Health inspection·December 21, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incidents (SRI's), review of the staffing schedule, review of time card punches, staff interviews and review of facility policy, the facility failed to implemented their policy to remove a staff from the duty following an abuse allegation and while an investigation was being completed. This affected one (#42) of 22 residents reviewed for abuse. Facility census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #42 revealed admission date 01/06/23. Diagnoses include, but not limited to, cerebral infarction, hemiplegia and hemiparesis, left non-dominant side, dysphasia, pain in left knee, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The Resident required clean-up assistance for eating and substantial/maximal assistance toileting hygiene. Review of the plan of care dated 11/22/23 revealed Resident #42 had a self-care deficit secondary to cerebral vascular accident (CVA) with left sided hemiplegia, decreased activity tolerance, compromised strength, and pain. Goals include maintain current ability to feed self meals every day after staff sets up trays as needed and will continue to participate with Activities of Daily Living (ADL) by washing upper body after set up. Interventions include allow resident ample time to absorb cues and complete tasks. Assist resident with meal consumption as needed. Assist with opening packages/containers as needed. Set up and supervise ADL's, assist and perform as needed. The resident is at risk for decline in bed mobility related to CVA and left sided weakness with goal for resident to assist with bed mobility with no more that extensive assistance of staff member. Interventions include observe for tolerance of bed mobility program; offer praise on efforts and participation as needed. State Tested Nurse Aide (STNA) to offer verbal and physical cues to resident to participate with bed mobility to fullest extent possible. Interview on 12/20/23 4:35 P.M. Resident #42 stated she had the remote out, asked the STNA #248 where to put the remote because the STNA had moved the bedside table. Resident #42 stated STNA #248 took the remote and threw it against the wall. She hit the resident's hand. Resident #50, roommate, told the STNA to leave the room. Another aide finished the shift. Resident #42 stated she thought the supervisor came back to talk to us on that same night. Review of SRI and investigation revealed Licensed Practical Nurse (LPN) #207 was aware of the incident on 11/25/23 and the Administrator was notified on 11/27/23. Review of time card punches for STNA #248 revealed she punched in on 11/24/23 at 7:06 A.M. and punched out on 11/25/23 at 7:56 A.M. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 365350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)