Health inspection·March 14, 2025

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 review of the facility's Self-Reported Incidents (SRI), facility investigation documentation, staff interview, and review of facility policy, the facility failed to ensure staff were immediately removed from the floor when allegations of staff to resident verbal abuse occurred. This affected one resident (#5) of four residents reviewed. The facility census was 65. Residents Affected - Few Findings Include: Review of Resident #5's medical record revealed an admission date of 02/08/22 and a discharge date of 02/27/25. Diagnoses included major depressive disorder, altered mental status, type II diabetes, anxiety disorder, chronic pain, and insomnia. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required supervision with toilet use and personal hygiene. Resident #5 was independent with dressing, transfer and mobility. Resident #5 required maximal assistance with bathing. Resident #5 displayed no behaviors at the time of the review. Review of Resident #5's care plan canceled 02/28/25 revealed supports and interventions for self-care deficit, anemia, pain, diabetes, and depression. Review of the facility's Self-Reported Incident (SRI) 255532 revealed on 12/27/24 staff witnesses reported Certified Nursing Assistant (CNA) #499 was frustrated and argumentative with Resident #5. Review of the investigation documentation found on 12/27/24 at approximately 5:00 P.M. Resident #5 was seated in the dinning room, got up and went back to her room to get her dentures. Resident #5 was still in her room when her dinner tray came out of the kitchen and CNA #499 took Resident #5's dinner tray down to her room. Resident #5 was reported to have been cussing and yelling at CNA #499. CNA #499 was observed coming out of Resident #5's room with a raised voice saying Resident #5 was not going cuss at her when she was doing what she was told to do. She proceeded to drop Resident #5's dinner tray on the nurses station counter. CNA #499 was directed by Registered Nurse (RN) #572 to place the tray back at Resident #5's seat in the dining room. CNA #499 complied and was overheard continuing to yell and argue with Resident #5. It was noted CNA #499 grabbed her coat and went out to take a smoke break. CNA #499 commented she was getting agitated and it was what she was told to do. CNA #499 was noted to have stayed out of the building for about 20 minutes before returning to the floor. In CNA #499's statement she indicated she came back into the facility and spoke with another unidentified staff about getting through the night and it would get better. At 6:38 P.M. the Director of Nursing (DON) received a phone call about the situation and advised RN #572 to have CNA #499 to go home. At approximately 7:07 P.M. Licensed Practical Nurse (LPN) #548 told CNA #499 the DON wanted her to Page 1 of 2 366125 366125 03/14/2025 Divine Rehabilitation and Nursing at Shane Hill 10731 State Route 118 Rockford, OH 45882

F 0610 Level of Harm - Minimal harm or potential for actual harm leave the building that night and to call in on Monday. At 7:15 P.M. CNA #499 clocked out. CNA #499 sent a text on 12/27/24 at 7:19 P.M. to the DON for confirmation she was to leave the building and reported she had already clocked out. The concern for staff to resident verbal abuse began on 12/27/24 at approximately 5:00 P.M. and CNA #499 continued to work in the facility until 7:15 P.M. when she clocked out. CNA #499 remained in the facility for approximately two hours after the concern arose. Residents Affected - Few Interview on 03/14/25 at 12:54 P.M. with the Director of Nursing (DON) and the Administrator verified the verbal altercation began between CNA #499 and Resident #5 at approximately 5:00 P.M. and CNA #499 remained in the facility until 7:15 P.M. when she clocked out. Review of the facility policy titled, Abuse, Neglect, and Exploitation, revised August 2024 revealed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after the investigation. The staff were to respond immediately to protect the alleged victim. 366125 Page 2 of 2