Health inspection·September 16, 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 staff interview, medical record review, and review of facility policy, the facility failed to report an allegation of verbal abuse to the state survey agency (SSA). This affected one (#66) of two residents reviewed for abuse. The facility census was 93. Findings include:Review of Resident #66's medical record revealed an admission date of 12/13/24. Diagnoses included chronic peripheral venous insufficiency, cerebral infarction (stroke), and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Review of the plan of care, initiated 12/27/24, revealed Resident #66 experienced an alteration in mood or behavior as evidenced by being paranoid and making false accusations regarding staff. Interventions included to contact the resident's family for support as needed, explain procedures before beginning them, provide medications as ordered, and observe and report any changes in mental status. During an interview on 09/10/25 at 10:59 AM, the Director of Nursing (DON) stated that on 07/09/25 a staff member, whose name she could not recall, approached her and stated that Resident #66 wanted to speak to her. The DON stated she spoke with Resident #66 directly, and the resident alleged that a staff member, Certified Nursing Assistant (CNA) #3, had cursed at them approximately one month prior (June 2025). The DON stated she interviewed the alleged perpetrator and potential witnesses, who all denied that the incident happened. The DON verified she did not report the allegation of verbal abuse involving Resident #66 to the SSA because staff stated that the incident did not occur and because the resident had an existing care plan related to making false allegations against staff. During a follow-up interview on 09/10/25 at 1:59 PM, the DON stated if a resident alleged that a staff member had cursed at them, it was considered verbal abuse, and she would report any allegation of abuse. However, according to the DON, this incident was a special instance where the resident had a known history of false allegations, and the resident did not feel threatened or experience any mental anguish. During an interview on 09/10/25 at 2:35 PM, the Administrator revealed she was unaware of Resident #66's allegation of verbal abuse until today. The Administrator stated any new allegation of abuse was investigated and treated as potentially valid, even when a resident had a care planned history of false accusations. The Administrator stated stated that with Resident #66's history of false accusations, if the DON immediately investigated the allegation, she did not expect the incident to be reported to the SSA. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the advents that caused the allegation did not involve abuse and did not result in serious bodily injury to the Administrator or designee of the facility and to other Page 1 of 2 366469 366469 09/16/2025 Siena Gardens Rehabilitation & Transitional Care 1055 State Route 125 Cincinnati, OH 45245

F 0609 officials, including the SSA in accordance with State law. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366469 Page 2 of 2