Health inspection·April 24, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, staff interviews, review of facility policy, review of self-reported incidents (SRIs) and review of facility investigation, the facility failed to report an allegation of abuse to the state agency. This affected one resident (#30) out of three residents reviewed for abuse. The facility census was 83. Findings included: Review of the medical record for Resident #30 revealed an admission of 03/09/21. Diagnoses included dementia, type 2 diabetes mellitus, benign prostatic hypertrophy, gastroesophageal reflux disease, repeated falls, chronic obstructive pulmonary disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 04/06/23, revealed the resident was cognitively impaired. The resident had a brief interview for mental status (BIMS) score of 07. Review of the plan of care for Resident #30 dated 11/15/22, revealed the resident could be verbally inappropriate towards staff. Interventions included administering medications as ordered, discussing/exploring feeling of anger/anxiety with resident, and maintaining consistent caregivers as schedule would permit. Review of the witness statement written by LPN #107 regarding the incident with Resident #30 and his family revealed that on 04/11/23 at 3:30 P.M., the family of the resident requested that staff put Resident #30 in his wheelchair so they could take the resident outside. Licensed Practical Nurse (LPN) #107 stated that she was unable to locate State Tested Nursing Assistant (STNA) #183. At 3:45 P.M., STNA #183 arrived on the floor. The family of Resident #30 approached LPN #107 at 3:50 P.M. stating there was a problem. The family member alleged that STNA #183 was being rude to them and cussing at them. LPN #107 walked down the hallway with the family member to the Resident #30's room. STNA #183 was noted in the hallway spinning around in a rolling chair talking on her personal phone. LPN #107 asked STNA #183 to help her place the resident in his wheelchair. STNA #183 stated that she does not have time for this expletive. His expletive has been rude to me. The family of Resident #30 tried to apologize to STNA #183 stating that he is like this with everyone. STNA #183 responded by saying expletive this, I am not on this expletive. At this time, LPN #107 stated that she escorted STNA #183 off the floor asking her to leave and not return to the floor. Review of the facility investigation dated 04/13/23, regarding the incident that occurred with Resident #30's family on 04/11/23, revealed the facility stepped in when they recognized a bad situation. STNA #183 was asked to leave the floor immediately. Administrative Registered Nurse (RN) #100 Page 1 of 4 365350 365350 04/24/2023 Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246

F 0609 Level of Harm - Minimal harm or potential for actual harm provided statements and documentation that LPN #107 was interviewed and STNA #183 was interviewed. STNA #183 had left the facility after the incident and did not care for any residents after being asked to leave the floor. STNA #183 was notified of her termination. No residents were interviewed that were cared for by STNA #183 on 04/11/23. The cameras were not accessed to review the details and specifics of the incident. Residents Affected - Few Interview on 04/19/23 at 11:55 A.M. with Licensed Practical Nurse (LPN) #107, revealed there was an incident between a State Tested Nursing Assistant (STNA) (identified as STNA#183) and the family member of Resident #30 that occurred in the last couple of weeks. LPN #107 was on shift when she heard STNA #183 using profanity towards a resident's family near the resident. LPN #107 immediately intervened between STNA #183 and the family members. LPN #107 escorted STNA #183 off the floor and checked on Resident #30 and his family and the incident was reported to the Director of Nursing (DON). Interview on 04/19/23 at 1:45 P.M. with Administrative RN #100 confirmed that the facility did not report this incident of alleged abuse to the state agency. Review of facility's SRI's for 04/11/22, revealed no documented evidence the facility created an SRI for the alleged staff-to-resident abuse. Further review of the SRI's revealed the facility created a verbal abuse allegation on 04/20/23 dated 04/12/23 at 2:11 P.M. The SRI was unsubstantiated. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 10/21/22, revealed the facility failed to implement their policy. Mental abuse is defined as including, but not limited to, humiliation, harassment, threats of punishment, or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner; There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment; cannot relate what has occurred; or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Finally, Notification/submission to the State Agency will be made by the Director of Nursing/designee within 24 hours of incident being identified. Follow up with the State Agency will be completed within five working days of the initial report. This deficiency represents non-compliance investigated under Complaint Number OH00140219. 365350 Page 2 of 4 365350 04/24/2023 Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interviews, review of facility's investigation, and review of facility policy, the facility failed to thoroughly investigate an alleged incident of staff-to-resident abuse. This affected one resident (#30) out of three residents reviewed for potential abuse. The facility census was 83. Residents Affected - Few Findings included: Review of the medical record for Resident #30 revealed an admission of 03/09/21. Diagnoses included dementia, type 2 diabetes mellitus, benign prostatic hypertrophy, gastroesophageal reflux disease, repeated falls, chronic obstructive pulmonary disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 04/06/23, revealed the resident was cognitively impaired. The resident had a brief interview for mental status (BIMS) score of 07. Review of the plan of care for Resident #30 dated 11/15/22 revealed the resident can be verbally inappropriate towards staff. Interventions included administering medications as ordered, discussing/exploring feeling of anger/anxiety with resident, and maintaining consistent caregivers as schedule would permit. Review of the witness statement written by Licensed Practical Nurse (LPN) #107 regarding the incident with Resident #30's family revealed that on 04/11/23 at 3:30 P.M., the family of the resident requested that staff put Resident #30 in his wheelchair so they could take the resident outside. LPN #107 stated that she was unable to locate State Tested Nursing Assistant (STNA) #183. At 3:45 P.M., STNA #183 arrived on the floor. The family of Resident #30 approached LPN #107 at 3:50 P.M. stating there was a problem. The family member alleged that STNA #183 was being rude to them and cussing at them. LPN #107 walked down the hallway with the family member to the Resident #30's room. STNA #183 was noted in the hallway spinning around in a rolling chair talking on her personal phone. LPN #107 asked STNA #183 to help her place the resident in his wheelchair. STNA #183 stated that she does not have time for this expletive. His expletive has been rude to me. The family of Resident #30 tried to apologize to STNA #183 stating that he is like this with everyone. STNA #183 responded by saying expletive this, I am not on this expletive. At this time, LPN #107 stated that she escorted STNA #183 off the floor asking her to leave and not return to the floor. Review of the facility's investigation dated 04/13/23, regarding the incident that occurred with Resident #30's family on 04/11/23, revealed the facility stepped in when they recognized a bad situation. STNA #183 was asked to leave the floor immediately. Administrative Registered Nurse (RN) #100 provided statements and documentation that LPN #107 was interviewed and STNA #183 was interviewed. STNA #183 had left the facility after the incident and did not care for any residents after being asked to leave the floor. STNA #183 was notified of her termination. No residents were interviewed that were cared for by STNA #183 on 04/11/23. The cameras were not accessed to review the details and specifics of the incident. Interview on 04/19/23 at 11:55 A.M. with LPN #107, revealed there was an incident between STNA #183 and the family member of Resident #30 that occurred in the last couple of weeks. LPN #107 was on shift when she heard STNA #183 using profanity towards a resident's family near the resident. LPN #107 immediately intervened between STNA #183 and the family members. LPN #107 escorted STNA #183 off 365350 Page 3 of 4 365350 04/24/2023 Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the floor and checked on Resident #30 and his family and the incident was reported to the Director of Nursing (DON). Interview on 04/19/23 at 1:45 P.M. with Administrative RN #100 verified the facilities investigation showed no proof STNA #183 was cursing at Resident #30; however, RN #100 agreed that the resident could hear his family getting yelled at by STNA #183 because they were right outside the room in the hallway. She agreed that she would feel some type of distress if someone was yelling at her family member. RN #100 confirmed that she did not interview those cognitively intact residents on the unit cared for by STNA #183 to confirm that no mistreatment had taken place. Additionally, the facility had cameras throughout the hallways and RN #100 confirmed those cameras were not reviewed as a part of the investigation. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 10/21/22, revealed the facility failed to implement their policy. Mental abuse is defined as including, but not limited to, humiliation, harassment, threats of punishment, or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner; There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment; cannot relate what has occurred; or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Additionally, It is the policy of facility that reports of abuse are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened if anything. The Administrator or designee will investigate the incident with the assistance of appropriate personnel. Staff are expected to cooperate during the investigation to assure the resident is fully protected. The investigation will include who was involved, resident statements (staff should attempt to interview non-verbal residents or cognitively impaired residents. If unable to be interviewed or if the resident declines to be interviewed then staff will observe the resident, assess resident behaviors, affect, and response interactions and document findings), resident's roommate statements, involved staff and witness statements of events, observations of resident and staff behaviors during the investigation, and environmental considerations. This deficiency represents non-compliance investigated under Complaint Number OH00140219. 365350 Page 4 of 4