Health inspection·June 11, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to protect residents from resident-to-resident physical abuse. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents. Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/04/22 with diagnoses including Parkinson's disease, dementia, reduced mobility, urinary tract infections, repeated falls, metabolic encephalopathy, hypertension, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #93 dated 05/10/24 revealed the resident had severe cognitive impairment. Review of the facility SRI #247741 dated 05/20/24 revealed on 5/20/24 at about 2:00 P.M. the unit manager heard a commotion and looked into the common area and witnessed two residents (Resident #60 and #18) on the ground holding onto each other. The unit manager separated the two residents, and redirected Resident #60 to his room, and assessed him for injury noting the resident sustained a skin tear. The unit manager left Resident #60 unattended and went to assess Resident #18 noting this resident also had a skin tear. Approximately 10 minutes after the incident, Resident #60 left his room and saw Resident #93 standing in the hallway. Resident #60 reached out and made contact with Resident #93's face. Resident #60 was very agitated and aggressive, and the unit manager remained with Resident #60 until emergency medical services (EMS) arrived to take him to the hospital. Review of a signed statement per State Tested Nursing Assistant (STNA) #440 dated 05/20/24 revealed the aide had heard a noise down the hallway and responded when he saw Resident #60 and Resident #18 rolling on the floor during an altercation between the two. Both residents sustained skin tears to their arms. Afterward Resident #60 was becoming increasingly aggressive with other residents on the halls and making sexual remarks to the women. Review of a signed statement per Licensed Practical Nurse (LPN) #91 dated 05/20/24 revealed the nurse was informed that Resident #60 had made contact with the face of Resident #93. Interview on 06/10/24 at 1:20 P.M. of Resident #93's representative confirmed she was sitting with Resident #93 in the doorway to his room on 05/20/24. The Representative stated Resident #93 was tossing a ball with another resident when Resident #60 walked up and asked Resident #93 if he was the guy who had thrown a ball at him. Resident #60 then slapped Resident #93 across the face. Resident Page 1 of 7 365344 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #93's representative confirmed she screamed and STNA #440 responded to the scream. Resident #93's representative confirmed the staff did not interview her regarding the incident she witnessed in which Resident #60 slapped Resident #93 across the face. Interview on 06/11/24 at 10:30 A.M. with the Director of Nursing (DON) confirmed the facility's investigation did not include interviews with the individuals that directly observed the second incident when Resident #60 slapped Resident #93 on 05/20/24. The DON confirmed the facility's investigation revealed Resident #60 slapped Resident #93 in the face. Interview 11/24 at 1:05 P.M. with STNA #440 confirmed he was working the day of the altercation between Resident #60 and Resident #18 in which they got into physical altercation in the lobby and scratched each other up pretty badly. Resident #18 was in the nurses' station attended by staff following the altercation while Resident #60 was left unattended in his room. STNA #440 confirmed that after approximately 10 to 15 minutes following the altercation between Resident #60 and #18, he heard Resident #93's representative screaming. STNA #440 further confirmed Resident #93's representative told him she had witnessed Resident #60 slap Resident #93 across the face. STNA #440 confirmed someone should have remained with Resident #60 after the altercation with Resident #18 to prevent him from hitting another resident. STNA #440 confirmed after Resident #60 slapped Resident #93, the Maintenance Director (MD) remained in the doorway of the Resident #60's room providing one on one supervision until Resident #60 could be transferred to the hospital in order to prevent him from harming anyone else. STNA #440 confirmed Resident #60 had a known history of physical altercations with other residents. Review of the abuse policy revised on March 2024 revealed residents had the right to be free from abuse. It was the facility policy to thoroughly investigate all alleged violations involving abuse. The investigation protocol included interviewing the resident, the accused, and all witnesses. This deficiency represents noncompliance investigated under Complaint Number OH00154319. 365344 Page 2 of 7 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to conduct thorough abuse investigations and failed to protect residents from abuse during pending abuse investigations. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/04/22 with diagnoses including Parkinson's disease, dementia, reduced mobility, urinary tract infections, repeated falls, metabolic encephalopathy, hypertension, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #93 dated 05/10/24 revealed the resident had severe cognitive impairment. Review of the facility SRI #247741 dated 05/20/24 revealed on 5/20/24 at about 2:00 P.M. the unit manager heard a commotion and looked into the common area and witnessed two residents (Resident #60 and #18) on the ground holding onto each other. The unit manager separated the two residents, and redirected Resident #60 to his room, and assessed him for injury noting the resident sustained a skin tear. The unit manager left Resident #60 unattended and went to assess Resident #18 noting this resident also had a skin tear. Approximately 10 minutes after the incident, Resident #60 left his room and saw Resident #93 standing in the hallway. Resident #60 reached out and made contact with Resident #93's face. Resident #60 was very agitated and aggressive, and the unit manager remained with Resident #60 until emergency medical services (EMS) arrived to take him to the hospital. Review of a signed statement per State Tested Nursing Assistant (STNA) #440 dated 05/20/24 revealed the aide had heard a noise down the hallway and responded when he saw Resident #60 and Resident #18 rolling on the floor during an altercation between the two. Both residents sustained skin tears to their arms. Afterward Resident #60 was becoming increasingly aggressive with other residents on the halls and making sexual remarks to the women. Review of a signed statement per Licensed Practical Nurse (LPN) #91 dated 05/20/24 revealed the nurse was informed that Resident #60 had made contact with the face of Resident #93. Interview on 06/10/24 at 1:20 P.M. of Resident #93's representative confirmed she was sitting with Resident #93 in the doorway to his room on 05/20/24. The Representative stated Resident #93 was tossing a ball with another resident when Resident #60 walked up and asked Resident #93 if he was the guy who had thrown a ball at him. Resident #60 then slapped Resident #93 across the face. Resident #93's representative confirmed she screamed and STNA #440 responded to the scream. Resident #93's representative confirmed the staff did not interview her regarding the incident she witnessed in which Resident #60 slapped Resident #93 across the face. Interview on 06/11/24 at 10:30 A.M. with the Director of Nursing (DON) confirmed the facility's investigation did not include interviews with the individuals that directly observed the second incident when Resident #60 slapped Resident #93 on 05/20/24. The DON confirmed the facility's investigation revealed Resident #60 slapped Resident #93 in the face. 365344 Page 3 of 7 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview 11/24 at 1:05 P.M. with STNA #440 confirmed he was working the day of the altercation between Resident #60 and Resident #18 in which they got into physical altercation in the lobby and scratched each other up pretty badly. Resident #18 was in the nurses' station attended by staff following the altercation while Resident #60 was left unattended in his room. STNA #440 confirmed that after approximately 10 to 15 minutes following the altercation between Resident #60 and #18, he heard Resident #93's representative screaming. STNA #440 further confirmed Resident #93's representative told him she had witnessed Resident #60 slap Resident #93 across the face. STNA #440 confirmed someone should have remained with Resident #60 after the altercation with Resident #18 to prevent him from hitting another resident. STNA #440 confirmed after Resident #60 slapped Resident #93, the Maintenance Director (MD) remained in the doorway of the Resident #60's room providing one on one supervision until Resident #60 could be transferred to the hospital in order to prevent him from harming anyone else. STNA #440 confirmed Resident #60 had a known history of physical altercations with other residents. Review of the abuse policy revised on March 2024 revealed residents had the right to be free from abuse. It was the facility policy to thoroughly investigate all alleged violations involving abuse. The investigation protocol included interviewing the resident, the accused, and all witnesses. This deficiency represents noncompliance investigated under Complaint Number OH00154319. 365344 Page 4 of 7 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, staff interview, and review of facility policy, the facility failed to ensure a plan of care and interventions were implemented for the areas of fall risk and incontinence. This affected two (Residents #104 and #120) of four residents sampled. The facility census was 126. Findings include: 1. Review of the medical record for Resident #104 revealed an admission date of 03/05/24 with diagnoses including acute respiratory failure, weakness, unsteadiness on feet, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #104 dated 03/05/24 revealed the resident had moderately impaired cognition and was always incontinent of bowel and bladder. Review of the fall risk evaluation for Resident #104 dated 03/06/24 revealed the resident was at high risk for falls. Review of the care plan for Resident #104 initiated 03/05/24 revealed no care plan or interventions had been developed for the resident for the areas of fall risk or incontinence. Interviewon 06/11/24 at 3:15 P.M with Regional Clinical Director (RCD) #555 confirmed the facility had not developed a fall risk or incontinence care plan for Resident #104 2. Review of the medical record for Resident #120 revealed an admission date of 03/19/24 with diagnoses including dysphagia, epilepsy, altered mental status, and repeated falls. Review of the admission MDS assessment for Resident #120 dated 03/25/24 revealed the resident had moderately impaired cognition and was always incontinent of bowel and bladder. Review of the fall risk evaluation for Resident #120 dated 03/20/24 revealed the resident was at high risk for falls. Review of the care plan for Resident #120 initiated 03/25/24 revealed no care plan or interventions had been developed for the resident for the areas of fall risk or incontinence. Interview on 06/11/24 at 10:50 A.M. with the Director of Nursing (DON) confirmed the facility had not developed a fall risk or incontinence care plan for Resident #120. Review of the facility policy titled Managing Falls and Fall Risk revised March revealed the staff, with input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 365344 Page 5 of 7 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents received care in accordance with the care plan in order to prevent falls. The facility also failed to investigate resident falls to determine the root cause of the fall and implement interventions to prevent recurrence. This affected two (Residents #36 and #120) of four residents reviewed for falls and accidents. The facility census was 126. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 01/23/13 with diagnoses including chronic obstructive pulmonary disorder, dementia, and reduced mobility. Review of the annual Minimum Data Set (MDS) assessment for Resident #36 dated 05/19/24 revealed the resident had severe cognitive impairment. Review of the state optional MDS assessment for Resident #36 dated 05/19/24 revealed the resident dependent upon two staff members for transfers, bed mobility, and toileting. Review of the care plan for Resident #36 dated 01/21/13 revealed the resident had an activities of daily living (ADL) self-care deficit. Interventions included staff should utilize a Hoyer lift for all transfers. Review of the physician's orders for Resident #36 revealed an order dated 05/14/24 for a Hoyer lift for all transfers. Observation on 06/10/24 at 3:08 P.M. revealed State Tested Nursing Assistant (STNA) #640 had Resident #36 up in the air in a Hoyer lift to transfer the resident to bed. There were no other staff members present in the room assisting STNA #640 with the transfer. Interview on 06/20/24 at 3:08 P.M. with STNA #640 confirmed two staff members were supposed to be present to transfer residents utilizing a Hoyer lift to prevent falls and accidents, but another staff member was not readily available to assist so the STNA was completing the transfer alone. Interview on 06/11/24 at 12:52 P.M. with the Director of Nursing (DON) on 06/11/24 confirmed two staff members were required to be present and assist when transferring a resident utilizing a Hoyer lift in order to prevent falls and accidents. Review of the facility policy titled Safe Lifting and Movement of Residents reviewed June 2024 revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility used appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care would be trained in the use of manual and mechanical lifting devices. Only staff with documented training on the safe use and care of the machines and equipment used in the facility would be allowed to lift or move residents. 2. Review of the medical record for Resident #120 revealed an admission date of 03/19/24 with diagnoses including dysphagia, epilepsy, altered mental status, and repeated falls. 365344 Page 6 of 7 365344 06/11/2024 Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the admission MDS assessment for Resident #120 dated 03/25/24 revealed the resident had moderately impaired cognition evidenced was always incontinent of bowel and bladder. Review of the care plan for Resident #120 initiated 03/19/24 revealed the care plan did not address the resident's fall risk and did not include interventions to prevent falls. Residents Affected - Few Review of the fall risk evaluation for Resident #120 dated 03/20/24 revealed the resident was at risk for falls. Review of the nurse progress note for Resident #120 dated 03/24/24 revealed the resident was found on the floor beside the bed on the left side. The nurse assessed Resident #120 and found no injuries except for redness noted to the left side of the resident's forehead. Resident #120 stated she slid onto the floor while trying to get up to the bathroom. Resident #120's call light was in reach, but the resident stated she did not know it was there and denied knowing how to call for help to get out of bed. Further record review for Resident #120 revealed it did not include an investigation of the resident's unwitnessed fall on 03/24/24. Interview on 06/11/24 at 10:50 A.M. with the DON confirmed Resident #120 was at risk for falls but the facility had not implemented a fall prevention care plan for the resident. The DON further confirmed Resident #120 had an unwitnessed fall on 03/24/24 but the facility had not conducted an investigation regarding the fall nor had the facility determined the root cause to the fall. Review of the facility policy titled Managing Falls and Fall Risk revised March 2018 revealed based on previous evaluations and current data, the staff would identify interventions related to the residents' specific risks and causes to try to prevent the residents from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. This deficiency represents noncompliance investigated under Complaint Number OH00154319. 365344 Page 7 of 7