Inspection·April 11, 2023

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 medical record review, staff interview, review of a self-reported incidents, and policy review, the facility failed to timely report an allegation of resident-to-resident physical abuse. This affected two (#46 and #57) out of four residents reviewed for abuse. The census was 63. Findings include: 1. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified severe protein-calorie malnutrition, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypothyroidism, type two diabetes mellitus without complications, other schizoaffective disorders, and other recurrent depressive disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 07. The resident was assessed to require extensive assistance for bed mobility and toilet use, limited assistance for transfer and dressing, and supervision for eating and personal hygiene. 2. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease, schizoaffective disorder, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. The resident was assessed to require limited assistance for personal hygiene and dressing, and supervision for bed mobility, transfer, eating, and toilet use. Review of the self-reported incident (SRI) regarding the alleged incident involving Resident #46 and Resident #57 revealed the SRI was created and submitted to the State Survey Agency on 04/04/23. The SRI indicated the alleged incident was reported to facility staff on 03/29/23. Interview on 04/06/23 at 2:45 P.M. with Assistant [NAME] President of Clinical Support #130 confirmed the alleged incident occurred on 03/29/23 and the SRI was not timely submitted. Review of the facility policy titled, Abuse and Neglect Procedural Guidelines, revised 08/29/19, revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment, including (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 5 Event ID: 366245 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 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 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)