Inspection·April 1, 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 medical record review, review of a Self-Reported Incident (SRI), abuse policy review, and interview, the facility failed to prevent a former employee, who verbally abused a resident, from entering the facility, including resident care areas. This affected one (Resident #26) of three residents reviewed for abuse. The facility census was 40. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of [DATE] with diagnoses including Alzheimer's disease, altered mental status, dementia with moderate with agitation, insomnia, anxiety disorder, transient ischemic attack, obstructive sleep apnea and vertigo. The resident received hospice services and expired on [DATE]. Review of SRI #253615, dated [DATE], revealed while on the D Hall nursing station/dining room, Certified Nursing Assistant (CNA) #54 verbally abused Resident #26. License Practical Nurse (LPN) #52 had assisted Resident #26 to the dining room to allow the breakfast tray cart to pass up the hallway. Resident #26 immediately propelled herself back beside the nurse's station, preventing the movement of the breakfast tray cart. CNA #54 approached Resident #26 and said, I am going to hit you in the nose, with the resident stating, please don't hit me. CNA #54 propelled Resident #26 back into the dining room and said, now stay the hell here. Following the incident, CNA #54 was immediately placed on suspension pending the investigation and subsequently resigned from his employment at the facility on [DATE]. The facility substantiated the allegation of abuse. Review of the facility's survey history revealed on [DATE] an onsite complaint investigation identified a concern related to an incident of verbal abuse involving Resident #26 and CNA #54. Non-compliance was identified and certification and licensure violations were issued. Following the incident, the facility implemented corrective actions including immediately suspending CNA #54 and providing education to all staff on the facility's abuse/neglect policy. Interview on [DATE] at 1150 A.M. with an anonymous person revealed she had witnessed CNA #54 on numerous occasions in the facility following the abuse incident and his termination from employment and she has reported this to the Director of Nursing (DON) who had done nothing about it. The Anonymous person stated they observed CNA #54 in the facility and had attended the Christmas party in [DATE]. The anonymous person stated the Director of Nursing also attended the Christmas party and knew CNA #54 was in the facility. Interview on [DATE] at 11:25 A.M. with Licensed Practical Nurse (LPN) #4 verified CNA #54 has been in the facility on several occasions to use the bathroom or sit in the nursing station until she is (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: 366249 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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)