Health inspection·March 19, 2025

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 review of facility submitted Self-Reported Incidents (SRIs), medical record review, staff interview, review of the facility investigation and review of facility policy, the facility failed to report an allegation of resident abuse to the Ohio Department of Health (ODH). This affected one (#03) of three residents reviewed for abuse. The facility census was 43. Findings include: Review of Resident #03's medical record revealed an admission date of 08/09/24. Diagnoses include dementia, depression, anxiety disorder, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #03 was cognitively impaired and required maximal staff assistance with activities of daily living (ADLs) and supervision with ambulation. Further review of Resident #03's medical record revealed no evidence of an incident involving potential abuse. Review of the facility submitted SRIs from 01/30/25 through 03/10/25 revealed no reported allegations of abuse involving Resident #03. Interview on 03/19/25 at 8:35 A.M. with the Administrator revealed on 03/03/25 ,Certified Nursing Assistant (CNA) #110 reported an allegation of abuse against Resident #03, perpetrated by Registered Nurse (RN) #112. CNA #110 did not witness the alleged abuse, but was informed about it by CNA #175. Former Director of Nursing (FDON) #200 was immediately notified and interviewed CNA #108, CNA #107, and RN #112. The Administrator stated Resident #03 had required a lot of attention from RN #112 that day. A CNA reported to RN #112 that another resident was having respiratory distress and needed RN #112. Reportedly, RN #112 rushed past Resident #03 and bumped shoulder to shoulder with the resident. Resident #03 did not stumble or fall during the incident. The Administrator stated CNA #110 apologized before the end of the shift and retracted the allegation. The Administrator confirmed the incident was not reported to the Ohio Department of Health as she felt the incident had been fully investigated and found the facility was not out of compliance. Review of the facility investigation, dated 03/03/25, confirmed the facility investigated the allegation of abuse, with no negative findings. Review of the facility policy titled, Abuse, Mistreatment, Exploitation, and Misappropriation of Resident Property, undated, revealed all allegations of abuse or serious bodily injury should be (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 2 Event ID: 366171 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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)