Health inspection·July 6, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the Ohio Department of Health's (state survey agency) enhanced information dissemination collection (EIDC) system (computer database used by nursing facilities to report allegations of abuse, neglect and exploitation), and policy review the facility failed to ensure an allegation of alleged physical abuse was reported to the state survey agency (The Ohio Department of Health) as required. This affected one (Resident #28) of three residents reviewed for abuse. The facility census was 26. Findings Include Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (3.0) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and required extensive assistance for two staff persons for completing her activities of daily living. Review of Resident #28's record revealed no there were no documented notifications of the incident being reported to the physician or the family/responsible party. Review of the incident report dated 05/25/24 revealed State Tested Nursing Assistant (STNA) #900 stated at about 11:40 P.M. on 05/24/24 she was sitting and doing daily charting when she heard screaming coming from Resident #28's room. Upon entering the room STNA #900 noted that Resident #28 was physically combative with STNA #901 whom was attempting to provide incontinence care. STNA #900 and STNA #901 worked together to calm Resident #28 down and successfully completed incontinence care. STNA #900 then stated after the incontinence care was completed STNA #901 laid Resident #28 down on the bed and subsequently smacked her on her head and told Resident #28 to quit that. Upon witnessing the incident STNA #900 stated to STNA #901 that she couldn't believe STNA #901 would do that STNA #901 replied She couldn't believe it either. Review of the statement provided by Licensed Practical Nurse (LPN) #999 dated 05/25/24 revealed she was made aware of the incident by STNA # 900 on 05/24/24 at 11:45 P.M. Upon notification LPN #999 immediately assessed Resident #28 with no negative findings. LPN #999 texted the Director of Nursing (DON) on 05/25/24 at 12:22 A.M., called the DON on 05/25/24 at 12:26 A.M. and left a voice mail, and called the Administrator/owner on 05/25/24 at 1:17 A.M. and left a voice mail. Review of the EIDC system revealed the alleged abuse perpetrated by STNA #901 against Resident #28 was not reported as required. Review of the policy entitled Abuse, Neglect and Misappropriation/Property dated 04/01/24 revealed Page 1 of 3 366031 366031 07/06/2024 Mill Manor Care Center 983 Exchange St Vermilion, OH 44089

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property must immediately be reported to the Administrator, the State survey and certification agency and other officials as mandated by Ohio law. Remove the abuser from the situation, ensure resident safety. All reports of suspected abuse, neglect, misappropriation of property will be reported to the department head and administrator as well as the resident's representative (sponsor) and physician immediately upon the notification of occurrence of suspected incident. The Administrator and DON verified in an interview on 07/06/24 at 10:00 A.M. that the facility did not report the incident to the state survey agency as required. This deficiency represents non-compliance investigated under Complaint Number OH00155240. 366031 Page 2 of 3 366031 07/06/2024 Mill Manor Care Center 983 Exchange St Vermilion, OH 44089

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure it completed a thorough investigation related to an allegation of physical abuse by staff to a resident. This affected one (Resident #28) of three residents reviewed for abuse. The facility census was 26. Residents Affected - Few Findings Include Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (3.0) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and required extensive assistance for two staff persons for completing her activities of daily living. Review of the incident report dated 05/25/24 revealed State Tested Nursing Assistant (STNA) #900 stated at about 11:40 P.M. on 05/24/24 she was sitting and doing daily charting when she heard screaming coming from Resident #28's room. Upon entering the room STNA #900 noted that Resident #28 was physically combative with STNA #901 whom was attempting to provide incontinence care. STNA #900 and STNA #901 worked together to calm Resident #28 down and successfully completed incontinence care. STNA #900 then stated after the incontinence care was completed STNA #901 laid Resident #28 down on the bed and subsequently smacked her on her head and told Resident #28 to quit that. Upon witnessing the incident STNA #900 stated to STNA #901 that she couldn't believe STNA #901 would do that STNA #901 replied She couldn't believe it either. Review of the statement provided by Licensed Practical Nurse (LPN) #999 dated dated 05/25/24 revealed she was made aware of the incident by STNA # 900 on 05/24/24 at 11:45 P.M. Upon notification LPN #999 immediately assessed Resident #28 with no negative findings. LPN #999 texted the Director of Nursing (DON) on 05/25/24 at 12:22 A.M., called the DON on 05/25/24 at 12:26 A.M. and left a voice mail, and called the Administrator/owner on 05/25/24 at 1:17 A.M. and left a voice mail. STNA #901 was not removed from her duties and continued to work the overnight shift the night of the incident 05/24/24-05/25/24. Further review of the investigation in the incident report revealed no residents were interviewed regarding observations of the 05/24/24 incident or any instances of care concerns with STNA #901. Review of the policy entitled Abuse, Neglect and Misappropriation/Property dated 04/01/24 revealed when an incident or suspected incident is reported, the director of nursing or appointed designee will investigate the incident along with appropriate personal. Investigation protocols in the facilities policy included Interview resident and obtain written statement if applicable. The Administrator and DON in an interview on 07/06/24 at 10:00 A.M. verified that the facility did not interview residents regarding the alleged abuse incident between STNA #901 and Resident #28. This deficiency represents non-compliance investigated under Complaint Number OH00155240. . 366031 Page 3 of 3