Health inspection·October 16, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility Self-Reported Incident (SRI) investigation, review of policy, observations and interviews, the facility failed to ensure Resident #7 and Resident #8 were free from physical abuse. This affected two residents (Resident #7 and #8) out of three residents reviewed for abuse. The facility census was 92. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/25/19 with diagnoses including schizoaffective disorder, drug-induced subacute dyskinesia, chronic obstructive pulmonary disease, insomnia, vascular dementia without behavior disturbance, psychotic disturbance or mood disturbance, schizophrenia, major depressive disorder, muscle weakness and abnormal gait. Review of Resident #8's Minimum Data Set (MDS) 3.0 assessment, dated 09/12/23 , revealed moderate cognitive deficit with a Brief Interview for Mental Status ( BIMS) score of 10 out of 15. Resident #8 had no physical or verbal behavior exhibited toward others, was a one-person physical assistance for bed mobility, one-person physical assist for walking in the room, needed supervision for dressing, eating and toilet use. Resident #8 had no broken teeth, or mouth or facial pain noted. Resident #8 had no surgical wounds or skin tears. Review of the comprehensive care plan, start date 06/14/23, documented Resident #8 was at risk for sexually oriented behavior related to dementia with behaviors and altered mental status. The goal was for Resident #8 to comply with staff directions and behave in a safe and respectful manner through next review date. Interventions included conduct an evaluation of sexually oriented behavioral symptoms to determine what Resident #8 is communicating through behavior, use creative refocusing to alter behavior patterns, redirection, and referral for a psychiatric evaluation and utilize psychoactive medication as warranted. 2. Review of Resident #7's medical record revealed an admission date of 09/30/21 with medical diagnoses including type two diabetes mellitus, schizophrenia, anxiety disorder, insomnia, unspecified intellectual disabilities, major depressive disorder and generalized anxiety disorder, Review of Resident #7's annual MDS 3.0 assessment, dated 07/06/23, revealed cognition was intact with a BIMS score of 15 out of 15. Resident #7 did not hallucinate or had delusions and had no physical or verbal behaviors exhibited toward others. Resident #7 needed one-person physical assist for bed mobility and was independent to walk. Resident #7 needed set up for dressing, eating and toilet use. Page 1 of 4 365353 365353 10/16/2023 Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112

F 0600 Level of Harm - Minimal harm or potential for actual harm potential verbal aggression when frustrated. Goal for Resident #7 was to verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included staff to remain calm and not raise voice, encourage Resident #7 to vent feelings, staff not to take resident's behavior personally, encourage resident to participate in individual or group activities, and notify physician related to medication. Residents Affected - Few Review of a nursing note dated 10/10/23 written by Licensed Practical Nurse ( LPN) #424 revealed loud voices with cursing and yelling in the room of Resident #7 and Resident #8. LPN #424 observed Resident #7 in Resident #8's bed. Resident #8 was on top of Resident #7 hitting him with his fist. Resident #7 was choking Resident #8 and hitting his face. Resident #8 was bleeding from the mouth and under right eye and his neck was very red. SR #8 had a laceration under his right eye. The medical director and family were informed. Review of the facility document titled Skin Grid Non-Pressure V5, dated 10/09/23, written by LPN #424 revealed Resident #8 had red marks on his neck and a skin tear on face measuring 0.5 centimeters (cm) in length by 0.5 cm in width and 0.1 cm depth. The wound had sanguineous bloody drainage. Review of a nursing note dated 10/10/23 written by LPN #325 revealed Resident #8 returned from the hospital that morning with no new orders and vital signs within normal limits. Resident #8 was moved to another room. A message was left for the guardian to call back regarding the update on the room change. Review of Resident #8's hospital emergency visit summary on 10/09/23 revealed an admission diagnosis of assault. Imaging tests were ordered of the cervical spine, head and maxillofacial bones and a chest x ray. All results were negative and Resident #8 was discharged back to the facility on [DATE] Review of the facility SRI investigation, dated 10/10/23 , revealed at 10:30 P.M. the administrator received a call from the second-floor charge nurse to report Resident #7 and Resident #8 were in an altercation. The preliminary investigation revealed Resident #7 stated the roommate (Resident #8) was masturbating in bed, and Resident #7 wanted him to stop. Resident #8 reported Resident #7 came over to his side of the room and began making derogatory remarks about his family. Both residents were immediately separated. Resident #8 had a laceration under his eye and was bleeding from the mouth. Police were called. Resident #7 was placed on every 15-minute checks and Resident #8 was transported to the emergency room. Both of the resident's representatives and physicians were notified. The facility unsubstantiated the allegation of abuse indicating the resident's indicated they had a disagreement, hit each other but denied feeling abused. Review of the witness statement dated 10/09/23 authored by State Tested Nursing Assistant (STNA) #379 revealed she heard the nurse responding to a resident altercation and followed the nurse down the hall. Resident #8 was on top of Resident #7 pounding him in the face with his fist. The staff worked together to deescalate the situation. Review of the witness statement dated 10/09/23 authored by Licensed Practical Nurse (LPN) #424 revealed she heard cursing and yelling and went to the room of Resident #7 and Resident #8 to find Resident #8 on top of Resident #7 hitting him in the face and Resident #7 was choking Resident #8. Review of the witness statement dated 10/09/23 authored by STNA #302 revealed she heard the nurse scream for help, went to the room of Resident #8 and Resident #7 and saw Resident #8 on top of 365353 Page 2 of 4 365353 10/16/2023 Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112

F 0600 Resident #7 punching him in the face. STNA #302 and the other staff broke up the fight. Level of Harm - Minimal harm or potential for actual harm Review of the witness statement dated 10/09/23 authored by STNA #311 revealed she witnessed Resident #7 and #8 fighting with each other. Residents Affected - Few Interview on 10/12/23 at 9:46 A.M. with the Executive Director( ED) revealed as of 09/01/23 Resident #7 and SR #8 were roommates. The ED verified the altercation with Resident #7 and #8. The ED verified SR #8 had a laceration under the eye and blood from the mouth and needed to go to the hospital emergency room. Resident #7 did not have any injuries and refused to go the hospital. Interview on 10/12/23 at 2:45 P.M. with Resident #8 revealed he felt Resident #7 did not like him because he masturbated. Resident #8 stated Resident #7 scratched him and he was not missing any teeth. Resident #8 stated he did not feel safe because his roommate would start fights with him. Resident #8 also stated he did not feel scared now that he was away from Resident #7. Observation during this interview revealed Resident #8 had a pink laceration under the right eye and a pink laceration on the neck. Interview on 10/10/23 at 3:00 P.M. with Resident #7 revealed Resident #8 did not have his curtain closed when he was masturbating and that bothered him. Resident #7 stated he was upset because nobody should have to see that. Interview on 10/12/23 with STNA #379 who witnessed the event stated Resident #7 would get upset easily. STNA #379 said Resident #8 had blood under his eye and blood in his mouth from the fight with Resident #7. Interview on 10/12/23 at 1:29 P.M. with LPN #332 stated Resident #8 had a cut under eye and welts around his neck from being choked during the fight with Resident #8. Resident #8 was nervous because of what happened but presently not scared. The ambulance took Resident #8 to the hospital emergency room for evaluation of his injuries. Interview on 10/12/23 at 1:32 P.M. with STNA #311 revealed she was in the linen room on the night of 10/09/23 and heard screaming. Resident #8 was on top of Resident #7 fighting. STNA #311 verified Resident #8 had a cut under his eye and a scratch on the resident's neck. Interview on 10/12/23 at 1:42 P.M. with STNA #329 revealed she was called to help with the altercation. Both residents were separated and kept safe that night. Interview on 10/12/23 at 5:30 P.M. with LPN #424 revealed she was sitting behind the nurse station and heard yelling down the hall. When LPN #424 entered the room Resident #8 was on top of Resident #7 and Resident #8 had a bloody mouth and a cut eye. LPN #424 called for help immediately and the staff separated the two residents to keep them safe. LPN #424 called 911 and stayed with Resident #8 until the ambulance arrived and transported the resident to the hospital. Interview on 10/12/23 at 12:49 P.M. with Social Worker Designee (SWD) #301 revealed both Resident #7 and #8 had no history of not getting along, but Resident#7 was uncomfortable with Resident #8 masturbating in their room. SWD #310 met with both residents on 10/12/23 and Resident #8 was educated to pull the curtain for privacy during masturbation. SWD #301 stated Resident #8 had a right to privacy and freedom from abuse. 365353 Page 3 of 4 365353 10/16/2023 Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/16/23 at 9:12 A.M. with the Director of Nursing (DON) revealed neither resident had ever shown signs of aggression. The DON stated the hospital stated no major injuries were sustained, only a laceration on Resident #8. Interview on 10/16/23 at 11:09 A.M. with the Director of Behavioral Health Psychologist #459 revealed Resident #8 was a quiet resident and never had problems with other roommates and Resident #7 was opinionated and religiously fixated, therefore, the masturbation bothered Resident #7 and provoked him against Resident #8 contributing to the fight. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated October 2022, documented the definition of abuse as the willful infliction of injury resulting in physical harm. The documented definition of willful as the means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00147293. . 365353 Page 4 of 4