Inspection·August 12, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility Self-Reported Incident (SRI) review, facility policy and procedure review, and interview, the facility failed to ensure Resident #40 was free from resident-to-resident physical abuse. Actual harm occurred on 07/27/23 when Resident #45 pushed Resident #40 to the floor after Resident #40 wandered into his room causing Resident #40 to fall to the floor and suffer a hip fracture that required surgical intervention at a local hospital. This affected one resident (Resident #40) of three residents reviewed for abuse. Findings include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was severely cognitively impaired and independently mobile. Review of the care plan dated 08/22/22 revealed Resident #40 wanders throughout the day and has a short attention span. Resident #45 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder, and anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact and required supervision for completing his activities of daily living. Review of a facility SRI) tracking number #237522 dated 07/28/23 revealed Resident #40 was observed on the floor in another resident's room (Resident #45's room) at 8:00 P.M. on 07/27/23. Resident #40 was observed laying on his left side. Upon assessment, Resident #40 was grimacing and expressed pain in his left hip. Local emergency services were contacted, and Resident #40 was transported to a local emergency room for evaluation. Upon evaluation in the emergency room, Resident #40 was admitted to the hospital with a hip fracture. At the time of the incident, residents in the room were asked what happened and did not respond to staff at the time of the incident. Follow-up interviews/investigation on 07/28/23 revealed, when residents were re-interviewed, Resident #45 admitted he pushed Resident #40 onto the floor. Resident #45's roommate (Resident #150) was also interviewed and revealed that he witnessed Resident #45 push Resident #40 to the floor. Per multiple staff interviews on (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 3 Event ID: 365432 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 365432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133 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)