Health inspection·January 31, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy the facility failed to prevent an incident of resident abuse involving Resident #37. This affected one resident (#37) of three residents reviewed for abuse. The facility census was 42. Findings include: Review of the facility survey history revealed on 01/26/24 an onsite complaint investigation identified a concern related to an incident of physical abuse involving Resident #37. As a result of this abuse incident, Resident #37, who had been hit in the head by a visitor, required staples to his head. Following the incident, the facility implemented an action plan to prevent future reoccurrences of abuse. This plan included a review of all residents with aggressive behaviors with care plans and interventions reviewed with necessary changes made as appropriate. The plan included education to staff to recognize resident triggers and redirecting/de-escalating behaviors and also included environmental observations and audits to ensure foreign objects were not accessible. Review of the medical record for Resident #37 revealed an admission date of 02/28/23 with diagnoses including Alzheimer's disease, anemia, muscle weakness, and dementia with psychotic disturbance. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and independent with eating, oral hygiene, toileting, dressing, and hygiene. Review of the care plan dated 11/28/23 revealed Resident #37 had the potential for mood swings and behavioral issues due to dementia and Alzheimer's disease. Interventions included non-pharmacological interventions such as a one-to-one attention, changing position or scenery, redirection or offering activities, providing a calming environment, and attempting to redirect behaviors. Review of a progress note for Resident #37, dated 01/26/24 at 11:34 P.M. revealed Resident #37 was in an altercation with another resident (Resident #4) who was in his room. There was no documented evidence of an assessment for injury, vital signs, neurological checks, physician notification, and/or responsible party notification following the incident. Review of the medical record for Resident #4 revealed an admission date of 01/23/24 with diagnoses including Alzheimer ' s disease, asthma hypertension and muscle weakness. The comprehensive MDS assessment had not yet been completed as the resident was a new admission. (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: 365401 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 365401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health Care Center 24613 Broadway Avenue Oakwood Village, OH 44146 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)