Health inspection·August 15, 2019

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 medical record review, staff interview, and review of facility policy, the facility failed to implement their abuse policy when allegations of staff to resident abuse were not investigated and timely reported to the State Agency. This affected one resident (#17) of three reviewed for abuse. The facility census was 92. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 10/20/17 with diagnoses including Sudden vision loss in the right eye, dysphagia (difficulty swallowing), and heart failure. Review of Resident #17's nursing progress note date 05/12/19 written by Licensed Practical Nurse (LPN) #215 revealed the nurse assisted the State Tested Nursing Aid (STNA) with personal care for Resident #17. The resident told LPN #215 and STNA #205 they were physically abusive to him when they were wiping him and he claimed it was sexual abuse. Interview with STNA #203 on 08/14/19 at 9:26 A.M. revealed she witnessed STNA #205 verbally abuse Resident #17 a few weeks ago and she reported it to the Administrator. She revealed Resident #17 reported to her on 07/14/19 he felt he had been abused when a staff member said to him, is this what your going to do now, piss yourself like a baby? STNA #203 stated she reported it to Social Service Worker (SSW) #204 who said she would notify the Director of Nursing (DON) right away. Resident #17 also revealed he had reported the allegation of verbal abuse to LPN #210 of the incident as well and said she would report the allegation to the Administrator. Interview with the Administrator on 08/14/19 at 11:38 A.M. revealed she was unaware of LPN #215's progress note dated 05/12/19 where Resident #17 claimed he was physically and sexually abused by LPN #215 and STNA #205. The Administrator also revealed she was unaware of the incident on 07/14/19 involving Resident #17 reporting alleged verbal abuse to STNA #203 and LPN #210. The Administrator further confirmed neither allegations of abuse were reported to the state agency or investigated in a timely manner. Interview with the DON on 08/14/19 at 4:49 P.M. revealed a phone interview was conducted with LPN #210 and LPN #215. The DON revealed LPN #210 did not recall any incident of Resident #17 alleging verbal abuse on 07/14/19. LPN #215 provided a statement which revealed when she went to do pericare with STNA #205, Resident #17 was saying ouch, you are beating me up and said they were sexually abusing him. LPN #215 revealed they did not want to leave him soiled and since there were two people in the room, she felt like it was a false allegation and just put the incident in the resident's nursing notes and did not report it. The DON confirmed it was the facility's policy to report any allegation of abuse. (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 6 Event ID: 365994 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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)