form approved centers for medicare & medicaid services b. wing AKRON OH, (X5) PREFIX COMPLETIO TAG PREFIX TAG F 0000

Transcription

1 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction (X3) DATE SURVEY COMPLETED b. wing 01/05/2016 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Holly Gerbasich CERTIFIED BED CAPACITY: 82 CENSUS: 49 MEDICARE: 4 MEDICAID: 37 OTHER: 8 At the time of the complaint investigation completed on 01/05/16, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:510B11 Facility ID:OH00995 if continuation sheet Page 1 of 1

2 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECED ED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION MASTER COMPLAINT NUMBER OH COMPLAINT NUMBER OH COMPLAINT NUMBER OH ADMINISTRATOR: Jena L. Dickman CERTIFIED BED CAPACITY: 82 CENSUS: 50 MEDICARE: 1 MEDICAID: 33 OTHER: 16 The following deficiencies are based on the complaint investigation completed on 01/08/14. No deficiencies were issued in regards to allegations contained in Complaint Number OH or Complaint Number OH laboratory director's or provider/supplier representative's signature title JENODJeKMON (x6) date 02/06/2014 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. form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 1 of 6

3 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F (c)(1)(ii)-(iii), (c)(2) - (4) F 0225 This plan of correction is prepared because it 02/06/2014 SS=D INVESTIGATE/REPORT is required by State and Federal law and not ALLEGATIONS/INDIVIDUALS because Windsong Care Center agrees with The facility must not employ individuals the allegations and citations listed on pages who have been found guilty of abusing, 1-9 of this statement of deficiencies. neglecting, or mistreating residents by a Windsong Care Center does not admit any court of law; or have had a finding entered deficiency is present. Further the submission into the State nurse aide registry of a Plan of Correction and the changes in concerning abuse, neglect, mistreatment any policy, procedure or activity is not an of residents or misappropriation of their admission of a deficiency. Windsong Care property; and report any knowledge it has Center is constantly reviewing and revising its of actions by a court of law against an policies, procedures and methods of health employee, which would indicate unfitness care service delivery. There are no for service as a nurse aide or other facility "subsequent remedial measures" undertaken staff to the State nurse aide registry or in response to the SOD and no admission can licensing authorities. be inferred from Windsong Care Center continuing process of enhancing the facilities The facility must ensure that all alleged practices. violations involving mistreatment, neglect, Windsong Care Center maintains that the or abuse, including injuries of unknown alleged deficiencies do not individually or source and misappropriation of resident collectively jeopardize the health and safety of property are reported immediately to the the residents, nor is there any potential for administrator of the facility and to other more than minimal harm as a result of any officials in accordance with State law action, practice, situation or incident alleged in through established procedures (including the SOD. to the State survey and certification This plan of correction shall operate as agency). Windsong Care Center written credible allegation of compliance effective January 22, The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is F 225 in progress. Resident #3 was discharged from the facility on 4/28/13. The results of all investigations must be Facility Director of Nursing was re-educated reported to the administrator or his on abuse policy and procedure by facility designated representative and to other Administrator on Re-education/policy officials in accordance with State law included immediate notification to (including to the State survey and Administrator of any/all allegations, initiating form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 2 of 6

4 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE certification agency) within 5 working days an immediate initial report to the State of the incident, and if the alleged violation Agency, suspension from duties of any is verified appropriate corrective action alleged perpetrator pending investigation must be taken. ensuring a thorough investigation of the allegation and submitting a final report to the State Agency within five (5) working days Facility Staff to be re-educated on facility This STANDARD is not met as evidenced Abuse policy and procedure by by: Administrator/designee. Re-education to be Based on record review and interview, the completed by facility failed to report an abuse allegation All abuse investigations to be reviewed by involving Resident #3. This affected one Administrator prior to submission of final resident (Resident #3) of three residents report to State Agency to ensure a thorough reviewed related to abuse. The facility investigation was completed. The facility will census was 50. communicate to Residents and Responsible Parties from the Administrator, the facility Findings include: concern and grievance process to include notification of any concern up to and including Resident #3 was admitted 01/31/13 with abuse. A letter will be given to all Residents diagnoses including status-post surgical and Responsible Parties as well as included repair of a fractured hip, atrial fibrillation, in the admission packet. Residents will be diabetes mellitus, congestive heart failure, educated monthly at Resident Council dementia and metabolic encephalopathy. meetings regarding facility concern and grievance process, abuse policy, and resident According to a Resident/Family Concern rights. Form, on 04/01/13 at 3:00 P.M. the All allegations of abuse will be reviewed director of nursing (DON) was notified by monthly by the QA committee to ensure Resident #3's wife regarding an allegation continued compliance with the facility abuse of inappropriate touch between a licensed policy/procedure. practical nurse (LPN #1) and the resident The potential exists for all residents in the which allegedly occurred on 03/29/13. facility to be affected by deficient practice relating to citation. All current Resident, The facility's investigation consisted on a Responsible Parties/Resident Sponsors, if statement from LPN #1, but there was no applicable, were interviewed to determine: date reflecting when the statement was 1. Do you feel that you have been abused or obtained. There were no other interviews neglected? completed. There was no evidence of an 2. Have you had anything of value taken attempt to obtain a resident statement or from you? to assess any potential psychosocial 3. Do you feel safe at Windsong? form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 3 of 6

5 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE distress, and no interviews from other residents for whom LPN #1 had provided care. Review of the facility's policy and procedure for Resident Abuse, dated May 2008 indicated an investigation protocol should include interviews with anyone who worked closely with the accused employee and /or alleged victim the day of the incident. Review of the time card log for LPN #1 revealed that she worked on 04/01/13 from 6:41 A.M. through 3:41 P.M. and on 04/02/13 from 7:35 A.M. through 5:14 P.M. as well as the rest of that week through 04/05/13. According to the Concern Form, LPN #1 "was advised not to enter that resident's room again." 4. If you felt that you were abused, neglected or had anything of value taken from you, would you feel comfortable reporting it to facility staff? The facility will follow the facility grievance/concern process and abuse policy for any areas of concern identified during the interviews. To ensure continued compliance, random Resident, Responsible Party/Resident Sponsor interviews will be conducted weekly times 4 weeks and the findings will be reported on in facility's monthly QA committee. On 01/06/14 at 1:30 P.M. the DON confirmed that LPN #1 was not suspended pending the investigation, the investigation was not thorough and the allegation was not reported to the State agency as required. This deficiency substantiates Complaint Number OH form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 4 of 6

6 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F (c) DEVELOP/IMPLMENT F 0226 F226 02/06/2014 SS=D ABUSE/NEGLECT, ETC POLICIES Resident #3 was discharged from the facility The facility must develop and implement on 4/28/13. written policies and procedures that Facility Director of Nursing was re-educated prohibit mistreatment, neglect, and abuse on abuse policy and procedure by facility of residents and misappropriation of Administrator on Re-education/policy resident property. included immediate notification to Administrator of any/all allegations, initiating an immediate initial report to the State Agency, suspension from duties of any This STANDARD is not met as evidenced alleged perpetrator pending investigation by: ensuring a thorough investigation of the Based on record review and interview the allegation and submitting a final report to the facility failed to implement their abuse State Agency within five (5) working days policy and procedures regarding an Facility Staff to be re-educated on facility allegation of abuse involving Resident #3. Abuse policy and procedure by This affected one resident (Resident #3) Administrator/designee. Re-education to be of three residents reviewed related to completed by abuse. The facility census was 50. All abuse investigations to be reviewed by Administrator prior to submission of final Findings include: report to State Agency to ensure a thorough investigation was completed. The facility will Resident #3 was admitted 01/31/13 with communicate to Residents and Responsible diagnoses including status-post surgical Parties from the Administrator, the facility repair of a fractured hip, atrial fibrillation, concern and grievance process to include diabetes mellitus, congestive heart failure, notification of any concern up to and including dementia and metabolic encephalopathy. abuse. A letter will be given to all Residents and Responsible Parties as well as included According to a Resident/Family Concern in the admission packet. Residents will be Form, on 04/01/13 at 3:00 P.M. the educated monthly at Resident Council director of nursing (DON) was notified by meetings regarding facility concern and Resident #3's wife regarding an allegation grievance process, abuse policy, and resident of inappropriate touch between a licensed rights. practical nurse (LPN #1) and the resident All allegations of abuse will be reviewed which allegedly occurred on 03/29/13. monthly by the QA committee to ensure continued compliance with the facility abuse The facility's investigation consisted on a policy/procedure. statement from LPN #1, but there was no The potential exists for all residents in the date reflecting when the statement was facility to be affected by deficient practice form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 5 of 6

7 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 01/08/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE obtained. There were no other interviews completed. There was no evidence of an attempt to obtain a resident statement or to assess any potential psychosocial distress, and no interviews from other residents for whom LPN #1 had provided care. Review of the facility's policy and procedure for Resident Abuse dated May 2008 indicated an investigation protocol should include interviews with anyone who worked closely with the accused employee and /or alleged victim the day of the incident. Review of the time card log for LPN #1 revealed that she worked on 04/01/13 from 6:41 A.M. through 3:41 P.M. and on 04/02/13 from 7:35 A.M. through 5:14 P.M. as well as the rest of that week through 04/05/13. According to the Concern Form, LPN #1 "was advised not to enter that resident's room again." relating to citation. All current Resident, Responsible Parties/Resident Sponsors, if applicable, were interviewed to determine: 1. Do you feel that you have been abused or neglected? 2. Have you had anything of value taken from you? 3. Do you feel safe at Windsong? 4. If you felt that you were abused, neglected or had anything of value taken from you, would you feel comfortable reporting it to facility staff? The facility will follow the facility grievance/concern process and abuse policy for any areas of concern identified during the interviews. To ensure continued compliance, random Resident, Responsible Party/Resident Sponsor interviews will be conducted weekly times 4 weeks and the findings will be reported on in facility's monthly QA committee. On 01/06/14 at 1:30 P.M. the DON confirmed that LPN #1 was not suspended pending the investigation, the investigation was not thorough and did not include interviews with anyone who worked closely with the accused employee and/or alleged victim the day of the incident as per the abuse policy. The DON also verified the allegation was not reported to the State agency as required. This deficiency substantiates Complaint Number OH form cms-2567(02-99) previous versions obsolete Event:T30Q11 Facility ID:OH00995 if continuation sheet Page 6 of 6

8 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 02/04/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Teresa Lane CERTIFIED BED CAPACITY: 82 CENSUS: 48 MEDICARE: 3 MEDICAID: 34 OTHER: 11 At the time of the complaint investigation completed on 02/04/15, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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. form cms-2567(02-99) previous versions obsolete Event:YNPC11 Facility ID:OH00995 if continuation sheet Page 1 of 1

9 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 02/24/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION MASTER COMPLAINT NUMBER OH COMPLAINT NUMBER OH COMPLAINT NUMBER OH ADMINISTRATOR: Teresa Lane, # CERTIFIED BED CAPACITY: 82 CENSUS: 54 MEDICARE: 4 MEDICAID: 30 OTHER: 20 At the time of the complaint investigation completed on 02/24/14, Windsong Care Center is in compliance with the Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Master Complaint Number OH , Complaint Number OH and Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:V55M11 Facility ID:OH00995 if continuation sheet Page 1 of 1

10 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 03/01/2016 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0000 INITIAL COMMENTS F 0000 ADMINISTRATOR: Holly Gerbasich CERTIFIED BED CAPACITY: 82 CENSUS: 45 MEDICARE: 2 MEDICAID: 36 OTHER: 7 At the time of the complaint survey completed on 03/01/16, Windsong Care Center is in substantial compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:KY1J11 Facility ID:OH00995 if continuation sheet Page 1 of 1

11 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 04/16/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION MASTER COMPLAINT NUMBER OH COMPLAINT NUMBER OH ADMINISTRATOR: Teresa Lane, # CERTIFIED BED CAPACITY: 82 CENSUS: 51 MEDICARE: 4 MEDICAID: 32 OTHER: 15 At the time of the complaint investigation completed on 04/17/14, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Master Complaint Number OH and Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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. form cms-2567(02-99) previous versions obsolete Event:DIZL11 Facility ID:OH00995 if continuation sheet Page 1 of 1

12 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 04/18/2016 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Kim Murphy, # CERTIFIED BED CAPACITY: 82 CENSUS: 47 MEDICARE: 4 MEDICAID: 16 OTHER: 27 At the time of the complaint investigation completed on O4/18/16, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:2HVS11 Facility ID:OH00995 if continuation sheet Page 1 of 1

13 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION PARTIAL EXTENDED SURVEY MASTER COMPLAINT NUMBER OH AND COMPLAINT NUMBER OH ADMINISTRATOR: Teresa Lane CERTIFIED BED CAPACITY: 82 CENSUS: 52 MEDICARE: 4 MEDICAID: 40 OTHER: 12 At the time of the complaint investigation and partial extended survey completed on 06/10/15, no deficiencies were issued in regard to allegations contained in Master Complaint Number OH and Complaint Number OH The following deficiencies are based on incidental findings discovered during the course of this complaint investigation. laboratory director's or provider/supplier representative's signature title (x6) date K M U r e M L E 07/06/2015 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. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 1 of 17

14 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0157 Continued From page 1 F 0157 F (b)(11) NOTIFY OF CHANGES F 0157 This plan of correction is prepared because it 06/29/2015 SS=D (INJURY/DECLINE/ROOM, ETC) is required by State and Federal law and not A facility must immediately inform the because Windsong Care Center agrees with resident; consult with the resident's the allegations and citations listed of this physician; and if known, notify the statement of deficiencies. Homestead II does resident's legal representative or an not admit any deficiency is present. Further interested family member when there is the submission of a Plan of Correction and an accident involving the resident which the changes in any policy, procedure or results in injury and has the potential for activity is not an admission of a deficiency. requiring physician intervention; a Homestead II is constantly reviewing and significant change in the resident's revising its policies, procedures and methods physical, mental, or psychosocial status of health care service delivery. There are no (i.e., a deterioration in health, mental, or "subsequent remedial measures" undertaken psychosocial status in either life in response to the SOD and no admission can threatening conditions or clinical be inferred from Homestead II continuing complications); a need to alter treatment process of enhancing the facilities practices. significantly (i.e., a need to discontinue an Windsong Care Center maintains that the existing form of treatment due to adverse alleged deficiencies do not individually or consequences, or to commence a new collectively jeopardize the health and safety of form of treatment); or a decision to the residents, nor is there any potential for transfer or discharge the resident from the more than minimal harm as a result of any facility as specified in o483.12(a). action, practice, situation or incident alleged in the SOD. The facility must also promptly notify the This plan of correction shall operate as resident and, if known, the resident's legal Windsong Care Center's written credible representative or interested family allegation of compliance effective 6/29/15. member when there is a change in room or roommate assignment as specified in F157 o483.15(e)(2); or a change in resident The facility will notify the Physician of rights under Federal or State law or significantly abnormal lab results. regulations as specified in paragraph (b) Residents #57 and #59 have been discharged (1) of this section. from the facility. No adverse effects were noted to either Resident # 57 or Resident # 59 The facility must record and periodically as a result of the abnormal labs prior to update the address and phone number of discharge home. the resident's legal representative or interested family member. All residents have the potential to be affected; therefore, an audit of current residents' lab form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 2 of 17

15 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0157 Continued From page 2 F 0157 This STANDARD is not met as evidenced by: Based on record review and staff interview, the facility failed to notify the physician of significantly abnormal laboratory results. This affected two (Residents #57 and #59) of six residents reviewed. Findings include: 1. Review of the medical record revealed Resident #59 was admitted to the facility on 04/15/14 with diagnoses that included acute choledocholithiasis (gall stones), hypertension, status post gall bladder removal. Physician progress note dated 04/29/15, documented the resident complained of abdominal pain that was not relieved with pain medications. Laboratory blood work results dated 04/27/15 for a blood chemistry test were abnormal as follows, with normal values in parentheses: results was conducted by the DON/ADON and completed by 6/17/2015, audit did not identify any other significantly abnormal/critical lab results that went unreported to the Physician. DON/Designee re-educated licensed nurses regarding notification of Physician with any significantly abnormal lab result on 6/11/2015. DON/Designee will monitor for compliance of timely physician notification of critical/significantly abnormal lab results 5 x week during daily rounds ongoing. Audit results will be forwarded to the Quality Assurance Committee for further review and recommendations. Protein = 5.4 Low ( g/dl) Albumin = 2.8 Low ( g/dl) Alkaline Phos = 888 High ( IU/L) AST (SGOT) = 410 High (4-40 IU/L) ALT (SGPT) = 405 High (4-55 IU/L) There was no documentation that Resident #59's physician was notified of the grossly abnormal laboratory levels. Resident #59 was transferred to the hospital on 04/29/15 for possible surgical removal of gall stones. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 3 of 17

16 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0157 Continued From page 3 F Review of the medical record revealed Resident #57 was admitted to the facility on 04/02/15 with diagnoses that included diabetes mellitus, chronic kidney disease, high cholesterol, and generalized muscle weakness. A laboratory test completed on 04/22/15 for a renal panel had abnormal results as follows, with normal results in parentheses: Carbon Dioxide = 16 Low (21-33 meq/l) BUN = 80 Critically High Level (7-21 mg/dl) Creatinine = 3.0 High ( mg/dl) Albumin = 2.7 = Low ( g/dl) There was no documentation that Resident #57's physician was notified of the abnormal lab results. The above information was verified with Corporate Nurse #10 on 05/27/15 at 12:45 P.M. Corporate Nurse #10 stated the residents' physicians should have been notified of the abnormal lab results as soon as the facility received the results. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 4 of 17

17 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 4 F 0223 F (b), (c)(1)(i) FREE FROM F 0223 F /29/2015 SS=J ABUSE/INVOLUNTARY SECLUSION The facility will prevent abuse to residents. The resident has the right to be free from Resident #27 remains in the facility. verbal, sexual, physical, and mental Resident #27 has had no adverse effects abuse, corporal punishment, and from the incident. Resident does not involuntary seclusion remember the incident. The resident's care plan was updated with interventions to be The facility must not use verbal, mental, used when resident exhibits restiveness to sexual, or physical abuse, corporal care. punishment, or involuntary seclusion. All residents have the potential to be affected by the deficient practice. This STANDARD is not met as evidenced by: We believe the deficient practice was addressed and remedied with the termination Based on medical record review, staff of the STNA #3, but no later than the interview, review of personnel records, in-servicing of all staff which occurred prior to and review of facility self-reported incident survey exit. reports, the facility failed to prevent physical abuse to one resident (Resident We believe we did more than required after #27). This resulted in Immediate the incident, but prior to the survey exit, Jeopardy for one resident (Resident #27) including: when a staff member held her arm down and spit in her face during care. Resident On 04/23/15 at 9:26 P.M., STNA #3 was sent #27 sustained a five inch by two inch home from work and did not return to work at bruise to the left wrist and forearm. This the facility. affected one of two residents reviewed in self-reported incidents for abuse and On 04/23/15, 04/24/15 and 04/25/15, The injury of unknown origin. DON/designees completed skin checks on current residents and found no new or On 06/01/15 at 3:23 P.M. the unexplained injuries. The skin checks were Administrator, Director of Nursing (DON), reviewed by the DON. and Regional Nurse #12 were notified that Immediate Jeopardy began on 04/22/15 On 04/24/15, Therapy Director #13, Social at 8:30 P.M. when State-Tested Nurse Service Director #14, Business Office Aide (STNA) #3 held down Resident #27's Manager #15 and Maintenance Director #16 arm during care and spit in the resident's interviewed the current interviewable face. This was witnessed by STNA #1 residents specifically in regard to STNA #1, form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 5 of 17

18 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 5 F 0223 and STNA #2. The incident was not reported until 04/23/15 at 9:25 P.M., when STNA #1 informed Licensed Practical Nurse (LPN) #4 of the incident. LPN #4 notified the DON on 04/23/15 at 9:26 P.M. and was instructed to immediately send STNA #3 home. Resident #27 was assessed from head to toe and a 5.2 inch by 2 inch area of ecchymosis (bruise) that was pale blue in color was noted on the left wrist and forearm The Immediate Jeopardy was removed on 04/24/15 when the facility implemented the following corrective actions: STNA #2 and STNA #3, and the care provided by them. All of these residents were also interviewed in regard to abuse or neglect since they resided in the facility and what they would do if they were abused. On 04/23/15, and 04/24/15, the DON and the Administrator/DON conducted inservice training on abuse reporting, intervention, and dealing with residents with behaviors. On 05/07/15, 05/29/15, 6/2/15 various staff members attended the Crisis Prevention Institute - Maintaining Safety in the Nonviolent Crisis Intervention Training Program.. On 04/23/15 at 9:26 P.M., STNA #3 On 05/01/15, STNA #1, STNA#2 and STNA#3 was sent home from work and did not were terminated from employment by the return to work at the facility. facility. On 04/23/15, 04/24/15 and 04/25/15, The NHA/designee began to randomly the DON, Registered Nurse (RN) #5, RN interview residents to determine whether any #11, RN #18, LPN #4, LPN #19, LPN #20, other potential abuse/allegations existed as LPN #21, and LPN #22, completed skin well as ensure they knew how to report such checks on all 53 residents and found no occurences as necessary. new or unexplained injuries. The skin checks were reviewed by the DON. The NHA/designee began to randomly interview facility staff with situational questions On 04/24/15, Therapy Director #13, to determine their competency with how to Social Service Director #14, Business react to a potential abuse situation as well as Office Manager #15 and Maintenance to determine whether any other potential for Director #16 interviewed the 41 abuse/abuse allegations existed that they interviewable residents specifically in were aware of. regard to STNA #1, STNA #2 and STNA #3, and the care provided by them. All of In response to ODH's opinion of on-going these residents were also interviewed in non-compliance and not because the facility regard to abuse or neglect since they feels a deficient practice still exists, facility resided in the facility and what they would Staff were again re-educated by form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 6 of 17

19 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 6 F 0223 do if they were abused. On 04/23/15, and 04/24/15, the DON and the Administrator conducted inservice training on abuse reporting, intervention, and dealing with residents with behaviors for 14 STNAs, 5 LPNs, 5 RNs, 7 Dietary Staff, 8 Housekeeping Staff, 13 Therapy Staff, 2 Activities Staff and 1 Social Service Staff. On 04/24/15, the DON and the Administrator interviewed 13 STNAs, 3 RNs and 4 LPNs in person or by phone in regard to witnessed abuse or neglect involving STNA #1, STNA #2 and STNA #3 and whether they ever witnessed any employee of the facility abuse or neglect any resident. They were also interviewed in regard to knowledge of abuse and/or neglect reporting. On 05/01/15, 3 STNAs, 2 RNs, 1 Therapy Staff, 1 Dietary Staff, the Business Office Manager #15 and Director of Maintenance #16, attended the Crisis Prevention Institute - Maintaining Safety in the Nonviolent Crisis Intervention Training Program. DON/designee by 6/29/15 regarding managing residents with dementia, residents with behaviors, abuse policy and timeliness of reporting allegations of abuse. Random staff interviews to be conducted by Administrator/Designee 2x week for 4 weeks with situational questions to determine their competency with how to react to a potential abuse situation as well as to determine whether any other potential for abuse/abuse allegations exist that they are aware of. Random resident interviews to be completed by Administrator/designee 2x week for 4 weeks to determine whether any other potential abuse/allegations exist as well as ensure they knew how to report such occurences as necessary. Audit results will be forwarded to the Quality Assurance Committee for further review and recommendations. On 05/01/15, STNA #1, STNA#2 and STNA#3 were terminated from employment by the facility. On 05/07/15, 3 STNAs, 1 RN, 7 Therapy Staff, 1 Housekeeping Staff attended the Crisis Prevention Institute - Maintaining Safety in the Nonviolent Crisis form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 7 of 17

20 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 7 F 0223 Intervention Training Program. A third training session was scheduled for 06/02/15 for 12 STNAs, 1 RN and 4 LPNs. On 05/29/15, the DON and Administrator conducted another inservice training on abuse reporting, intervention, and dealing with residents with behaviors for 1 Housekeeping Staff, 1 Dietary staff and two Therapy staff. On 06/02/15, from 9:10 A.M. until 10:00 A.M. the surveyor interviewed STNA #7, STNA #8, STNA #9, LPN #10 and RN #1 regarding abuse, neglect, misappropriation, reporting, and protection of residents. All answered the abuse questions correctly and stated they would report any suspected abuse, neglect and misappropriation immediately to a supervisor. All stated they were recently in-serviced at the end of April or early May for abuse, neglect, reporting and dealing with residents with behaviors. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as training on abuse reporting, intervention, and dealing with residents with behaviors has not been completed for all staff including 5 STNAs, 1 RN and 1 Housekeeping staff. Findings include: form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 8 of 17

21 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 8 F 0223 Review of the medical record revealed Resident #27 was admitted to the facility on 07/06/09 with diagnoses that included dementia with behavior disturbance, anxiety and depressive disorder. Review of a facility self-reported incident (SRI) dated 04/23/15, revealed an incident of witnessed abuse that the facility substantiated. The report indicated STNA #1 reported to LPN #4 on 04/23/15 at 9:25 P.M., that on 04/22/15 at approximately 8:30 P.M., STNA #1 was assisting STNA #2 in providing care for Resident #27. Resident #27 was resistive to care and combative with staff. STNA #3 entered the room to provide further assistance. STNA #1 and STNA #2 witnessed STNA #3 hold Resident #27's arms down and then spit in the resident's face. LPN #4 reported this to the DON on 04/23/15. Review of STNA #1's written statement dated 04/23/15, revealed STNA #3 grabbed Resident #27's arms by the wrist and held her arms back. STNA #3 then told the resident, "You better not bite me. You already bit me once and I had to go to the hospital. I promise you'll never bite me again." Resident #27 then blew her lips and spit at STNA #3. STNA #3 then spit on Resident #27's face and it landed on her cheek. STNA #3 let go of the resident's arms and said, "Now wipe it off." Review of the facility's investigation report form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 9 of 17

22 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 9 revealed the allegation of physical abuse was substantiated when the facility determined that STNA #3 held down Resident #27's arms and spit in her face in retaliation for the resident spitting in STNA #3's face. F 0223 Review of a nursing progress note dated 04/23/15 at 9:26 P.M., and written by the DON, indicated the DON received a call from LPN #4 who stated STNA#1 told her that on 04/22/15 at approximately 8:30 P.M., she and STNA#2 were assisting Resident #27 to bed. The resident was agitated, yelling and swinging her arms around. RN #5 entered the room and attempted to calm and reassure Resident #27. The STNAs were able to transfer the resident to bed. Once in bed, Resident #27 became agitated again. STNA#3 entered the room and held on to the resident's arm. Resident #27 started spitting and STNA#3 told the resident not to spit, and then STNA#3 spit at the resident. The DON instructed LPN #4 to send STNA#3 home. Resident#27 was assessed from head to toe. An area of ecchymosis (bruising) was observed on her left anterior wrist and forearm, 5.2 inches by 2 inches and pale blue in color. Review of the undated, written statement provided by RN #5 referenced the incident on 04/22/15 and revealed that after Resident #27 was in bed, RN #5 asked STNA #1, STNA #2 and STNA #3 if they required more assistance and they expressed they did not. RN #5 left the form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 10 of 17

23 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 10 room. At that time, RN #5 did not observe a bruise on Resident #27's arm. On the morning of 04/23/15 (no time provided), STNA #6 showed RN #5 the bruise on Resident #27's left arm. F 0223 Review of a nursing progress note for Resident #27 dated 04/24/15 at 7:51 A.M. and written by the DON, documented there was an ecchymotic area on the left anterior wrist and forearm that was purple with red edges and measured 5.2 inches by 2 inches. The above information was verified with the DON on 05/27/15 at 3:19 P.M. The DON stated that the facility substantiated the abuse occurred and that STNA #3 was terminated from the facility. Review of the facility investigation report documented that upon notification of the 04/22/15 incident; the facility initiated an investigation and notified the State agency. STNA #3 was sent home from the facility. Review of STNA #3's time card/punch detail revealed the STNA clocked out on 04/23/15 at 9:25 P.M. STNA #3 did not punch in to work again after that. Review of STNA #3's personnel file revealed STNA #3 was terminated from the facility via phone on 05/01/15. Review of STNA #1's time card/punch detail revealed STNA #1 last punched out of the facility on 04/24/15 at 6:36 A.M. and did not punch in to work again after that. Review of STNA #1's personnel file revealed STNA #1 was terminated from form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 11 of 17

24 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 11 employment at the facility on 05/01/15. F 0223 Review of STNA #2's time card/punch detail revealed STNA #2 punched out of the facility on 04/22/15 at 10:33 P.M. STNA #2 did not punch in to work again after that. Review of STNA's personnel file revealed STNA #2 was terminated from employment at the facility on 05/01/15. During an interview on 06/01/15 at 11:21 A.M., the facility Administrator stated that on 04/23/15, LPN #4 notified the DON of the incident of abuse that occurred on 04/22/15. On 04/23/15 STNA #3 was sent home. The facility initiated an investigation of the incident. The facility also initiated an investigation into the bruise on Resident #27's left arm and wrist. The Administrator stated that STNA #1, STNA #2 and STNA #3 came to the facility in the morning (unable to provide exact time) of 04/24/15 as part of the investigation and re-enacted the incident of 04/22/15. The Administrator stated they were not able to determine if the bruise was caused by STNA #1 or STNA #3. STNA #2 was at the foot of the bed. The facility determined that STNA #3 did spit in Resident #27's face, and terminated STNA #3 on 05/01/15. The facility terminated STNA #1 and STNA #2 on 05/01/15 for failure to immediately report the incident of abuse. On 06/02/15 at 8:30 A.M. the surveyor observed Resident #27. There were no form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 12 of 17

25 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECED ED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0223 Continued From page 12 visible bruises. The surveyor attempted to interview Resident #27. Resident #27 was not interviewable; she was very pleasant, very confused and did not answer questions appropriately. F 0223 form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 13 of 17

26 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0225 Continued From page 13 F 0225 F (c)(1)(ii)-(iii), (c)(2) - (4) F 0225 F /29/2015 SS=D INVESTIGATE/REPORT The facility will prevent abuse to residents. ALLEGATIONS/INDIVIDUALS Resident #27 remains in the facility. The facility must not employ individuals Resident #27 has had no adverse effects who have been found guilty of abusing, from the incident. Resident does not neglecting, or mistreating residents by a remember the incident. The resident's care court of law; or have had a finding entered plan was updated with interventions to be into the State nurse aide registry used when resident exhibits restiveness to concerning abuse, neglect, mistreatment care. of residents or misappropriation of their All residents have the potential to be affected property; and report any knowledge it has by the deficient practice. of actions by a court of law against an We believe the deficient practice was employee, which would indicate unfitness addressed and remedied with the termination for service as a nurse aide or other facility of the STNA #3, but no later than the staff to the State nurse aide registry or in-servicing of all staff which occurred prior to licensing authorities. survey exit. Furthermore, post incident interviews of current facility staff and residents The facility must ensure that all alleged that resided in the facility at that time were violations involving mistreatment, neglect, interviewed by the IDT team to determine or abuse, including injuries of unknown whether any other potential for abuse/abuse source and misappropriation of resident allegations existed. Staff were specifically property are reported immediately to the asked situational questions and how they administrator of the facility and to other would respond to the situation. officials in accordance with State law In response to ODH's opinion of on-going through established procedures (including non-compliance and not because the facility to the State survey and certification feels a deficient practice still exists, facility agency). Staff were again re-educated by DON/designee by 6/29/15 regarding The facility must have evidence that all managing residents with dementia, residents alleged violations are thoroughly with behaviors, abuse policy and timeliness of investigated, and must prevent further reporting allegations of abuse. potential abuse while the investigation is Random staff interviews to be conducted by in progress. Administrator/Designee 2x week for 4 weeks to ensure there are no concerns related to The results of all investigations must be abuse. Random resident interviews to be reported to the administrator or his completed by Administrator/designee 2x week designated representative and to other for 4 weeks to ensure there are no resident officials in accordance with State law concerns related to abuse. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 14 of 17

27 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECED ED B Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0225 Continued From page 14 F 0225 (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Audit results will be forwarded to the Quality Assurance Committee for further review and recommendations. This STANDARD is not met as evidenced by: Based on record review, staff interview, review of facility self-reported incident reports, and review of facility investigation report, the facility failed to ensure that an incident of witnessed physical abuse was reported immediately to the facility administrator. This affected one resident (Resident #27) involved in one of two self-reported incident (SRI) reports reviewed. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on 07/06/09 with diagnoses that included dementia with behavior disturbance, anxiety and depressive disorder. Review of facility Self-Reported Incident (SRI) report #89191 dated 04/23/15 revealed an incident of witnessed abuse that the facility substantiated. State Tested Nurse Aide (STNA) #1 reported to the Director of Nursing (DON) on 04/23/15 at 9:35 P.M. that on 04/22/15 at approximately 8:30 P.M., STNA #1 was assisting STNA #2 care for Resident #27. Resident #27 was resistive to care and combative with staff. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 15 of 17

28 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0225 Continued From page 15 STNA #3 entered the room to offer assistance. STNA #1 witnessed STNA #3 spit in Resident #27's face and hold her arm down. This resulted in a five inch by two inch bruise to Resident #27's left forearm. F 0225 Review of the facility investigation report revealed the allegation of physical abuse was substantiated when the facility determined that STNA #3 held down Resident #27's arm and spit in Resident #27's face in retaliation for Resident #27 spitting in STNA #3's face. The investigation revealed STNA #1 did not report the witnessed incident of 04/22/15 until 04/23/15 when she approached LPN #5 and told her of the incident. A written statement by STNA #2 who also witnessed the incident on 04/22/15 dated 04/24/15 contained no documentation that STNA #2 notified anyone of the incident that occurred on 04/22/15. On 05/27/15 at 3:19 P.M. interview of the DON revealed the DON stated she was called at home on 04/23/15 by LPN #5 and notified of the incident of abuse that occurred on 04/22/15. The DON stated STNA #1 did not notify anyone of the incident until 04/23/15, and STNA #2 did not notify anyone at all until required to give a written statement as part of the investigation. The DON stated it was facility policy that all allegations or observations of abuse and any suspected abuse were to be immediately reported. form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 16 of 17

29 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 06/10/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECED ED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE F 0225 Continued From page 16 The DON stated that both STNA #1 and STNA #2 were terminated by the facility for failure to report an incident of abuse. F 0225 form cms-2567(02-99) previous versions obsolete Event:13CO11 Facility ID:OH00995 if continuation sheet Page 17 of 17

30 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction (X3) DATE SURVEY COMPLETED b. wing 07/26/2016 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N 0000 INITIAL COMMENTS F 0000 AMENDED INFORMAL DISPUTE RESOLUTION COMPLETED ON 09/26/2016. COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Kimberly Murphy, # CERTIFIED BED CAPACITY: 82 CENSUS: 47 MEDICARE: 2 MEDICAID: 27 OTHER: 18 At the time of the complaint investigation completed on 07/26/16, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date KIMBERLY.MURPHY 08/ 19/2016 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:3RQ411 Facility ID:OH00995 if continuation sheet Page 1 of 1

31 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 08/06/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION ADMINISTRATOR: Teresa Lane CERTIFIED BED CAPACITY: 82 CENSUS: 53 MEDICARE: 3 MEDICAID: 34 OTHER: 16 At the time of the complaint survey completed on 08/06/14, Windsong Care Center is in substantial compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities in regard to allegations contained in Complaint Number OH , excluding the Life Safety Code. laboratory director's or provider/supplier representative's signature title (x6) date 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. form cms-2567(02-99) previous versions obsolete Event:XUZI11 Facility ID:OH00995 if continuation sheet Page 1 of 1

32 STATEMENT O F DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 08/28/2014 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICICIENCY MUST BEPRECEDED BY FULL ID PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Teresa Lane LNHA # CERTIFIED BED CAPACITY: 82 CENSUS: 52 MEDICARE: 4 MEDICAID: 32 OTHER: 16 At the time of the complaint investigation completed on 08/28/14, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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. form cms-2567(02-99) previous versions obsolete Event:UQGV11 Facility ID:OH00995 if continuation sheet Page 1 of 1

33 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction (X3) DATE SURVEY COMPLETED b. wing 09/08/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Holly Gerbasich, #5642 CERTIFIED BED CAPACITY: 82 CENSUS: 53 MEDICARE: 0 MEDICAID: 35 OTHER: 18 At the time of the complaint investigation completed on 09/08/15, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:9SVF11 Facility ID:OH00995 if continuation sheet Page 1 of 1

34 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction (X3) DATE SURVEY COMPLETED b. wing 10/01/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBER OH ADMINISTRATOR: Holly Gerbasich, #5642 CERTIFIED BED CAPACITY: 82 CENSUS: 52 MEDICARE: 2 MEDICAID: 33 OTHER: 17 At the time of the complaint investigation completed on 10/01/15, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Number OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:V7UN11 Facility ID:OH00995 if continuation sheet Page 1 of 1

35 STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY DEFICIENCIES PRO VIDER/SUPPLIER/CLIA COMPLETED b. wing 10/07/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION MASTER COMPLAINT NUMBER OH COMPLAINT NUMBER OH COMPLAINT NUMBER OH ADMINISTRATOR: Holly Gerbasich CERTIFIED BED CAPACITY: 82 CENSUS: 48 MEDICARE: 1 MEDICAID: 33 OTHER: 14 The following deficiency is based on the complaint investigation completed on 10/07/15. laboratory director's or provider/supplier representative's signature title HOLLY.GERBASICH (x6) date 11/03/2015 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:ETW911 Facility ID:OH00995 if continuation sheet Page 1 of 5

36 STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY DEFICIENCIES PRO VIDER/SUPPLIER/CLIA a. building b. wing COMPLETED 10/07/2015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0225 Continued From page 1 F 0225 F (c)(1)(ii)-(iii), (c)(2) - (4) F 0225 This plan of correction is prepared because it 10/23/2015 SS=D INVESTIGATE/REPORT is required by State and Federal law and not ALLEGATIONS/INDIVIDUALS because Windsong Care Center agrees with The facility must not employ individuals the allegations and citations listed of this who have been found guilty of abusing, statement of deficiencies. Windsong Care neglecting, or mistreating residents by a Center does not admit any deficiency is court of law; or have had a finding entered present. Further the submission of a Plan of into the State nurse aide registry Correction and the changes in any policy concerning abuse, neglect, mistreatment procedure or activity is not an admission of a of residents or misappropriation of their deficiency. Windsong Care Center is property; and report any knowledge it has constantly reviewing and revising its policies, of actions by a court of law against an procedures and methods of health care service employee, which would indicate unfitness delivery. There are no "subsequent remedial for service as a nurse aide or other facility measures" undertaken in response to the SOD staff to the State nurse aide registry or and no admission can be inferred from licensing authorities. Windsong Care Center continuing process of enhancing the facilities practices. The facility must ensure that all alleged violations involving mistreatment, neglect, Windsong Care Center maintains that the or abuse, including injuries of unknown alleged deficiencies do not individually or source and misappropriation of resident collectively jeopardize the health and safety of property are reported immediately to the the residents, nor is there any potential for administrator of the facility and to other more than minimal harm as a result of any officials in accordance with State law action, practice, situation or incident alleged in through established procedures (including the SOD. The census at the time was 48 to the State survey and certification This plan of correction shall operate as agency). Windsong Care Center's written credible allegation of compliance effective 10/23/15. The facility must have evidence that all alleged violations are thoroughly The facility will report an allegations of investigated, and must prevent further misappropriation as required. potential abuse while the investigation is in progress. Resident #49 no longer resides in the facility. The facility did report the allegation on 10/8/15. The results of all investigations must be The tablet was replaced on 10/13/2015. reported to the administrator or his form cms-2567(02-99) previous versions obsolete Event:ETW911 Facility ID:OH00995 if continuation sheet Page 2 of 5

37 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 10/07/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0225 Continued From page 2 F 0225 designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to report an allegation of misappropriation involving Resident #49 to the State agency as required and failed to ensure a thorough investigation was completed following the allegation. This affected one resident (Resident #49) of five sampled residents. All Staff were re-educated in regard to misappropriation to include immediate reporting and initiating an investigation by DON/designee from 10/8/15 through 10/22/15. Random residents interviews were completed by the Interdisciplinary Team to ascertain if any other residents had concerns related to misappropriation. Random interviews will continue to take place weekly for 4 weeks to ensure there are no concerns not previously investigated and reported, if necessary. Results will be forwarded to facility QAPI Committee. Findings include: Record review revealed Resident #49 was discharged from the facility on 08/29/15. Following the resident's discharge the resident's daughter had been in contact with the facility to make arrangements to pick up resident's belongings on 09/04/15. On 09/04/15 the resident's daughter was onsite and retrieved the belongings as planned. However, on 09/15/15 the daughter contacted the facility administrator and indicated the resident was missing a form cms-2567(02-99) previous versions obsolete Event:ETW911 Facility ID:OH00995 if continuation sheet Page 3 of 5

38 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction a. building b. wing (X3) DATE SURVEY COMPLETED 10/07/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0225 Continued From page 3 computer tablet from the belongings that were picked up on 09/04/15. F 0225 Record review revealed no evidence of a written, completed investigation of the missing tablet had been completed. There were no statements from staff available to review and no written evidence the facility investigated the item as missing. Additionally, the missing tablet was not reported to the State agency as an allegation of misappropriation. On 10/06/15 at 2:38 P.M. interview with the administrator revealed Resident #49's daughter had come to pick up her father's belongings and had told her that she couldn't find a computer tablet that the resident had in the facility. The administrator explained that she told the daughter that when she unpacked all of her fathers belongings, to call her and let her know if the computer tablet was found or not. The administrator indicated she spoke again to the daughter on 09/29/15 regarding another subject and the tablet wasn't mentioned so she did not do any follow up at that time. The administrator indicated after the allegation was initially made, she did talk to staff, but verified there was no written investigation completed, the allegation was not reported to the State agency and the status of the tablet was not determined. This deficiency substantiates Complaint form cms-2567(02-99) previous versions obsolete Event:ETW911 Facility ID:OH00995 if continuation sheet Page 4 of 5

39 STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY DEFICIENCIES PRO VIDER/SUPPLIER/CLIA COMPLETED b. wing 10/07/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N F 0225 Continued From page 4 Number OH F 0225 form cms-2567(02-99) previous versions obsolete Event:ETW911 Facility ID:OH00995 if continuation sheet Page 5 of 5

40 STATEMENT OF DEFICIENCIES (X1) PRO VIDER/SUPPLIER/CLIA (x2) multiple construction (X3) DATE SURVEY COMPLETED b. wing 11/17/2015 (X4) ID SUMMARY STATEMENT O F DEFICIENCIES ID PROVIDER'S PLAN O F CORRECTION (X5) (EACH DEFICICIENCY MUST BEPRECEDED (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO BY FULL CRO SS-REFERENCED TO THE APPROPRIATE N 0000 INITIAL COMMENTS F 0000 COMPLAINT INVESTIGATION COMPLAINT NUMBERS OH and OH ADMINISTRATOR: Holly Gerbasich, # CERTIFIED BED CAPACITY: 82 CENSUS: 44 MEDICARE: 5 MEDICAID: 28 OTHER: 11 At the time of the complaint investigation completed on 11/17/15, Windsong Care Center is in compliance with the provisions of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, excluding the Life Safety Code, in regard to allegations contained in Complaint Numbers OH and OH laboratory director's or provider/supplier representative's signature title (x6) date 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 suivey 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. form cms-2567(02-99) previous versions obsolete Event:BKWS11 Facility ID:OH00995 if continuation sheet Page 1 of 1

41 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Midwest Division of Survey and Certification Chicago Regional Office 233 North Michigan Avenue, Suite 600 Chicago, IL CENTERS FOR MEDICARE & MEDICAID SERVICES CMS Certification Number (CCN): July 27, 2015 By Certified Mail Ms. Teresa Lane, Administrator Windsong Care Center 120 Brookmont Road Akron, OH Dear Ms. Lane: SUBJECT: NOTICE OF IMMEDIATE IMPOSITION OF REMEDIES Cycle Start Date: June 10,2015 SURVEY RESULTS On June 10, 2015, a complaint investigation was completed at Windsong Care Center by the Ohio Department of Health (ODH) to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. This survey revealed that your facility was not in substantial compliance and found the most serious deficiency to place the health and safety of your residents in immediate jeopardy. This deficiency was cited as follows, including the level of scope and severity (S/S): F223 S/S: J (b), (c)(l)(i) Free From Abuse/involuntary Seclusion In addition, the following cited deficiency constitutes substandard quality of care, and a partial extended survey was performed: F S/S: J (b), (c)(l)(i) -- Free From Abuse/involuntary Seclusion Surveyors found a situation of immediate jeopardy to patient health and safety that began on April 22, 2015 and was removed on April 24, On June 24, 2015, a life safety code survey and on June 29, 2015, a health survey were completed at Windsong Care Center by the Ohio Department of Health (ODH) to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. These surveys revealed that your facility was not in substantial compliance and found the most serious deficiency to place the health and safety of your residents in immediate jeopardy. This deficiency was cited as follows, including the level of scope and severity (S/S): F323 S/S: J (h) Free of Accident Hazards/Supervision/Devices In addition, the following cited deficiency constitutes substandard quality of care, and an extended survey was performed: F323 - S/S: J (h) Free of Accident Hazards/Supervision/Devices Surveyors found a situation of immediate jeopardy to patient health and safety that began on June 14, 2015 and was removed on June 27, However, they also found that your facility continued

42 Page 2 not to be in substantial compliance with Federal requirements as a result of uncorrected deficiencies at severity level 2. The State advised you of the deficiencies noted above and provided you with a copy of the survey reports (CMS-2567). SUMMARY OF ENFORCEMENT REMEDIES As a result of the survey findings, and as authorized by the Centers for Medicare & Medicaid Services (CMS), the Ohio Department of Flealth notified you on July 20, 2015 of the imposition of the following remedy, as well as your appeal rights: Mandatory denial of payment for new Medicare & Medicaid admissions effective September 10, 2015 The State survey agency notified you they were recommending that the CMS impose an additional remedy. We concur with the State's recommendation and are imposing the following remedy: Federal Civil Money Penalty effective April 22, 2015 The authority for the imposition of remedies is contained in subsections 1819(h) and 1919(h) of the Social Security Act ("Act") and Federal regulations at 42 CFR 488 Subpart F, Enforcement of Compliance for Long-Term Care Facilities with Deficiencies. DENIAL OF PAYMENT FOR NEW ADMISSIONS Mandatory denial of payment for all new Medicare admissions is imposed effective September 10, 2015 if your facility does not achieve compliance within the required three months. This action is mandated by the Act at Sections 1819(h)(2)(D) and 1919 (h)(2)(c) and Federal regulations at 42 CFR (b). We will notify CGS Administrators that the denial of payment for all new Medicare admissions is effective on September 10, We are further notifying the State Medicaid agency that they must also deny payment for all new Medicaid admissions effective September 10, You should notify all Medicare and Medicaid residents admitted on or after this date of the restriction. The remedy must remain in effect until your facility has been determined to be in substantial compliance or your provider agreement is terminated. Please note that the denial of payment for new Medicare admissions includes Medicare beneficiaries enrolled in managed care plans. It is your obligation to inform Medicare managed care plans contracting with your facility of this denial of payment for new admissions. TERMINATION If your facility has not attained substantial compliance by December 10, 2015, your Medicare and Medicaid participation will be terminated effective with that date. This action is mandated by the Act at Sections 1819(h) and 1919(h) and Federal regulations at 42 CFR and We are required to provide the general public with notice of an impending termination and will publish a notice in a local newspaper prior to the effective date of termination. If termination goes into effect, you may take steps to come into compliance with the Federal requirements for long term care facilities and reapply to establish your facility's eligibility to participate as a provider of services under Title XVIII of the Act. Should you seek re-entry into the Medicare program, the Federal regulation at 42 CFR will apply.

43 Page 3 CIVIL MONEY PENALTY In determining the amount of the Civil Money Penalty (CMP) that we are imposing for each day of noncompliance, we have considered your facility's history, including any repeated deficiencies; its financial condition; and the factors specified in the Federal requirement at 42 CFR We are imposing the following CMPs: Federal Civil Money Penalty of $3, per day for the two (2) days beginning April 22, 2015 and continuing through April 23, 2015 for a total of $7, Federal Civil Money Penalty of $ per day for the fifty-one (51) days beginning April 24, 2015 and continuing through June 13, 2015 for a total of $5, Federal Civil Money Penalty of $4, per day for the thirteen (13) days beginning June 14, 2015 and continuing through June 26, 2015 for a total of $52, Federal Civil Money Penalty of $ per day beginning June 27, 2015 The CMP continues to accrue at the amount of $ per day until you have made the necessary corrections to achieve substantial compliance with the participation requirements, or your provider agreement is terminated. However, the amount of the CMP may be increased or decreased if we find that the noncompliance changes. If you believe that you have documented evidence that should be considered in establishing the amount of the CMP, the following documents should be submitted to this office within fifteen (15) days from the receipt of this notice: Written, dated request specifying the reason financial hardship is alleged List of the supporting documents submitted Current balance sheet Current income statements Current cash flow statements Most recent full year audited financial statements prepared by an independent accounting firm, including footnotes Most recent full year audited financial statements of the home office and/or related entities, prepared by an independent accounting firm, including footnotes Disclosure of expenses and amounts paid/accrued to the home office and/or related entities Schedule showing amounts due to/ffom related companies or individuals included in the balance sheets. The schedule should list the names of related organizations or persons and indicate where the amounts appear on the balance sheet (e.g., Accounts Receivable, Notes Receivable, etc.) If the nursing home requests an extended payment schedule of more than twelve (12) months duration, the provider must submit a letter from a financial institution denying the provider s loan request for the amount of the CMP The CMP is due and payable and may be placed in escrow account fifteen days after one of the following, whichever occurs first: The date on which an Independent IDR process is completed, if applicable or The date which is 90 calendar days after the date of the notice of imposition of the civil money penalty. CMP REDUCED IF HEARING WAIVED If you waive your right to a hearing, in writing, within 60 calendar days from receipt of this notice, the amount of your CMP will be reduced by thirty-five percent (35%). To receive this reduction, the written

44 Page 4 waiver should be sent to the Centers for Medicare & Medicaid Services, Division of Survey and Certification, 233 North Michigan Avenue, Suite 600, Chicago, Illinois The failure to request a hearing within 60 calendar days from your receipt of this notice does not constitute a waiver of your right to a hearing for purposes of the 35% reduction. Any subsequent survey that results in a finding of continued noncompliance may affect the CMP. If, based on the new finding, the previously imposed CMP amount is continued or the CMP amount is changed, and you choose not to accept the new finding, it will be necessary for you to submit an additional request for a hearing on the subsequent survey finding. Alternatively, you may submit a written waiver of your right to a hearing on the subsequent survey finding. A CMP case number will be assigned to your case only when the final CMP is due and payable. At that time you will receive a notice from this office with the CMP case number and payment instructions. Prior to the assignment of a CMP case number, you must ensure that your facility s name, CMS Certification Number (CCN), and the enforcement cycle start date appear on any correspondence pertaining to this CMP. Your CMS Certification Number (CCN) is. The start date for this cycle is June 10,2015. NURSE AIDE TRAINING PROHIBITION Federal law, as specified in the Act at 1819(f)(2)(B) and 1919(f)(2)(B), prohibits approval of nurse aide training and competency evaluation programs and nurse aide competency evaluation programs offered by, or in, a facility which, within the previous two years, has operated under a 1819(b)(4)(C)(ii)(II) or 1919(b)(4)(C)(ii) waiver (i.e., waiver of full-time registered professional nurse); has been subject to an extended or partial extended survey as a result of a finding of substandard quality of care; has been assessed a total civil money penalty of not less than $5,000; has been subject to a denial of payment, the appointment of a temporary manager or termination; or, in the case of an emergency, has been closed and/or had its residents transferred to other facilities. Because the facility was subject to a partial extended survey, this provision is applicable to your facility. Therefore, Windsong Care Center is prohibited from offering or conducting a Nurse Aide Training and/or Competency Evaluation Program (NATCEP) for two years from June 10, You will receive further information regarding this from the State agency. Further, this prohibition remains in effect for the specified period even though selected remedies may be rescinded at a later date if your facility attains substantial compliance. However, under Public Law , you may contact the State agency and request a waiver of this prohibition if certain criteria are met. APPEAL RIGHTS This formal notice imposed: Federal Civil Money Penalty effective April 22, 2015 Mandatory denial of payment for new Medicare & Medicaid admissions effective September 10, 2015 If you disagree with the finding of noncompliance which resulted in this imposition and the finding of noncompliance which resulted in the continuation of the previously imposed remedy and the finding of SQC which resulted in the loss of NATCEP approval, you or your legal representative may request a hearing before an administrative law judge of the Department of Health and Human Services, Departmental Appeals Board (DAB). Procedures governing this process are set out in Federal regulations at 42 CFR , et. seq.

45 Page 5 You are required to file your appeal electronically at the Departmental Appeals Board Electronic Filing System Web site (DAB E-File) at To file a new appeal using DAB EFile, you first need to register a new account by: (1) clicking Register on the DAB E-File home page; (2) entering the information requested on the "Register New Account" form; and (3) clicking Register Account at the bottom of the form. If you have more than one representative, each representative must register separately to use DAB E-File on your behalf. The address and password provided during registration must be entered on the login screen at sessions/new to access DAB E-File. A registered user's access to DAB EFile is restricted to the appeals for which he is a party or authorized representative. Once registered, you may file your appeal by: Clicking the File New Appeal link on the Manage Existing Appeals screen, then clicking Civil Remedies Division on the File New Appeal screen. Entering and uploading the requested information and documents on the "File New Appeal- Civil Remedies Division" form. At minimum, the Civil Remedies Division (CRD) requires a party to file a signed request for hearing and the underlying notice letter from CMS that sets forth the action taken and the party's appeal rights. A request for a hearing should identity the specific issues and the findings of fact and conclusions of law with which you disagree, including a finding of substandard quality of care, if applicable. It should also specify the basis for contending that the findings and conclusions are incorrect. The DAB will set the location for the hearing. Counsel may represent you at a hearing at your own expense. All documents must be submitted in Portable Document Format ("PDF"). Any document, including a request for hearing, will be deemed to have been filed on a given day, if it is uploaded to DAB E-File on or before 11:59 p.m. ET of that day. A party that files a request for hearing via DAB E-File will be deemed to have consented to accept electronic service of appeal-related documents that CMS files, or CRD issues on behalf of the Administrative Law Judge, via DAB E-File. Correspondingly, CMS will also be deemed to have consented to electronic service. More detailed instructions for using DAB E-File in cases before the DAB s Civil Remedies Division can be found by clicking the button marked E-Filing Instructions after logging-in to DAB E-File. For questions regarding the E-Filing system, please contact E-File System Support at OSDABImmediateOffice@hhs.gov. Please note that all hearing requests must be filed electronically unless you have no access to the internet or a computer. In those circumstances, you will need to provide an explanation as to why you are unable to file electronically and request a waiver from e-filing with your written request. Such a request should be made to: Department of Health and Human Services Departmental Appeals Board, MS 6132 Civil Remedies Division Attention: Nancy K. Rubenstein, Director 330 Independence Avenue, SW Cohen Building, Room G-644 Washington, D.C A request for a hearing must be filed no later than 60 days from the date of receipt of this notice.

46 Page 6 INFORMAL DISPUTE RESOLUTION The State agency offered you an opportunity for informal dispute resolution (IDR) following its survey visits. A request for IDR will not delay the effective date of any enforcement action. However, IDR results will be considered when applicable. INDEPENDENT INFORMAL DISPUTE RESOLUTION (INDEPENDENT IDR) In accordance with 42 CFR , when a civil money penalty subject to being collected and placed in an escrow account is imposed, you have one opportunity to question cited deficiencies through an Independent IDR process. You may also contest scope and severity assessments for deficiencies which resulted in a finding of SQC or immediate jeopardy. To be given such an opportunity, you are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies (or why you are disputing the scope and severity assessments of deficiencies which have been found to constitute SQC or immediate jeopardy) to: Brian Dean, Interim Bureau Chief Bureau of Regulatory Enforcement 246 N. High Street, Third Floor Columbus, OH BRC@odh.ohio.gov This request must be sent within 10 calendar days of receipt of this offer. An incomplete Independent IDR process will not delay the effective date of any enforcement action. CONTACT INFORMATION If you have any questions regarding this matter, please contact Mai Le-Yuen, Principal Program Representative, at (312) Information may also be faxed to (443) All correspondence should be directed to Mai Le-Yuen in our Chicago office. Sincerely, /s/ Jean Ay Branch Manager Long Term Care Certification & Enforcement Branch cc: Ohio Department of Health Ohio Department of Medicaid Ohio Department of Aging

47 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Midwest Division of Survey and Certification Chicago Regional Office 233 North Michigan Avenue, Suite 600 Chicago, IL CIVIS CENTERS FOR MEDICARE & MEDICAID SERVICES CMS Certification Number (CCN): Ms. Teresa Lane, Administrator Windsong Care Center 120 Brookmont Rd Akron, OH Dear Ms. Lane: August 28, 2015 By Facsimile SUBJECT: DISPOSITION OF REMEDIES Cycle Start Date: June 10, 2015 PRIOR NOTICE On July 23, 2015, we informed you that we were imposing remedies due to the failure of your facility to be in substantial compliance with the applicable Federal requirements for nursing homes participating in the Medicare and Medicaid programs. SUBSEQUENT VISITS AND SUMMARY OF ENFORCEMENT REMEDIES The Ohio Department of Health conducted revisits of your facility on June 29, 2015 and August 10, The revisits found your facility to be in substantial compliance with the participation requirements effective July 4, As a result of the survey findings, the final status of remedies is as follows: See Civil Money Penalty below Mandatory denial of payment for new Medicare and Medicaid admissions, which was imposed effective September 10, 2015, is rescinded. We are notifying your Medicare Administrative Contractor and the State Medicaid agency of the rescission of the denial of payment remedy Mandatory termination of your Medicare & Medicaid provider agreements, which was to be effective December 10,2 015, will not be imposed The authority for the imposition of remedies is contained in subsections 1819(h) and 1919(h) of the Social Security Act ("Act") and Federal regulations at 42 CFR 488 Subpart F, Enforcement of Compliance for Long-Term Care Facilities with Deficiencies. CIVIL MONEY PENALTY (CMP) As we informed you on July 23, 2015, CMPs were imposed against your facility for failure to comply with the Federal requirements. This action was taken pursuant to the authority contained

48 Page 2 in Sections 1819(h) and 1919(h) of the Social Security Act and Federal regulations at 42 CFR Section These CMPs are as follows: Federal Civil Money Penalty of $3, per day for the two (2) days beginning April 22, 2015 and continuing through April 23, 2015 for a total of $7, Federal Civil Money Penalty of $ per day for the fifty-one (51) days beginning April 24, 2015 and continuing through June 13, 2015 for a total of $5, Federal Civil Money Penalty of $4, per day for the thirteen (13) days beginning June 14, 2015 and continuing through June 26, 2015 for a total of $52, Federal Civil Money Penalty of $ per day for the seven (7) days beginning June 27, 2015 and continuing through July 3, 2015 for a total of $ The total CMP amount due is $65, APPEAL RIGHTS We previously advised of your right to appeal the noncompliance that resulted in the finding of SQC which resulted in the loss of NATCEP approval and the imposition of the remedy of: Federal Civil Money Penalty effective April 22, 2015 Please refer to that notice and note the deadline for that appeal. As of this date, we have not received a request for a hearing. There are no other outstanding appeal issues. CONTACT INFORMATION If you have any questions regarding this matter, please contact me, at (312) Information may also be faxed to (443) All correspondence should be directed to me in our Chicago office. Sincerely, /s/ Mai Le-Yuen Principal Program Representative Long Term Care Certification & Enforcement Branch cc: Ohio Department of Health Ohio Department of Medicaid Ohio Department of Aging

49 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking #89191 Date: 04/24/2015 Name of Facility: Address: AKRON, OH Telephone: (330) Federal Prorider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 04/23/2015 a. Category of allegation/suspicion W Physical abuse Sexual abuse r Injury of unknown source ^ Neglect Emotional verbal abuse r " Misappropriation Brief Description of Allegation/Suspicion: It was reported to this Administrator, on 4/23/2015 around 10PM. by the DON that charge nurse phoned her about an STNA who alleges witnessing another STNA abuse a resident. b. Alleged/suspected perpetrator Facility staff or other care provider Another resident ^ Family/visitor P Unknown c. Initial source of allegation/suspicion " Resident victim Visitor/family F Staff 1 Rumor/gossip Resident witness P Unusual circumstances III. INVOLVED RESIDENT Date of Birth: Did resident proride meaningful information when interviewed? f~ Yes F No Relevant Conditions: difficulty walking: lack of coordination: depressive disorder: dementia: anxiety; Wliat effect did incident have on Resident? unknown at this time Page 1 of 4

50 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occurance: 04/23/2015 Time of Occurance: 09:35 PM Location of Occurance: Narrative Summary of Incident: It was reported to DON at 9:35pm on 4/23/15 by charge nurse that STNA reported to her that on 4/22/15 at approx. 8:30 pm. while assisting STNA I to care for r e s i d e n t t h a t she witnessed s t n a spit in Residentface and was holding her ami down. Head to toe assessment completed on I. which revealed a pale blue bruise on the anterior wrist and forearm approx. 5?x2?. Resident denied pain. Physician and family of resident notified of alleged incident and investigation. Resident has BIMS score of 4 and no recollection of any incident related to the spitting or the bruise when questioned. S T N A ^J was sent home immediately upon DON notification of incident. Upon further investigation the following day. were suspended for investigation. Facility began investigation. Witness statements obtained. Then post-review of statements, facility called involved staff in for interviews and re-enactment. After the interviews and re-enactment, facility feels resident obtained the bruise to her arm while the care was being provided to her with the 3 aides in the room. Resident was being resistive to care. After this review, facility feels the STNA^B. did hold residents arm down to prevent being hit in the face. Facility also feelshl did spit in resident?s face in retaliation for the resident spitting at S T N A ^. Therefore. S T N A ^. is terminated. The other 2 STNA witnesses also terminated related to individual actions associated with incident. Page 2 of 4

51 VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: v Substantiated Unsubstantiated Facility Investigators: Name / Title of facility investigator: Administrator Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: This incident was reported to Officer Ben Campbell. Officer took preliminary report on 4/24/2015 based on what was report to DON. Office also took picture of bruise on resident left forearm. Police report # As a result of its investigation, the facility has done the following: On 4/23/15. upon notification to DON of incident, education was started on timely abuse reporting and abuse policy for all staff. Also upon notification of incident to DON on 4/23/15. DON directed a skin check on all residents in facility. Skin checks did not reveal any other injuries of unknown origin. All residents were interviewed to ascertain if they had any care/abuse concerns. All mu sing staff were interviewed regarding any care/abuse concerns they were aware of which gave the facility the opportunity to again, re-educate on the abuse policy. On 4/23/15. facility also began re-education to all nursing staff on interventions to use when residents are exhibiting behaviors and/or resistive to care. Crisis Prevention Institute training is scheduled for 5/1/15 and 5/7/15 for musing staff. Yes Page 3 of 4

52 Page 4 of 4

53 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FA C ILITY IN FO R M A TIO N Tracking #89235 Date: 04/24/2015 Name of Facility: Address: AKRON, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N n. INCIDENT IN FO R M A TIO N DATE OF DISCOVERY 04/24/2015 a. C ategory o f allegation/suspicion r* Physical abuse Sexual abuse Emotional verbal abuse Injury of unknown source ^ Neglect r " Misappropriation Brief Description of Allegation/Suspicion: It was reported to the DON that r c s id e n t^ ^ ^ ^ ^ ^ ^ ^ ^ H has an injury of link own origin. b. A lleged/suspected perpetrator Facility staff or other care provider ^ Another resident Family/visitor Unknown c. Initial source o f allegation/suspicion Resident victim Visitor/family I " Staff r Rumor, gossip 1 Resident witness Unusual circumstances III. IN V O LV ED RESID EN T Date of Did resident proride meaningful information when interviewed? Relevant Conditions: Debility: disorders of soft tissue; dementia: hypothyroidism. Yes W No What effect did incident have on Resident? unknown Page 1 of 3

54 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 04/23/2015 Time of Occuranee: 09:45 PM Location of Occuranee: Narrative Summary of Incident: It was reported to DON at 9:35pm on 4/23/15 by charge nurse that STNA I reported to her that on at approx. 8:30 pm. while assisting V. APPLICABLE STATEMENTS to that ST N A ^^^^^^^M holding Tliis resident?s ami down. Head to toe assessment completed o n ^. on 4/23/15 revealed a pale blue bruise on the anterior wrist and forearm approx. 57x2?. Resident denied pain. Physician and family of resident notified of alleged incident and investigation. Resident has BIMS score of 4 and no recollection of any incident related to the spitting or the bruise when questioned. STN A ^J. was sent home immediately upon DON notification of incident. Upon further investigation the following day. ST N A?s^J. a n d ^ J. were suspended for investigation. Facility began investigation. Witness statements obtained. Then post-review of statements, facility called involved staff in for interviews and re-enactment. After the interviews and re-enactment, facility feels resident obtained the bruise to her arm while the care was being provided to her with the 3 aides in the room. Resident was being resistive to care. After tliis review, facility feels the STNA^B. did hold residents arm down to prevent being hit in the face. Therefore, STNA^B. is terminated. The other 2 STNA witnesses also terminated related to individual actions associated with incident. VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: 17 Substantiated Page 2 of 3

55 r Unsubstantiated Facility Investigators: Name / Title of facility investigator: Administrator Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: This incident was reported to officer Ben Campbell, who took initial report. This officer also took pictures of bruise located on this resident's left forearm. As a result of its investigation, the facility has done the following: It was reported to DON at 9:35pm on 4/23/15 by charge nurse ^ J. that STNA reported to her that on 4/22/15 at approx. 8:30 pm, while assisting STNA to care for resident I that she witnessed STNA holding This resident?s arm down. Head to toe assessment completed on ^ J. on 4/23/15 revealed a pale blue bruise on the anterior wrist and forearm approx. 5?x2?. Resident denied pain. Physician and family of resident notified of alleged incident and investigation. Resident has BIMS score of 4 and no recollection of any incident related to the spitting or the bruise when questioned. STNA ^. was sent home immediately upon DON notification of incident. Upon further investigation the following day, STNA?s I. were suspended for investigation. Facility began investigation. Witness statements obtained. Then post-review of statements, facility called involved staff in for interviews and re-enactment. After the interviews and re-enactment, facility feels resident ^ J. obtained the bruise to her arm while the care was being provided to her with the 3 aides in the room. Resident was being resistive to care. After this review, facility feels the STNA I. did hold residents arm down to prevent being hit in the face. Therefore, STNA. is terminated. The other 2 STNA witnesses also terminated related to individual actions associated with incident. Yes Page 3 of 3

56 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 11/04/2015 Name of Facility: Address: AKRON, OH Telephone: (330) Federal Prorider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 11/04/2015 a. Category of allegation/suspicion W Physical abuse [ Sexual abuse Injury of unknown source ^ Neglect 1 " Emotional verbal abuse r Misappropriation Brief Description of Allegation/Suspicion: Resident alleged about 2 1/2 weeks ago. she was treated roughly by an STNA at night. b. Alleged/suspected perpetrator Facility staff or other care provider ^ Another resident Family/visitor Unknown c. Initial source of allegation/suspicion W Resident victim Visitor/family r Staff 1 Rumor, gossip [ Resident witness P Unusual circumstances III. INVOLVED RESIDENT Date of Did resident proride meaningful information when interviewed? Yes W No Relevant Conditions: Chronic intractable pain, anxiety, dementia, muscle atrophy, panic disorder, osteoarthritis Wliat effect did incident have on Resident? Resident stated this happened about a "couple and a half weeks ago". The aide turned her by herself and she wants there to be two people because it hurts too bad when there is only one to turn her. Page 1 of 3

57 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 11 /04/2015 Time of Occuranee: 07:30 AM Location of Occuranee: Resident Room Narrative Summary of Incident: Residentalleged a black girl with short hair and ponytails "beat her up" about weeks ago. Upon further conversation w ith ^ ^ ^ ^ ^ ^ ^ f. the STXA tinned and repositioned the resident by herself, pushing and pulling on the resident's shoulders and sides/hips. This resident has had increasing behaviors and a mental status change over the past several days. She is being treated for a urinary tract infection and hospice is reviewing her pain medications. She has chronic pain and is less distressed when two people turn and reposition her using the draw sheet. She can assist with holding onto the grab bar but can't hold herself over due to muscle wasting and generalized weakness. said she didn't want the 'girl' to get in trouble but she wanted her to be more gentle and have someone else help. V. APPLICABLE STATEMENTS VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Evidence is inconclusive Facility Investigators: Name / Title of facility investigator: DON Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: No Page 2 of 3

58 As a result of its investigation, the facility has done the following: After a conversation with the resident, it was determined that the STNA turned and repositioned by herself and it is unclear if she utilized a draw sheet. There is no evidence that the STNA intended any harm to the resident. A head to toe assessment was completed with no recent injury or bruising noted. Hospice will review pain management, the resident is to be a 2 person turn and reposition and staff re-educated on the proper way to turn and reposition using a draw sheet, causing less distress to the resident and lessen the chance of injury. The STNA will be provided with one on one education upon return from suspension. Page 3 of 3

59 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident FACILITY INFORMATION Tracking # Date: 11/16/2015 Name of Facility: Address: 120BROOKMONTRD AKRON, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 11/16/2015 a. Category of allegation/suspicion l"~ Physical abuse [ Sexual abuse Emotional verbal abuse Injury of unknown source Neglect r Misappropriation Brief Description of Allegation/Suspicion: res family reported someone took pictures of their dad and laughed b. Alleged/suspected perpetrator v Facility staff or other care provider Family/visitor Another resident Unknown c. Initial source of allegation/suspicion Resident victim v Visitor/family I Rumor, gossip Resident witness I " Staff P Unusual circumstances III. INVOLVED RESIDENT Name: Date of Birth: Did resident proride meaningful information when interviewed? O Yes 7 No Relevant Conditions: copd. dementia with behavioral disturbance, ckd. pvd. lewy body dementia WTiat effect did incident have on Resident? none Page 1 of 3

60 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occurance: 11/16/2015 Time of Occurance: 06:45 AM Location of Occurance: Resident bathroom Narrative Summary of Incident: At approximately 6:45 AM. was assisted to the bathroom in his room. As usual, the resident was given the call light next to the toilet and he was provided with some privacy by closing the door while the STNA stood light outside the room door just a few feet from the bathroom door. Per interview with the nurse and STNA's, J. I f B l B typically pulls the call light as soon as he is ready for assistance. When he did not pull the light after approximately 3-4 minutes, the STNA knocked on the door then enter to s e e ^ ^ ^ ^ J seated on the floor with his legs outstretched in front of him while his right side was leaning against the side of the sink coimter. The nurse was immediately notified and the resident was assessed for ROM and pain. did say that he had hit the right side of his head and side as he fell, but he was not experiencing much pain at that time. Upon assessment, there were no visible injuries. He was assisted to the WC per the STNA and nurse. The MD a n d ^ ^ ^ ^ ^ ^ ^ ^ f were notified of the fall. When family arrived in the facility a few hours later, the fall was explained to them and they req u ested ^^^^^^f go out to the hospital for evaluation of his painful right side and head. At that time, family told staff that. iwibb said there were 2 tall, bald black men in the bathroom when he fell and they were laughing and taking pictures of him. has dementia and recently has been experiencing hallucinations. The STNA that t o i l e t e d i s black and the nurse is bald but white. There was no evidence found to indicate that there had been anyone in the bathroom w ith ^ ^ ^ ^ ^ ^ f when he fell nor was anyone laughing and taking pictures of him. V. APPLICABLE STATEMENTS a. Witness Name: Date of Birth: b. Alleged perpetrator Full Name Date of Birth: VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Page 2 of 3

61 I Evidence is inconclusive Facility Investigators: Name / Title of facility investigator: DON Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: No As a result of its investigation, the facility has done the following: No evidence was found to indicate any intentional harm came to this resident. Staff assisted him to the bathroom, gave him the call light and provided some privacy while remaining in close proximity to the room. was only alone in the BR for 3-4 minutes, then immediately assessed and assisted back to a chair. The MD and family were notified and an investigation into the fall was initiated. The immediate intervention for was supervised toileting. Staff will continue to follow the resident plan of care and immediately report any incident for assessment of the resident, new intervention and investigation. Page 3 of 3

62 Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 12/30/2015 Name of Facility: Address: AKRON, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N SELF REPORTED INCIDENT FORM II. INCIDENT INFORMATION DATE OF DISCOVERY 12/30/2015 a. Category of allegation/suspicion l"~ Physical abuse Sexual abuse r Emotional verbal abuse Injury of unknown source ^ Neglect 17 Misappropriation Brief Description of Allegation/Suspicion: res reported to staff he was missing $20.00 b. Alleged/suspected perpetrator Facility staff or other care provider r Another resident Fanhly/visitor r Unknown c. Initial source of allegation/suspicion W Resident victim Visitor/family r Staff 1 Rumor, gossip [ Resident witness n Unusual circumstances III. INVOLVED RESIDENT Date of Did resident provide meaningful information when interviewed? [ 7 Yes r No Relevant Conditions: dementia with behavorial disturbances, pvd. acute kidney disease, epilepsy. DMII What effect did incident have on Resident? none Page 1 of 2

63 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 12/30/2015 Time of Occuranee: 01 ;30 PM Location of Occuranee: res room Narrative Summary of Incident: Res reported to staff he gave stna $20 12/29/15 to purchase cigarettes for him. res stated he never received cigarettes or money back V. APPLICABLE STATEMENTS VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated r Evidence indicates abuse, neglect or misappropriation did NOT occur F Evidence is inconclusive Abuse, neglect or misappropriation is not suspected Facility Investigators: Name / Title of facility investigator: Administrator Was allegation/suspicion reported to law enforcement and/or another state agency? No If Yes: As a result of its investigation, the facility has done the following: stna was immediately suspended, witness statements were obtained from res. and staff. Facility unable to substantiate at tills time. Facility reimbursed resident. Res experienced no ill psychosocial effects due to incident and continues with his normal activities. Page 2 of 2

64 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 01/11/2016 Name of Facility: Address: AKRON, OH Telephone: (330) Federal Prorider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 01/11/2016 a. Category of allegation/suspicion l"~ Physical abuse [ Sexual abuse Injury of unknown source Neglect 1 " Emotional verbal abuse r Misappropriation Brief Description of Allegation/Suspicion: stna reported another stna mistreated res by covering her with blankets. Stna immediately removed from facility and investigation started, res head to toe assessment completed no red marks or bruising, md and family notified. b. Alleged/suspected perpetrator Facility staff or other care provider Another resident ^ Family/visitor P Unknown c. Initial source of allegation/suspicion " Resident victim ["" Visitor/family 7 Staff r Rumor, gossip ^ Resident witness P Unusual circumstances III. INVOLVED RESIDENT Date of Birth: Did resident proride meaningful information when interviewed? Relevant Conditions: altered mental status, anxiety, dysphasia, dementia I- Yes [7 No What effect did incident have on Resident? none Page 1 of 3

65 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 01/10/2016 Time of Occuranee: 09:00 PM Location of Occuranee: res room Narrative Summary of Incident: STXA reported to nurse another STNA mistreated the resident. STNA stated he covered res with blankets and flicked res in the mouth. Alleged STNA was immediately removed from facility. Facility immediately initiated investigation. V. APPLICABLE STATEMENTS VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Evidence is inconclusive Facility Investigators: Name / Title of facility investigator: DON Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: No As a result of its investigation, the facility has done the following: Page 2 of 3

66 Immediate head to toe assessment completed on the res, no marks or bruises noted. Interviewed roommate, and other alert and orientated res on unit where alleged STNA works. Interviewed other staff who work with alleged STNA. Based on interview with res roommate who was in room at time of alleged incident facility believes incident did not occur. Other res were very complimentary of alleged STNA. Res had psychosocial assessment complete and no ill effects. As preventative STNA will no longer care for said res. Page 3 of 3

67 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 01/18/2016 Name of Facility: W IN D S O N G CAR E CENTER Address: 120 BRO O K M O N T RD AKR O N, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 01/18/2016 a. Category of allegation/suspicion l"~ Physical abuse [ Sexual abuse r Emotional verbal abuse Injury of unknown source Neglect r Misappropriation Brief Description of Allegation/Suspicion: res reported to housekeeper she was dropped 3 times yesterday during transfer b. Alleged/suspected perpetrator Facility staff or other care provider r Another resident Familyvisitor r Unknown c. Initial source of allegation/suspicion Resident victim Visitor/family I7 Staff I Rumor, gossip [ Resident witness n Unusual circumstances III. INVOLVED RESIDENT Date of Did resident proride meaningful information when interviewed? Relevant Conditions: major depression, anxiety, obesity, diabetes \7 Yes f~ No What effect did incident have on Resident? none Page 1 of 3

68 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occurance: 01/17/2016 Time of Occurance: 04:00 PM Location of Occurance: res room Narrative Summary of Incident: Facility immediately started investigation, employees were suspended pending investigation. After completing investigation facility determined therapy was in room while transferring resident from bed to wheelchair, during transfer res was lowered to floor by staff. Due to res obesity staff had a difficult time picking her up off floor, due to her being around 300#. Therapy and STNA had to obtain assistance from LPN at no point was res dropped on floor 3 times. V. APPLICABLE STATEMENTS a. Witness Name: Date of Birth: b. Alleged perpetrator Full Name Date of Birth: VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Evidence is inconclusive Facility Investigators: Name / Title of facility investigator: administrator Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: No As a result of its investigation, the facility has done the following: Page 2 of 3

69 All staff involved were suspended pending investigation, res was sent to hospital for xray per her request. X ray was negative for fracture. Res returned to facility to continue rehab. The res will continue to work towards goal in therapy and her goal is to return home. Page 3 of 3

70 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 01/26/2016 Name of Facility: W IN D S O N G CAR E CENTER Address: 120 BRO O K M O N T RD AKR O N, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 01/26/2016 a. Category of allegation/suspicion l"~ Physical abuse Sexual abuse r Emotional verbal abuse Injury of unknown source ^ Neglect r Misappropriation Brief Description of Allegation/Suspicion: Res reported to ER another res touched her breast b. Alleged/suspected perpetrator ^ Facility staff or other care provider F Another resident Familyvisitor r Unknown c. Initial source of allegation/suspicion W Resident victim Visitor/family r Staff I Rumor, gossip [ Resident witness n Unusual circumstances III. INVOLVED RESIDENT Date of Did resident proride meaningful information when interviewed? Relevant Conditions: anxiety, major depression, diabetes, gerd \7 Yes f~ No What effect did incident have on Resident? unknown Page 1 of 3

71 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 01/26/2016 Time of Occuranee: 11 ;30 AM Location of Occuranee: res room Narrative Summary of Incident: Tliis administrator received a call from social worker in the ER at Akron City hospital. She reported told dr. in ER on 2 separate occasions another male res touched her breast. She stated she did not tell anyone at facility. The social worker at hospital let me know she would be contacting the Copley police to file a report. This administrator immediately went to er to interview res. V. APPLICABLE STATEMENTS VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Evidence is inconclusive Facility Investigators: Name / Title of facility investigator: administrator Was allegation/suspicion reported to law enforcement and/or another state agency? If Yes: Upon interview with Paul Webb he was closing investigation. The report # is He stated no charges would be filed and tliis case would be closed at this time. Yes As a result of its investigation, the facility has done the following: Page 2 of 3

72 Administrator went to Er to interview resident. At ER this administrator met with detective Paul Webb. Detective interviewed res and then administrator collected witness statement from res. While interviewing res this res admitted she did not make facility aware of allegation. This res is alert and orientated x3. The suspected perpetrator is alert and orientated x 3. During interview res stated was her boyfriend and he was in her room watching tv. He touched her breast 1 time above the shirt. She asked him to stop he did immediately and left her room. We interviewed he denied any wrong doing and he stated she asked him to be his girlfriend and he said he only wanted to be friends. Upon returning from hospitalwas offered room change and him as well due to rooms being in close proximity of each other, both refused. Social service to follow up for emotional support. Both residents continue on with daily activities per there norm. Page 3 of 3

73 Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 02/14/2016 Name of Facility: W IN D S O N G CAR E CENTER Address: 120 BRO O K M O N T RD AKR O N, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N SELF REPORTED INCIDENT FORM II. INCIDENT INFORMATION DATE OF DISCOVERY 02/14/2016 a. Category of allegation/suspicion W Physical abuse F Sexual abuse r Emotional verbal abuse Injury of unknown source F Neglect r Misappropriation Brief Description of Allegation/Suspicion: res reported stna pushed her out of her wheelchair b. Alleged/suspected perpetrator Facility staff or other care provider r Another resident Fanhly/visitor r Unknown c. Initial source of allegation/suspicion [7 Resident victim F Visitor/family r Staff F Rumor, gossip F Resident witness n Unusual circumstances III. INVOLVED RESIDENT Name: Date of Birth: Did resident provide meaningful information when interviewed? Relevant Conditions: [7 Yes F No major depression, hepatic failure, dysphagia, history of falls, muscle wasting, unspecified cirohosis of liver What effect did incident have on Resident? none Page 1 of 3

74 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 02/14/2015 Time of Occuranee: 11 ;40 PM Location of Occuranee: res room Narrative Summary of Incident: res reported to nurse she was pushed down by stna. Res stated her roomates tv was too loud and she lowered the volume and changed the channel. She then reported she was standing in between her bed and her tv and the stna pushed her down. V. APPLICABLE STATEMENTS VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: Substantiated F Unsubstantiated r Evidence indicates abuse, neglect or misappropriation did NOT occur F Evidence is inconclusive Abuse, neglect or misappropriation is not suspected Facility Investigators: Name / Title of facility investigator: don Was allegation/suspicion reported to law enforcement and/or another state agency? No If Yes: As a result of its investigation, the facility has done the following: STNA immediately removed from floor and sent home. Investigation was immediately started. Complete head to toe assessment completed with no findings. Physician and poa notified. Alert and orientated res were interviewed on the hall with no additional allegations. No ill psych social effects noted. Page 2 of 3

75 Page 3 of 3

76 SELF REPORTED INCIDENT FORM Pursuant to ORC 3721 and 42 CFR , this form must be filed with the Ohio Department of Health within five days of incident I. FACILITY INFORMATION Tracking # Date: 06/17/2016 Name of Facility: W IN D S O N G CAR E CENTER Address: B R O O K M O N T R D AKRO N, OH Telephone: (330) Federal Provider Number: Fax: (330) State License Number: 1871N II. INCIDENT INFORMATION DATE OF DISCOVERY 06/17/2016 a. Category of allegation/suspicion I Physical abuse I Sexual abuse [" Emotional verbal abuse ~ Injury of unknown source Neglect Misappropriation Brief Description of Allegation/Suspicion: Potential staff to resident physical interaction. b. Alleged/suspected perpetrator F Facility staff or other care provider Family/visitor Another resident Unknown c. Initial source of allegation/suspicion Resident victim F Visitor/family P Staff r Rumor/gossip [ Resident witness P Unusual circumstances III. INVOLVED RESIDENT Date of Did resident proride meaningful information when interviewed? F Yes r No Relevant Conditions: Alzheimer's Disease: Acquired absence of kidney: hyperlipidemia: other intestinal obstruction Wliat effect did incident have on Resident? No adverse psychosocial effects noted at this time. Page 1 of 3

77 IV. SUMMARY OF INCIDENT (attach supporting documentation) Date of Occuranee: 06/17/2016 Time of Occuranee: 09:00 AM Location of Occuranee: Resident Room Narrative Summary of Incident: On 6/17/16 at approximately 9:00am. administrator received a phone call from resident tat it was reported to him by residents granddaughter hit the resident. Facility started investigation immediately. STNA was not in facility and was suspended pending investigation via telephone. Nursing completed head to toe assessment, no marks, reddened areas, or bruises noted to resident. MD notified with no new orders. Resident has a BIMS score of 7 and dx of Alzheimer's, hyperlipidemia, cognitive communication deficit, generalized muscle weakness, limited insight, and impaired judgment. Facility completed thorough investigation. Interviews completed with alleged perpetratorwho denied any negative interactions or physical contact with the resident. Interview completed with residents granddaughter via telephone who denied reporting or witnessing this allegation. Interviews completed with alert and oriented residents related to with positive comments le "good aide", "good person", "never had any issues". Statements obtained from staff working the same shift and following shift on 6/16/16. All staff statements reflected that resident was in good spirits for the duration of their shift. Resident told multiple staff members different stories about alleged incident ie that physical contact was a "tap on the shoulder, jokingly", "patted me on the back." etc. Upon initial interview with resident conducted by LNHA. resident stated that no one was in the room at the time of occurrence but told another staff interviewer that the granddaughter was in the room and witnessed the incident. Resident has remained in pleasant spirits and no ill psychosocial effects have been noted. Resident continues to socialize with staff and peers per noun. Facility unsubstantiates the claim due to the residents cognitive status, inconsistency in the stoiy. due to the STNA and son who made allegation having a personal history prior to residents admission, and the granddaughter denying incident happening while she was present in the facility. V. APPLICABLE STATEMENTS a. Witness Name: Date of Birth: b. Alleged perpetrator Page 2 of 3

78 VI. CONCLUSION a. Facility conclusion/disposition Based on the facility s investigation, the allegation/suspicion is: I Substantiated F Unsubstantiated F Evidence indicates abuse, neglect or misappropriation did NOT occur Evidence is inconclusive Facility* Investigators: Name / Title of facility investigator: Administrator Was allegation/suspicion reported to law enforcement and/or another state agency? No If Yes: As a result of its investigation, the facility has done the following: As a precaution, all musing staff re-inserviced on abuse policy. Page 3 of 3