Health inspection·January 4, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of staff to resident verbal abuse for Resident #53. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/09/23 and discharge date of 11/17/23. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic hemiplegia and convulsions. Resident #53 required staff assistance with all activities of daily living which fluctuated based on time of day, mood, pain, or fatigue. There were no behaviors documented in the care plan. Review of the progress note dated 10/26/23 and authored by Assistant Director of Nursing (ADON) #266 indicated Resident #53 reported not liking staff's tone of voice when providing care but denied being fearful or mistreated. Staff were educated. Review of progress note dated 11/13/23 at 11:51 A.M. and authored by the Director of Nursing (DON) indicated interviewing Resident #53 after speaking to the Ombudsman regarding an allegation made to the Ombudsman on 11/10/23. Resident #53 did not voice to the staff at the facility. Discussed with Resident #53 regarding a shower which occurred in the prior week. Resident #53 requested a certain nursing assistant (unnamed) not provide a shower but could assist with other activities including brushing teeth or helping with meals. Resident #53 denied being abused but voiced the nursing assistant (unnamed) was rude with a tone. The DON and Ombudsman inquired if Resident #53 was fearful which Resident #53 replied no but stated, care from the other facility was better. Review of shower documentation revealed Resident #53 received a shower on 11/09/23 by State Tested Nursing Assistant (STNA) #240. There were no skin areas noted. Review of a written witness statement by Licensed Practical Nurse (LPN) #287, undated, indicated Resident #53 requested to be brought to ADON #266. LPN #287 asked Resident #53 what was needed because Page 1 of 8 365991 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was the nurse and could help. Resident #53 reported wanting her bath items which were left in the shower room. LPN #287 told Resident #53 it would be retrieved after passing a medication which was already prepared for administration. LPN #287 then retrieved the bath items. LPN #287 told Resident #53 to quit perseverating on things and keep busy, it was not an emergency, and we would take care of it. Review of staff education entitled Teachable Moment, dated 10/26/23, and signed by LPN #287 revealed an identified issue as tone of voice when speaking with a resident, and a solution of staff member educated and apologized to the resident. LPN #287 included a written statement which denied having a bad tone with resident (unnamed) but understood people take things differently. Review of a written witness statement by STNA #240, dated 11/10/23, revealed when STNA #240 approached Resident #53 to assist with oral care, Resident #53 indicated not wanting STNA #240 to provide care anymore due to what happened on 11/09/23. STNA #240 described providing a shower to Resident #53 on 11/09/23. Prior to the shower, Resident #53 toileted and then after the shower during drying, Resident #53 stated she was urinating on the floor. STNA #240 asked why, because she could have assisted her to the toilet. Resident #53 made no response. On 11/10/23, STNA #240 asked Resident #53 about what happened on 11/09/23 and Resident #53 indicated STNA #240 was not being nice when asking her why she urinated on the floor and no longer wanted STNA #240 to care for her. After the shower on 11/09/23, STNA #240 described helping Resident #53 with many things after it happened including lunch and activities. Review of an email dated 11/13/23 at 9:17 A.M. from Ombudsman #294 to the DON stated there was an allegation of verbal abuse that needed follow-up. Resident #53 reported during the previous week on a shower day that STNA #237 was yelling at her. Resident #53 only told her sister. Ombudsman #294 indicated to the DON ability to review what was reported, and a need to ensure the DON followed the facility process for investigation. Review of staff education entitled Teachable Moment, dated 11/13/23, and signed by STNA #240 revealed an identified issue of customer service, and solution as to be mindful of tone of voice when speaking to others. STNA #240 included a written statement which denied raising her voice when offering to put resident (unnamed) on the toilet. Interviews on 01/04/24 from 9:18 A.M. to 9:21 A.M. with LPN #224 and STNA #267 verified all staff mistreatment or abuse was reported to the DON or Administrator. Interview on 01/04/24 at 10:16 A.M. with the DON confirmed receipt of an email from Ombudsman #294 with a statement there was an allegation of abuse. Ombudsman #294 reported STNA #237 yelled at Resident #53. After receipt of the email, I interviewed Resident #53 and looked at the nursing schedule. It was determined it was not STNA #237, but STNA #240 who was educated. STNA #240 denied yelling at Resident #53 during the shower, so she was educated on tone of voice. Resident #53 denied feeling abused but indicated feeling STNA #240 was being rude and did not like STNA #240's tone. Resident #53 voiced feeling safe, and Ombudsman #294 was present during the interview on 11/13/23. The DON indicated following up with administration including a regional staff member. It was decided not to file a Self-Reported Incident (SRI) because it wasn't an allegation of abuse because Resident #53 said it wasn't abuse. It was more of a customer service concern. Interview on 01/04/24 at 10:33 A.M. with STNA #240 verified an incident occurred with Resident #53 on 11/10/23 which involved the events of 11/09/23 during a shower. When STNA #240 approached 365991 Page 2 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #53 on 11/10/23 to brush her teeth, Resident #53 stated she did not want me to take care of her anymore but did not explain why. Later, Resident #53 indicated to STNA #240 being upset about the shower on 11/09/23. STNA #240 confirmed reporting the concern to the DON on 11/10/23. Afterward, the DON requested STNA #240 write it a statement of what happened. When Resident #53 was showered, STNA #240 provided toileting and after the shower Resident #53 urinated on the floor. STNA #240 asked her why, and Resident #53 responded because she had to. STNA #240 indicated Resident #53 was on medication for a urinary tract infection at the time. So, using a towel, STNA #240 cleaned it up and told Resident #53 that she could have put Resident #53 on the toilet if Resident #53 had told her. STNA #240 proceeded to get Resident #53 dressed and continued to provide care during the day including lunch assistance and other activities. STNA #240 asked the DON about the incident, and the DON reported talking to Resident #53 who stated not feeling abused, so STNA #240 did not have to stop working for an investigation. STNA #240 confirmed continuing to provide care for Resident #53 after the incident. Interview on 01/04/24 at 10:53 A.M. with the DON verified STNA #240 reported on 11/10/23 of Resident #53 not wanting to receive care from STNA #240 anymore. The DON directed STNA #240 to write a statement which she reviewed. The DON interviewed Resident #53 who reported STNA #240 was rude, and it was about Resident #53 going to the bathroom on the floor. Resident #53 never stated STNA #240 yelled or indicated being threatened, just not wanting STNA #240 to provide showers anymore but could do other care like brushing teeth, meals, and activities. Resident #53 kept stating STNA #240 was rude and did not provide any details. The DON informed the Administrator education was going to be provided to STNA #240. On 11/13/23, Ombudsman #294 sent an email, but the DON indicated already being aware of the incident because of the statement STNA #240 wrote. Ombudsman #294 indicated more details would be provided but it happened in the previous week, so the DON waited for Ombudsman #294 to provide more information. Ombudsman #294 did come to the facility later and we both talked to Resident #53. The Administrator was aware. The DON verified knowledge of Resident #53 reporting to ADON #266 on 10/26/23 of a staff member being rude or mean. The DON indicated Resident #53 thought when people spoke to her, they were being rude or mean. The DON denied memory of interviewing Resident #53 after being made aware of the incident on 10/26/23. Interview on 01/04/24 at 11:07 A.M. with STNA #237 confirmed caring for Resident #53 on multiple occasions but there were no issues. STNA #237 indicated Resident #53 had demanding behaviors. Resident #53 verbalized statements such as staff not wanting to help or did not care for them but nothing specific just things were not done right. STNA #237 verified any report from a resident involving someone being mean verbal or physical would be reported to the DON or Administrator. STNA #237 reported hearing staff talk about Resident #53 reporting people being mean, but the response was Resident #53 always talks that way. Interview on 01/04/24 at 11:20 A.M. with ADON #266 verified on 10/26/23, Resident #53 reported not liking the tone of voice by LPN #287. Resident #53 denied being fearful. ADON #266 indicated talking to LPN #287 and obtaining a written statement. LPN #287 stated Resident #53 wanted supplies from the shower, but LPN #287 was passing medications. What was gathered was Resident #53 wanted it done immediately. ADON #266 confirmed giving LPN #287 education and reported to the DON on 10/26/23. The DON agreed with providing LPN #287 education. With an allegation of abuse, we immediately separate people to make sure of no harm or injury from anyone being accused, and it is reported to the DON. Since Resident #53 requested LPN #287 bring her to me, they were separated, and Resident #53 was not fearful at the time. ADON #266 indicated if she was present during the incident, she would have separated them. ADON #266 stated not feeling the need to investigate because Resident #53 reported not feeling fearful and in danger. ADON #266 verified just interviewing Resident #53 on 10/26/23, and if 365991 Page 3 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0607 Level of Harm - Minimal harm or potential for actual harm Resident #53 felt in fear, ADON #266 would have made sure the abuse investigation was executed. ADON #266 stated the facility abuse policy and procedure was executed when a resident stated they were in fear, danger, or abused. ADON #266 indicated just going off residents' wording since they entrust in us. If a resident was not cognitively able to report, ADON #266 would look for witnesses and ask if they were mistreated. ADON #266 stated having to trust what was said to be correct. Residents Affected - Few Interview on 01/04/24 at 12:45 P.M. with the DON verified ADON #266 reported the incident on 10/26/23 with Resident #53. ADON #266 indicated talking to Resident #53 and was directed to do education. The abuse policy would not be implemented because Resident #53 and ADON #266 did not state it was abuse, only Resident #53 complained about tone. Interview on 01/04/24 at 12:55 P.M. with the Administrator confirmed being aware of both incidents with Resident #53. Resident #53 was interviewed regarding whether anything occurred, and Resident #53 stated nothing occurred. We started an investigation by talking to Resident #53 after receipt of the email on 11/13/23 to see if it was valid. Ombudsman #294 sent it four days after it happened and because it was so far back, we wanted to make sure it was an allegation. Ombudsman #294 stated to follow our process which was to investigate. We talk to residents with any allegation, and if a resident does not allege, then there is no allegation. The abuse policy was only implemented if a resident indicated abuse. An abuse allegation would be reported if a resident was not able to state it. The Administrator verified not being aware of the 10/26/23 incident with Resident #53 until the time of the survey. The Administrator stated it must be found out if it is abuse before initiating the policy. If a resident stated someone abused me, then it would be reported and investigated. Ombudsman #294 indicated to follow-up. I took it as to check first, so we talked to Resident #53 and determined it was not abuse. This was because Resident #53 stated it was not abuse, so Resident #53 did not make an allegation. We did not know where Ombudsman #294 received the information. Since Resident #53 was not stating being abused, then I am going to believe the resident. We did do an investigation. We talked to Resident #53. There must be discussion to determine whether it is reportable and whether it falls into those requirements, so I disagree with implementing the abuse policy because Resident #53 did not say she was abused. Review of the facility policy, Abuse, Neglect & Misappropriation, dated 05/25/23, revealed in the event an allegation was made, the facility would take measures to protect residents from harm during an investigation. An employee who is alleged or accused of being a party to abuse, would be immediately removed from the area of resident care, interviewed by facility leadership for a written statement and not left alone after completing the statement. The employee would be asked to vacate the facility until further investigation of the incident was completed, and the employee would be notified of the findings of the investigation. This deficiency represents non-compliance investigated under Complaint Number OH00149488. 365991 Page 4 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

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 interview, record review and policy review, the facility failed to report an allegation of staff-to-resident verbal abuse for Resident #53 to the state agency. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/09/23 and discharge date of 11/17/23. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic hemiplegia and convulsions. Resident #53 required staff assistance with all activities of daily living which fluctuated based on time of day, mood, pain, or fatigue. There were no behaviors documented in the care plan. Review of the progress note dated 10/26/23 and authored by Assistant Director of Nursing (ADON) #266 indicated Resident #53 reported not liking staff tone of voice when providing care but denied being fearful or mistreated. Staff were educated. Review of the progress note dated 11/13/23 at 11:51 A.M. and authored by Director of Nursing (DON) indicated interviewing Resident #53 after speaking to the Ombudsman regarding an allegation made to the Ombudsman on 11/10/23. Resident #53 did not voice to the staff at the facility. Discussed with Resident #53 regarding a shower which occurred in the prior week. Resident #53 requested a certain nursing assistant (unnamed) not provide a shower but could assist with other activities including brushing teeth or helping with meals. Resident #53 denied being abused but voiced the nursing assistant (unnamed) was rude with a tone. DON and Ombudsman inquired if Resident #53 was fearful which Resident #53 replied no but stated, care from the other facility was better. Review of shower documentation revealed Resident #53 received a shower on 11/09/23 by State Tested Nursing Assistant (STNA) #240. There were no skin areas noted. Review of a written witness statement by Licensed Practical Nurse (LPN) #287, undated, indicated Resident #53 requested to be brought to ADON #266. LPN #287 asked Resident #53 what was needed because she was the nurse and could help. Resident #53 reported wanting her bath items which were left in the shower room. LPN #287 told Resident #53 it would be retrieved after passing a medication which was already prepared for administration. LPN #287 then retrieved the bath items. LPN #287 told Resident #53 to quit perseverating on things and keep busy, it was not an emergency, and we would take care of it. Review of staff education entitled Teachable Moment, dated 10/26/23, and signed by LPN #287 revealed an identified issue as tone of voice when speaking with a resident, and a solution of staff member educated and apologized to the resident. LPN #287 included a written statement which denied having 365991 Page 5 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0609 a bad tone with resident (unnamed) but understood people take things differently. Level of Harm - Minimal harm or potential for actual harm Review of a written witness statement by STNA #240, dated 11/10/23, revealed when STNA #240 approached Resident #53 to assist with oral care, Resident #53 indicated not wanting STNA #240 to provide care anymore due to what happened on 11/09/23. STNA #240 described providing a shower to Resident #53 on 11/09/23. Prior to the shower, Resident #53 toileted and then after the shower during drying, Resident #53 stated she was urinating on the floor. STNA #240 asked why, because she could have assisted her to the toilet. Resident #53 made no response. On 11/10/23, STNA #240 asked Resident #53 about what happened on 11/09/23, and Resident #53 indicated STNA #240 was not being nice when asking her why she urinated on the floor and no longer wanted STNA #240 to care for her. After the shower on 11/09/23, STNA #240 described helping Resident #53 with many things after it happened including lunch and activities. Residents Affected - Few Review of an email dated 11/13/23 at 9:17 A.M. from Ombudsman #294 to the DON stated there was an allegation of verbal abuse that needed follow-up. Resident #53 reported during the previous week on a shower day, STNA #237 was yelling at her. Resident #53 only told her sister. Ombudsman #294 indicated to the DON ability to review what was reported, and a need to ensure the DON followed the facility process for investigation. Review of staff education titled Teachable Moment, dated 11/13/23, and signed by STNA #240 revealed an identified issue of customer service, and solution as to be mindful of tone of voice when speaking to others. STNA #240 included a written statement which denied raising her voice when offering to put resident (unnamed) on the toilet. There was no evidence that the facility filed a Self-Reported Incident (SRI) for Resident #53. Interviews on 01/04/24 from 9:18 A.M. to 9:21 A.M. with LPN #224 and STNA #267 verified all staff mistreatment or abuse was reported to the DON or Administrator. Interview on 01/04/24 at 10:16 A.M. with the DON confirmed receipt of an email from Ombudsman #294 with a statement there was an allegation of abuse. Ombudsman #294 reported STNA #237 yelled at Resident #53. After receipt of the email, I interviewed Resident #53 and looked at the nursing schedule. It was determined it was not STNA #237, but STNA #240 who was educated. STNA #240 denied yelling at Resident #53 during the shower, so she was educated on tone of voice. Resident #53 denied feeling abused but indicated feeling STNA #240 was being rude and did not like STNA #240's tone. Resident #53 voiced feeling safe, and Ombudsman #294 was present during the interview on 11/13/23. The DON indicated following up with administration including a regional staff member. It was decided not to file an SRI because it wasn't an allegation of abuse because Resident #53 said it wasn't abuse. It was more customer service. Interview on 01/04/24 at 10:33 A.M. with STNA #240 verified an incident occurred with Resident #53 on 11/10/23 which involved the events of 11/09/23 during a shower. When STNA #240 approached Resident #53 on 11/10/23 to brush her teeth, Resident #53 stated she did not want me to take care of her anymore but did not explain why. Later, Resident #53 indicated to STNA #240 being upset about the shower on 11/09/23. STNA #240 confirmed reporting the concern to the DON on 11/10/23. Afterward, the DON requested STNA #240 write a statement of what happened. When Resident #53 was showered, STNA #240 provided toileting and after the shower Resident #53 urinated on the floor. STNA #240 asked her why, and Resident #53 responded because she had to. STNA #240 indicated Resident #53 was on medication for a urinary tract infection at the time. So, using a towel, STNA #240 cleaned it up and told 365991 Page 6 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0609 Level of Harm - Minimal harm or potential for actual harm Resident #53 that she could have put her on the toilet if Resident #53 had told her. STNA #240 proceeded to get Resident #53 dressed and continued to provide care during the day including lunch assistance and other activities. STNA #240 asked the DON about the incident, and the DON reported talking to Resident #53 who stated not feeling abused, so STNA #240 did not have to stop working for an investigation. STNA #240 confirmed continuing to provide care for Resident #53 after the incident. Residents Affected - Few Interview on 01/04/24 at 10:53 A.M. with the DON verified STNA #240 reported on 11/10/23 of Resident #53 not wanting to receive care from STNA #240 anymore. The DON directed STNA #240 to write a statement which she reviewed. The DON interviewed Resident #53 who reported STNA #240 was rude, and it was about Resident #53 going to the bathroom on the floor. Resident #53 never stated STNA #240 yelled or indicated being threatened, just not wanting STNA #240 to provide showers anymore but could do other care like brushing teeth, meals, and activities. Resident #53 kept stating STNA #240 was rude and did not provide any details. The DON informed the Administrator education was going to be provided to STNA #240. On 11/13/23, Ombudsman #294 sent an email, but the DON indicated already being aware of the incident because of the statement STNA #240 wrote. Ombudsman #294 indicated more details would be provided but it happened in the previous week, so the DON waited for Ombudsman #294 to provide more information. Ombudsman #294 did come to the facility later and we both talked to Resident #53. The Administrator was aware. The DON verified knowledge of Resident #53 reporting to ADON #266 on 10/26/23 of a staff member being rude or mean. The DON indicated Resident #53 thought when people spoke to her, they were being rude or mean. The DON denied memory of interviewing Resident #53 after being made aware of the incident on 10/26/23. Interview on 01/04/24 at 11:07 A.M. with STNA #237 confirmed caring for Resident #53 on multiple occasions, but there were no issues. STNA #237 indicated Resident #53 had demanding behaviors. Resident #53 verbalized statements such as staff not wanting to help or did not care for them but nothing specific just things were not done right. STNA #237 verified any report from a resident involving someone being mean, verbal, or physical, would be reported to the DON or Administrator. STNA #237 reported hearing staff talk about Resident #53 reporting people being mean, but the response was Resident #53 always talks that way. Interview on 01/04/24 at 11:20 A.M. with ADON #266 verified on 10/26/23, Resident #53 reported not liking the tone of voice by LPN #287. Resident #53 denied being fearful. ADON #266 indicated talking to LPN #287 and obtaining a written statement. LPN #287 stated Resident #53 wanted supplies from the shower, but LPN #287 was passing medications. What was gathered was Resident #53 wanted it done immediately. ADON #266 confirmed giving LPN #287 education and reported to the DON on 10/26/23. The DON agreed with providing LPN #287 education. With an allegation of abuse, we immediately separate people to make sure of no harm or injury from anyone being accused, and it is reported to the DON. Since Resident #53 requested LPN #287 bring her to me, they were separated, and Resident #53 was not fearful at the time. ADON #266 indicated if she was present during the incident, she would have separated them. ADON #266 stated not feeling the need to investigate because Resident #53 reported not feeling fearful and in danger. ADON #266 verified just interviewing Resident #53 on 10/26/23, and if Resident #53 felt in fear, ADON #266 would have made sure the abuse investigation was executed. ADON #266 stated the facility abuse policy and procedure was executed when a resident stated they were in fear, danger, or abused. ADON #266 indicated just going off residents' wording since they entrust in us. If a resident was not cognitively able to report ADON #266 would look for witnesses and ask if they were mistreated. ADON #266 stated having to trust what was said to be correct. Interview on 01/04/24 at 12:45 P.M. with the DON verified ADON #266 reported the incident on 10/26/23 with Resident #53. ADON #266 indicated talking to Resident #53 and was directed to do education. 365991 Page 7 of 8 365991 01/04/2024 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The abuse policy would not be implemented because Resident #53 and ADON #266 did not state it was abuse, only Resident #53 complained about tone. Interview on 01/04/24 at 12:55 P.M. with the Administrator confirmed being aware of both incidents with Resident #53. Resident #53 was interviewed regarding whether anything occurred, and Resident #53 stated nothing occurred. We started an investigation by talking to Resident #53 after receipt of the email on 11/13/23 to see if it was valid. Ombudsman #294 sent it four days after it happened and because it was so far back, we wanted to make sure it was an allegation. Ombudsman #294 stated to follow our process which was to investigate. We talk to residents with any allegation, and if a resident does not allege, then there is no allegation. The abuse policy was only implemented if a resident indicated abuse. An abuse allegation would be reported if a resident was not able to state it. The Administrator verified not being aware of the 10/26/23 incident with Resident #53 until the time of the survey. The Administrator stated it must be found out if it is abuse before initiating the policy. If a resident stated someone abused me, then it would be reported and investigated. Ombudsman #294 indicated to follow-up. I took it as to check first, so we talked to Resident #53 and determined it was not abuse. This was because Resident #53 stated it was not abuse, so Resident #53 did not make an allegation. We did not know where Ombudsman #294 received the information. Since Resident #53 was not stating being abused, then I am going to believe the resident. We did do an investigation. We talked to Resident #53. There must be discussion to determine whether it is reportable and whether it falls into those requirements, so I disagree with implementing the abuse policy because Resident #53 did not say she was abused. Review of the facility policy, Abuse, Neglect & Misappropriation, dated 05/25/23, revealed in the event an allegation was made, the facility would make accurate and timely reporting of incidents both alleged and substantiated to officials in accordance with the state law. All alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made, for those alleged violations that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. The results of the facility's investigation must be reported to the survey agency. This deficiency represents non-compliance investigated under Complaint Number OH00149488. 365991 Page 8 of 8