had intact cognition and required supervision or touching assistance with activities of daily living (ADLs.) Review of the hospital note for Resident #3 dated 11/20/24 timed at 9:47 P.M. revealed the resident was admitted with complaints of back pain and alleged he had been pushed by an employee at the facility during an altercation on 11/18/24 which caused the resident to fall backwards. Review of the physician progress note for Resident #3 dated 11/20/24 revealed during hospital transfer the resident reported a recent altercation with a staff member a couple of days prior and noted worsening back pain. Review of local hospital case management initial assessment for Resident #3 dated 11/22/24 timed at 4:12 P.M. revealed the resident alleged the social worker at the facility had pushed him down causing him to fall. Review of the facility Self-Reported Incident (SRI) involving Resident #3 initiated 11/26/24 at 10:42 A.M. revealed the Administrator became aware of the allegation of abuse per Resident #3 towards SSD #233 through the Surveyor. SSD #233 was suspended pending investigation on 11/26/24. The facility was unable to substantiate the allegation of abuse. Interview on 11/25/24 at 4:29 P.M. with the Director of Nursing (DON) confirmed hospital staff had informed her on 11/22/24 that Resident #3 had alleged Social Services Director (SSD) #233 had pushed him down to the ground on 11/18/24. Interview on 11/26/24 at 9:42 A.M. with the Administrator confirmed he was not aware of Resident (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: 365572 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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)