Health inspection·November 27, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to document in the medical record an incident involving Resident #14 getting stuck in a stairwell. This affected one resident (#14) of three residents reviewed for accurate documentation. The facility census was 91. Findings include: Record review was conducted for Resident #14 who admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic neuropathy, cerebral infarction, morbid obesity, generalized anxiety disorder, abnormalities of gait and mobility, need for assistance for personal care, contractures of muscles lower left leg, contracture of muscle right lower leg, infarction of spinal cord, major depressive disorder recurrent severe without psychotic features, muscle weakness and borderline personality disorder. Review of the Minimum Data Set ( MDS) 3.0 assessment for Resident #14, dated 10/01/23, revealed Resident #14 had clear speech, was able to make self-understood, was able to understand others and had intact cognition with no signs of delirium, or disorganized thinking or hallucination, no rejection of care or wandering. Resident #14 had limited range of motion of upper extremity and lower extremities and a wheelchair was used for mobility. Resident #14 was low risk for elopement and depended on staff assistance for mobility off the unit. Review of Resident #14's plan of care dated 09/21/23 revealed she had a deficit in self-care activites related to generalized muscle weakness, type two diabetes, stroke and infarction of spinal cord requiring extensive assistance of one staff person for mobility. Further review of the medical record revealed no documentation in October 2023 through 11/20/23 of Resident #14 getting stuck in a stairwell and later found by staff. Observation of the stairwell on 11/20/23 revealed an unsecured door on the first floor opened into a stairwell with steps going up to the second floor. There were no steps going down to a lower level. Interview was conducted on 11/20/23 at 12:50 P.M. with Resident #14 who revealed she had requested to sit in the first floor activity room after buying herself something from the vending machine, and the aide who took her to the activity room was suppose to come get her within 20 minutes. Resident #14 stated she was confused how to get back to the elevator because it was the first time she was downstairs so another resident ended up pushing her into a stairwell on the first floor. Resident #14 Page 1 of 2 365185 365185 11/27/2023 Park Center Healthcare and Rehabilitation 5665 South Ave Youngstown, OH 44512

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she was crying for help and another resident heard her crying for help and told staff someone was in the stairwell. Resident #14 stated she felt upset and anxious, and it felt like she was in the stair well for two hours. Resident #14 stated the Assistant Director of Nursing (ADON) was notified of the incident after the staff found Resident #14. An interview was conducted on 11/20/23 at 4:56 P.M. with State Tested Nurse Assistant ( STNA) #334 who revealed about two weeks prior Resident #14 asked STNA #334 to go to the vending machine around 5:50 P.M. STNA #334 wheeled Resident #14 into the elevator on the second floor and rode down to the activities room where the vending machine was so the resident could use her own debit card for vending. Resident #14 requested to stay in the activities room to look around at magazines after her purchase and asked STNA #334 to come back to get her in about 20 minutes. STNA #334 went back to the second floor to finish her end of day duties and returned in twenty minutes to find the resident was missing from the activities room by the vending machine. STNA #334 looked for Resident #14 on the first floor and did not find the resident so STNA #334 immediately notified Resident #14's nurse who found the resident within twenty minutes because Resident #14 began yelling and another resident heard her yelling. Resident #14 was found on the first floor behind a door leading to the stairwell going up to the second floor. STNA #334 could not recall exactly which day this incident occured. STNA #334 said another resident had pushed Resident #14 into the stairwell. Interview on 11/21/23 at 9:00 A.M. with Resident #01 revealed he heard Resident #14 asking for help in the stair well because his room was next to the stair well on the second floor. Resident #01 stated Resident #14 was found a few minutes after he alerted a nurse. Interview on 11/21/23 at 12:18 P.M. with the assistant director of nursing ( ADON) #302 revealed Resident #14 was mentally ill and was not a harm to herself or others. ADON #302 stated a staff member brought Resident #14 to the vending machine and Resident #14 stated they were shoved into a stairwell. ADON #302 verified the incident was not documented in the resident record of Resident #14. Interview on 11/21/23 at 1:26 P.M. with the Director of Nursing ( DON) revealed she was not notified by ADON #302 of the incident therefore she did not document the incident. The DON stated after interview with staff it was revealed another resident who was now discharged pushed Resident #14 into a stair well. Interview on 11/21/23 at 2:10 P.M. with Licensed Practical Nurse ( LPN) #306 revealed LPN #306 found Resident #14 in the first floor stair well around 6:45 P.M. because another resident (Resident #01) heard Resident #14 yelling for help. Resident #14 needed help to wheel out of the stair well because she did not know how to open the door behind her. LPN #306 did not know what day this happened because LPN #306 did not document the incident in the resident's record. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00148157. 365185 Page 2 of 2