Health inspection·January 30, 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 staff interview, resident interview, medical record review, and policy review, the facility failed to ensure that all allegations of abuse/mistreatment were reported immediately to the administrator of the facility. This affected one of 69 residents (Resident #15). Findings include: Interview with Licensed Practical Nurse (LPN) #75 on 01/29/24 at 5:03 A.M. revealed that, approximately a week prior, State Tested Nursing Assistant (STNA) #76 had bragged to her about cursing at Resident #15 because he cursed at her. LPN #75 stated she had reported this to Registered Nurse (RN) #77, who was working that night and was her supervisor. LPN #75 stated she did not know if the administrator was aware of the allegation or not. Review of the medical record for Resident #15 revealed an admission date of 07/30/16 and diagnoses including hemiplegia following a cerebral infarction, diabetes, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment completed 12/08/23 revealed a brief interview for mental status score of 15, indicating intact cognition. Review of the record did not reveal any allegations of abuse/mistreatment documented prior to 01/29/24. The plan of care dated 12/13/23 included that the resident had periods of anger if he had to wait and would curse at staff. Interview with Resident #15 on 01/29/24 at 6:10 A.M. revealed he denied any abuse/mistreatment by staff and stated he was never cursed at by staff. He stated he felt comfortable reporting if something did happen. Interview with RN #77 on 01/29/24 at 10:00 A.M. revealed she denied that LPN #75 had reported anything to her regarding STNA #76. Interview with STNA #76 on 01/29/24 at 10:26 A.M. revealed she denied stating that she had cursed at Resident #15. She stated that she had never cursed at a resident. Interview with the Director of Nursing on 01/29/24 at 7:03 A.M. revealed there had been no reported allegations of abuse/mistreatment in the past two months. He stated facility administration was not aware of the allegation reported to the surveyor by LPN #75. Review of the facility policy (dated November 2016) titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property must be reported immediately to the Administrator or designee. (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: 365721 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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)