Health inspection·March 13, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facilities self reported investigation review, and facilities policy review, the facility failed to timely report an allegation of physical abuse to the State Agency for Resident #85. This affected one (Resident #85) of three residents reviewed for abuse. The facility census was 100. Findings include: Review of the medical record for Resident #85 revealed an admission date of 07/21/20 with diagnoses including aphasia (difficulty speaking), diabetes mellitus and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had moderately impaired cognition. She had adequate hearing, clear speech, was able to understand others and was able to make herself understood. Review of the facility Self-Reported Investigation (SRI) #245035 dated 03/10/24 revealed the facility was investigating the potential for physical abuse to Resident #85 by State Tested Nurse Aide (STNA) #204. Findings were as follows: -Statement dated 03/10/24 from the Director of Nursing (DON) stated the local police department arrived on 03/10/24 for an alleged physical abuse investigation called in by Resident #85's son. The DON stated the facility was unaware of this allegation and they immediately initiated an in-house investigation. She stated STNA #204 was suspended, Resident #85 was assessed and there were no negative findings noted. -Witness Statement dated 03/10/24 by STNA #204 to the local police department revealed on 03/07/24 he was working on the same unit that Resident #85 resided. He stated another staff member had asked him to assist in repositioning Resident #85 in bed. STNA #204 stated he went into the room with STNA #203, assisted to reposition Resident #85 and then left the room. He stated later in the shift he overheard Resident #85 at the nurse's station using the phone stating to her son that he had punched her in the face during care. He stated STNA #203 asked to speak to Resident #85's son and she explained what had happened during care and that the resident was never hit. -Witness Statement dated 03/10/24 by STNA #203 to the local police department revealed on Thursday (03/07/24), after she was done with care, she needed assistance to reposition Resident #85 in bed. She stated she had asked STNA #204 to assist her and he came in the room, they repositioned Resident #85 in bed and then he left. STNA #203 stated she spoke to Resident #85's son on the phone and explained what had happened, he told her that he knew his mom was not telling the truth. STNA #203 stated Page 1 of 2 365432 365432 03/13/2024 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when Resident #85's son arrived at the facility he asked STNA #203 to go to his mother's room with him and then he lectured his mother that she needed to stop telling lies on the workers. -Additional statement dated 03/10/24 by STNA #203 revealed she was at the nurse's station when Resident #85 called her son on 03/07/24. Resident #85 made accusations that STNA #204 hit her in the face. STNA #203 asked to speak to Resident #85's son and updated him that STNA #204 did not hit his mother. -Statement dated 03/10/24 by Licensed Practical Nurse (LPN) #201 revealed she had been at the nurse's station and overheard the telephone conversation when Resident #85 called her son stating STNA #204 had hit her in the head (this did not specify the date of the telephone call). LPN #201 stated STNA #203 had intervened and asked to speak to Resident #85's son. She stated STNA #203 updated the son that herself and STNA #204 had repositioned his mother only and he did not hit the resident. Interview on 03/13/24 at 9:16 A.M. with the DON revealed the police department came to the facility on [DATE] stating Resident #85's son had made an allegation of abuse against STNA #204. She stated she suspended STNA #204 immediately and began an investigation for which she had not found any evidence to substantiate abuse. Interview on 03/13/24 at 9:57 A.M. with Resident #85 revealed she alleged STNA #204 hit her in the head three to four times. She could not recall the exact date that this had occurred. Interview on 03/13/24 at 10:05 A.M. with STNA #203 revealed she had been providing care to Resident #85 on an unknown date with STNA #204. She stated she had provided hygiene and grooming to Resident #85 but then needed assist pulling her up in bed. She had asked STNA #204 to assist her and he came in , assisted with pulling her up in bed and then he left the room. She stated she spoke to Resident #85's son later in the shift when Resident #85 was alleging STNA #204 had hit her in the head. She stated she spoke to the son and clarified that Resident #85 was never hit in the head. She denied updating her supervisor of the allegation. Interview on 03/13/24 at 11:06 A.M. with STNA #204 revealed he had assisted STNA #203 on 03/06/24 with repositioning Resident #85. He stated he went in the room, put on gloves, used the draw sheet to pull the resident up in bed and then left the room. He stated Resident #85 called her son later in the shift and told him that he had hit her. STNA #204 stated he never hit the resident and another STNA got on the phone to clarify what had happened during care of the resident. He denied updating his supervisor of the situation. Interview on 03/13/24 at 12:28 P.M. with the Administrator verified staff should've timely reported the allegation of physical abuse to Resident #85 to their immediate supervisor. Review of facility policy titled Abuse, Neglect and Exploitation, revised 08/30/23 revealed staff should report all incidents of abuse immediately to their direct supervisors. The policy also stated if the event that caused the allegation involves abuse or serious bodily injury, it should be reported to the Department of Health immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number OH00151937. 365432 Page 2 of 2