Health inspection·June 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy, and self-reported incident (SRI) review, the facility failed to timely report an injury of unknown origin. This affected one resident (Resident #175) of three residents reviewed for abuse. The facility census was 151. Findings included: Review of the closed medical record for Resident #175 revealed an admission date of 06/05/25 with diagnosis including but not limited to abscess of bursa right hip, methicillin resistant staphylococcus aureus infection, and Alzheimer's Disease. Resident #175 was discharged to hospital of 06/15/25. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #175 was rarely/never understood. Resident #175 was dependent on staff for all activities of daily living (ADL'S) and always incontinent of bladder and bowel. Review of the care plan dated 06/06/25 revealed Resident #175 had a ADL/self-care deficit due to weakness, dementia, bacteremia, and status post incision and drainage (I/D) right hip. Interventions included check and change every two hours, a mechanical lift with two person assist for transfers, administer medications per orders, encourage participation in ADL'S, observe for pain, and Occupational Therapy (OT) and Physical Therapy (PT) for evaluation and treat. Review of the progress note dated 06/15/25 at 7:05 P.M. called discharge status note, authored by Licensed Practical Nurse (LPN) 301 revealed Resident #175 had a change in condition with a temperature of 102.9 Fahrenheit. Review of the progress note dated 06/15/25 at 10:04 P.M., authored by LPN #400, revealed the hospital emergency department called to ask questions and requested to speak to supervisor and informed her Resident #175 was being admitted to hospital. Review of the progress noted dated 06/16/25 at 01:40 A.M., authored by Director of Nursing (DON), revealed she called the hospital and spoke with the nurse there regarding admitting diagnosis of sepsis along with several fractures to right hip, and hospital nurse verbalized that infection could cause damage to bones. Hospital nurse asked DON about falls and DON reported no falls. Review of the progress note dated 06/16/25 at 09:15 A.M., authored by DON, revealed she contacted Physician #500 regarding update on Resident #175. DON reported Physician #500 revealed due to Resident #174's age and comorbidities, and infection would cause bone breakdown. DON called Resident #175's Page 1 of 3 365289 365289 06/24/2025 Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646

F 0609 granddaughter regarding hospitalization, and she verbalized there was no way she would have fallen. Level of Harm - Minimal harm or potential for actual harm Review of the progress note dated 06/16/25 at 5:34 P.M., authored by DON, revealed she attempted several times throughout the shift to speak with hospital staff to get updated. At this time the main priority was Resident #175's abscess and potential surgery for possible drain placements. Cardiologist ordered test to determine whether Resident #175 was a candidate for surgery. Residents Affected - Few Review of the facility submitted SRI history for the month of June 2025 revealed the facility did not report an injury of unknown origin related the hospitals' report of multiple fractures. Review of the investigation started on 06/16/25 revealed all twenty-four nursing staff were interviewed with no knowledge of injury of unknown origin or falls. DON instructed Registered Nurse (RN) #316, unit manager working evening shift to start whole house skin sweeps on all residents. All residents in house had full skin sweeps completed with no negative outcomes. Interview on 06/18/25 at 11:55 A.M. with DON revealed she did not consider Resident #175's three (3) new fractures and dislocated right hip an injury of unknown origin due to Physician #500 revealed it was caused by infection, therefore it was not reported to the state agency. DON reported she did start an investigation originally with interviews and statements but then stopped after the physician's report. DON denied Resident #175 having any falls during her stay. Interview on 06/18/25 at 4:13 P.M. with Physician #500 reported she received a call from the nursing home on [DATE] regarding Resident #175 change in condition of not eating and a temperature. Physician #500 reported she ordered to send the resident to hospital for evaluation. Physician #500 reported she later received a call from DON on 06/16/25 regarding Resident #175 diagnoses of multiple right hip fractures, dislocation of right hip, and infection. Physician #500 reported she does not have privileges at the hospital and the information was provided to her by the DON. Physician #500 reported she believed the infection could cause multiple fractures and hip dislocations. Interview on 06/23/25 at 6:36 A.M. with RN #316 reported she came into work on 06/15/25 for her assigned shift at 11:00 P.M. and received a text from LPN #400 stating she received a call from the hospital regarding Resident #175. LPN #400 confirmed the nurse from the hospital informed her Resident #175 had multiple new fractures to her hip and the entire hip area was dislocated, she reported it, and the hospital nurse wanted the supervisor to call her back. RN # 316 reported she called the hospital back to speak with the nurse, who was on lunch, so she spoke with the the resident physician who confirmed Resident #175 had multiple new fractures to her hip, it was dislocated, and he didn't say if the fractures were traumatic or pathological. RN # 316 reported she let the resident physician know Resident #175 had no reported injury at facility and had a bowel movement on 06/15/25. RN # 316 confirmed the resident physician told her Resident #175 was admitted for sepsis, multiple fractures of hip and hip dislocation. RN #316 reported she contacted DON and left a voice message to call back. RN #316 reported she contacted Assistant Director of Nursing (ADON) and left a voice message to call back and contacted the on call nurse manager RN #282 and reported to her what happened. Interview on 06/23/25 at 9:08 A.M. via phone with Certified Nursing Assistant (CNA) 253 verified she was not interviewed regarding the injury of unknown origin for Resident #175. (CNA) 253 reported on 06/18/25, when the agency entered the building, DON had asked her to write a statement regarding Resident #175 regarding the incident on 06/15/25. Interview on 06/23/25 at 10:26 A.M. with DON confirmed an injury of unknown origin should be 365289 Page 2 of 3 365289 06/24/2025 Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646

F 0609 reported immediately within two hours. Level of Harm - Minimal harm or potential for actual harm Interview on 06/23/25 at 10:32 A.M. with Regional Nurse #501 confirmed injury of unknown origin should be reported immediately within two hours. Residents Affected - Few Interview on 06/24/25 at 06:37 A.M. with RN #316 confirmed she did not initiate any education with staff. RN # 316 confirmed DON instructed her to begin skin sweeps on all residents and take statements from staff working. Interview on 06/24/25 at 10:37 A.M. with the Administrator confirmed an injury of unknown origin is to be reported with a SRI immediately within two hours. Administrator reported he follows the Ohio Department of Health regulations to report within two hours. Review of facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 10/2022, revealed an injury is classified as an Injury of Unknown Source when both the following conditions are met: 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2. the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over the time. This deficiency represents non-compliance investigated under Complaint Number OH00166746. 365289 Page 3 of 3