Health 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 Page 1 of 3 365432 365432 08/12/2023 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0689 Level of Harm - Actual harm Residents Affected - Few 07/28/23, Resident #40 was engaging in typical baseline behaviors (continuous wandering) in the time leading up the incident. Per baseline Resident #40 was easily re-directable by staff when wandering behaviors became intrusive to others. At 8:00 P.M., staff observed Resident #40 at the nurse's station. Between 8:00 P.M. and 8:30 P.M., Resident #40 was observed by multiple staff ambulating in the hallway eating a snack and standing at the nurse's station. Between 8:15 P.M. and 8:30 P.M, Licensed Practical Nurse (LPN) #900 was finishing her medication pass on Resident #40's unit. LPN #900 observed the door closed in Resident #45's and thought she heard Resident #40 talking. LPN #900 proceeded to the door and knocked and opened it and observed Resident #40 on the floor. Upon assessment and consultation with Resident #40 primary care physician, an order was obtained to send Resident #40 to a local hospital for evaluation. Interview with the Administrator on 08/12/23 at 10:15 A.M. verified the events of the SRI. Review of the facility policy entitled Ohio Abuse Policy, dated 10/03/22, revealed This Facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The deficient practice was corrected on 07/28/23 when the facility implemented the following corrective actions: • The facility conducted head to toe assessment on the residents involved in the altercation. The injured resident (Resident #40) was sent to the hospital for evaluation on 7 /27/23. • Residents #40 and #45's attending physicians were notified of the altercation and any injuries identified. No new orders received. • The facilities consulting psychiatrist was notified of the altercation and scheduled follow-up visit. • The responsible parties for the residents involved in the altercation were informed. • The facility notified the local police department of the incident. • The facility submitted an initial SRI to the Ohio Department of Health on 7/28/23. • 365432 Page 2 of 3 365432 08/12/2023 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0689 To identify other potential like residents, on 7/28/23 residents that were unable to be interviewed, had a head-to-toe skin observation completed for potential signs of abuse. No negative findings were noted. Level of Harm - Actual harm • Residents Affected - Few To prevent this from recurring, on 07/28/23 the facility completed an audit of residents who were intrusive wanderers, and residents who were territorial of their room. No other residents who were territorial with their room were noted or they had interventions in place, i.e. stop signs. • The Director of Nursing/ Designee educated facility all staff on its abuse policy and re-directive and behavioral techniques related to intrusive wanderers and residents who were territorial of their room on 07 /28/23. • A quality assurance and performance improvement meeting was completed on 07/28/23 to address the issue and develop procedures to prevent other similar reoccurrences. • To monitor and maintain ongoing compliance the facility will conduct five resident head-to-toe observations weekly for four weeks then monthly for two months to ensure there are no identified cases of potential abuse. Audit results will be submitted to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendation. This deficiency represents noncompliance investigated under Self-Reported Incident, Control Number OH00145207. 365432 Page 3 of 3