Inspection·October 25, 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), and review of the facility policy, the facility failed to timely report an allegation of staff to resident physical abuse. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 65 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/24/23 with diagnoses including muscle weakness, unsteadiness on feet, difficulty walking, paranoid schizophrenia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/04/24 revealed the resident was moderately cognitively impaired. Review of the facility SRI form for Resident #9 dated 10/11/24 timed at 8:38 A.M. revealed the facility reported an allegation of physical abuse per Licensed Practical Nurse (LPN) #205 towards Resident #9. Review of witness statements per Certified Nursing Assistants (CNAs) # 163 and #166 obtained by the Director of Nursing (DON) on 10/11/24 revealed between approximately 4:00 A.M. to 4:30 A.M. on 10/11/24 the two CNAs witnessed LPN #205 place his hands on the chest of Resident #9 and push him backwards, causing the resident to fall. CNA#163 reported sending a text message to Facility Scheduler (FS) #200 at 4:20 A.M. on 10/11/24 stating they had a serious issue at the facility and a second text message at 4:38 A.M. on 10/11/24 asking to speak to FS #200 privately when FS #200 arrived at the facility. CNA #163 reported FS #200 responded to the text messages at 4:43 A.M. on 10/11/24 by replying with the word okay. Interview on 10/25/24 at 10:20 A.M. with Assistant Director of Nursing (ADON) #156 confirmed FS #200 called her at 6:54 A.M. on 10/11/24 to report an allegation of abuse per LPN #205 towards Resident #9 which had allegedly occurred sometime between 4:00 A.M. and 4:30 A.M. on 10/11/24. ADON #156 confirmed she immediately called the DON and reported the allegation to the DON because the DON was closer to the facility. The ADON confirmed all allegations of abuse should be reported to administration immediately. Telephone interview on 10/25/24 at 11:52 A.M. with FS #200 confirmed on 10/11/24 at 6:30 A.M. CNAs #163 and #166 reported an allegation of physical abuse per LPN #205 towards Resident #9 which they witnessed on 10/11/24 around 4:00 A.M. to 4:30 A.M. FS #200 stated the CNAs said they did not report (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: 365932 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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)