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 (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 2 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 03/13/2024 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)