Inspection·April 29, 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, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (Resident #36) of three residents reviewed for abuse. The facility census was 78. Findings include: Review of the medical record for Resident #36 revealed admission date of 10/09/23 with diagnoses including type two diabetes mellitus, atrial fibrillation, peripheral vascular disease, congestive heart failure and fracture of the right humerus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #36 dated 04/08/24 indicated the resident had intact cognition. Review of the facility SRIs for 2024 revealed there were no reports related to Resident #36. Interview on 04/23/24 at 9:42 A.M. with the Administrator confirmed the facility investigated an allegation reported by staff on 03/26/24 of an inappropriate relationship between Licensed Practical Nuse (LPN) #10 and Resident #36. Staff had reported the relationship as inappropriate and that they had witnessed LPN #10 hug and kiss Resident #36. During the investigation of the allegation LPN #10 was placed on administrative leave. Further interview with the Administrator confirmed the facility was unable to substantiate abuse. Interview on 04/23/24 at 11:42 A.M. with State Tested Nursing Assistant (STNA) #44 confirmed the STNA had heard other staff talking about Resident #36 and LPN #10 having an inappropriate relationship. STNA #44 confirmed she had seen Resident #36 and LPN #10 exit the elevator together and they were both laughing. When the doors opened, the resident thanked the nurse and called her honey. STNA #44 confirmed she reported this to the nurse manager because she felt that something was going on between Resident #36 and LPN #10, some sort of inappropriate relationship. Interview on 04/23/24 at 11:57 A.M. with LPN #111 confirmed she had witnessed LPN #10 hug residents and/or kiss them on the cheek or the forehead, but she didn't think anything of it. LPN #11 confirmed LPN #10 was overly nice to the residents and seemed like she wanted them to like her. Interview with the Administrator and the Regional Director of Operations (RDO) confirmed the Administrator informed the RDO of the allegations made by staff on 03/26/24 regarding LPN #10 and Resident #36. The Administrator confirmed the facility investigated the allegation and did place the alleged (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: 365643 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 365643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Portsmouth Health and Rehab 727 Eighth Street Portsmouth, OH 45662 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)