Health inspection·December 5, 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 interviews, review of the facility Self-Reported Incident, review of facility witness statements, and review of facility policy, the facility failed to ensure an allegation of physical abuse was reported timely and appropriately. This affected one resident (#39) of the three residents reviewed for abuse during the complaint survey. The facility census was 55. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, dementia with psychotic disturbance, and psychosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/15/24, revealed the resident was rarely/never understood and had long and short term memory problems. Review of the facility Self-Reported Incident (SRI), dated 12/01/24 and timed 11:44 A.M., revealed on 12/01/24 at 11:09 A.M. Activities Director #500 reported to the Administrator an allegation of abuse by Certified Nursing Assistant (CNA) #111 against Resident #39. No notification to the local law enforcement agency or the residents family or representative were documented. The Administrator unsubstantiated the allegation of abuse due to the he said,she said nature with no real evidence that the abuse occurred. Review of the witness statement for CNA #100, obtained on 12/03/24, revealed on 12/01/24 at approximately 7:40 A.M. CNA #100 and CNA #111 were providing care for Resident #39 when the resident became combative with the staff members. CNA #111 reportedly was rough with the resident while moving the residents limbs to get her dressed. Once dressed, CNA #100 and CNA #111 were able to transfer Resident #39 to her wheelchair but during the process the resident attempted to bite CNA #111 and the CNA responded by pushing the residents head roughly while stating Don't bite me. Resident #39 was still attempting to bite CNA #111 and the CNA responded by open-handed smacking and pushing the residents head to the side with enough force to move CNA #100 who was on the other side of the resident. CNA #100 reported she could only gasp during the incident as it was a complete surprise to her. CNA #100 and CNA #111 then brushed the residents hair and straightened her shirt out. CNA #100 reported inspecting the residents head where CNA #111 had smacked her before CNA #111 wheeled the resident out to the lobby. Review of the witness statement for Hospice Employee #500, dated 12/04/24, revealed on 12/01/24 between 10:00 A.M. and 11:00 A.M., CNA #100 a residents room to answer a call light and asked Hospice (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: 366250 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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)