Health inspection·June 3, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure staff treated Resident #109 with dignity and respect. This affected one resident (#109) out of three residents reviewed for abusive treatment in the facility. The facility census was 108. Findings include: Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, restlessness, depression, insomnia, malnutrition, asthma, anorexia, high blood pressure, kidney failure, spondylosis, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 had severe cognitive impairment, had behaviors including wandering and refusing care, and was independent with transfers and ambulation. Resident #109's plan of care initiated on 05/03/24 indicated a risk for falls related to impaired cognition related to diagnosis of Alzheimer's disease, behavioral symptoms, incontinence, restlessness/agitation, hearing loss, history of left pubis fracture and recent admission to the facility. Review of the nursing progress note dated 05/26/24 stated Resident #109's family alerted the staff that while Resident #109 was seated in the dining room, State Tested Nursing Assistant (STNA) #115 was telling her to sit down in her chair and assisted Resident #109 to sit down. STNA #115 was removed from the situation. Resident #109 was assessed and found no injuries and denied complaints of pain or discomfort. A review of SRI tracking number 247958 indicated Resident #109's family approached Assistant Director of Nursing (ADON) #119 on 05/26/24 and reported when the family entered the dining room, they saw STNA #115 speaking loudly and sternly to Resident #109. STNA #115 was telling Resident #109 to sit down in her wheelchair and attempted to reposition Resident #109. Resident #109's family intervened and then left the dining room to report the incident to ADON #119. STNA #115 was asked to leave the dining room and sent home pending an investigation of the incident. Resident #109 was interviewed but was unable to recount what happened. Resident #109 was assessed and found no injuries and was not exhibiting signs of anxiety or distress. STNA #115 was interviewed and stated Resident #109 was constantly attempting to stand up out of her wheelchair, and STNA #115 asked her multiple times to sit down in a stern tone. STNA #115 stated she attempted to reposition Resident #109 in her wheelchair and was worried Resident #109 might fall. Resident #109's family confronted STNA #115 about the way Page 1 of 5 365633 365633 06/03/2024 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was interacting with Resident #115 and words were exchanged between STNA #115 and Resident #109's family. An interview with Licensed Practical Nurse (LPN) #116 indicated STNA #115 was involved in an altercation with Resident #109 in which STNA #115 grabbed the back of Resident #115's pants to force her to sit down and prevent her from falling. An interview on 05/30/24 at 8:24 A.M. with ADON #119 revealed she was present in the facility on 05/26/24 when the incident between Resident #109 and STNA #115 occurred. ADON #119 stated Resident #109's family walked in the dining room and heard STNA #115 yelling at Resident #109 asking her to sit down and grabbing the back of Resident #109's pants to forcefully make her sit down. ADON #119 stated when the family intervened, STNA #115 became defensive and told the family to not tell her how to do her job. ADON #119 stated she removed STNA #115 from dining room and conducted an interview with STNA #115. ADON #119 indicated STNA #115 was frustrated because Resident #109 kept trying to stand and walk out of the dining room during the meal service. STNA #115 reported the family was aggressive towards her, and she felt defensive. ADON #119 stated she had STNA #115 write a statement regarding the incident before sending her home pending the outcome of the investigation. ADON #119 stated she conducted an interview with STNA #117 who was in the dining room at the time of the incident between Resident #109, STNA #115, and Resident #109's family. STNA #117 reported STNA #115 aggressively pulled Resident #109 down in her chair and was yelling at Resident #109 in a loud voice. An interview with STNA #117 on 05/30/24 at 11:14 A.M. indicated she witnessed the interaction between Resident #109 and STNA #115. STNA #115 was yelling at Resident #109 to sit down and forcefully pulled Resident #109 down by the back of her pants to make her sit down. When the family intervened, STNA #115 started to argue with them and told them to not tell her how to do her job. STNA #117 stated she thought STNA #115 could have handled the situation differently without becoming angry. An interview with STNA #115 on 05/30/21 at 11:21 A.M. indicated Resident #109 was constantly attempting to get up and walk away from her wheelchair. She was worried Resident #109 would fall and held the back of Resident #109's waistband on her pants and assisted her to sit down in the wheelchair. She did not use a gait belt and tugged on Resident #109's belt loop to pull her down to a seated position. She was yelling at Resident #109 to sit down because Resident #109 was very hard of hearing. Resident #109 was resisting her efforts to guide her back to a seated position and may have appeared aggressive, but this was not her intention. An interview with Resident #36 on 06/03/24 at 8:30 A.M. revealed she was present in the dining room during the incident between Resident #109 and STNA #115. Resident #36 stated Resident #109 was trying to stand up and walk away from her wheelchair and STNA #115 had to keep directing her to sit down so she wouldn't fall. Resident #36 stated STNA #115 was trying to assist Resident #109 her own way and could have interacted with Resident #109 in a different manner while helping Resident #109. An interview with the Director of Nursing (DON) on 06/03/24 at 11:30 A.M. verified the above findings. A review of the undated facility policy titled Resident Rights indicated it was the facility's policy to provide resident centered care that meets the psychological, physical, and emotional needs/concerns of residents. Safety of residents, visitors and employees was the top priority of care. Care for residents would be performed in a safe and respectful manner. Residents have the right to voice how they want to be treated. Employees would notify their immediate supervisor when care or treatment was refused. The procedure included when providing care to speak respectfully to residents. 365633 Page 2 of 5 365633 06/03/2024 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0550 This deficiency is an incidental finding identified during the complaint investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 3 of 5 365633 06/03/2024 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure Resident #83's sponsor was notified of significant changes in Resident #83's condition. This affected one resident (#83) out of three residents reviewed for changes in condition. The facility census was 108. Findings include: Review of the medical record revealed Resident #83 was admitted on [DATE] with diagnoses including cerebral vascular disease, vascular dementia pulmonary disease, high blood pressure, atherosclerotic heart disease, hyperlipidemia, iron deficiency anemia major depressive disorder, insomnia, osteoporosis, diaphragmatic hernia, gastroesophageal reflux disease with esophageal obstruction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had a significant change in her ability to sit up from a lying down position and from sitting to standing. The MDS assessment dated [DATE] indicated she was independent in the ability to sit up from a lying down position and from sitting to standing. The MDS assessment dated [DATE] indicated Resident #83 needed maximum assistance of one staff member to assist her to sit up from a lying down position and from sitting to standing. Resident #83's MDS assessment dated [DATE] indicated she was severely cognitively impaired. A review of Resident #83's physician order dated 04/16/24 revealed an order to administer cephalexin (antibiotic) 500 milligrams three times a day orally for the treatment of a wound infection. There was no documented evidence in the medical record that Resident #83's family/responsible party were notified of the significant change in condition or the wound infection. An interview with Minimum Data Set Registered Nurse (MDS RN) #118 on 06/03/24 at 11:30 A.M. revealed she was responsible for attending the interdisciplinary plan meetings to discuss significant changes in a resident's condition. MDS RN #118 stated the licensed nurses were responsible for notification of a resident's representative and/or power of attorney. An interview with Director of Nursing (DON) on 06/03/24 at 12:00 P.M. verified the above findings. A review of the facility's undated policy titled Notification of Change in Condition indicated circumstances requiring notification included but was not limited to: • Accidents • Significant change in resident's physical, mental, or psychological condition such as deterioration in health, mental or psychological status. • 365633 Page 4 of 5 365633 06/03/2024 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0580 New treatment Level of Harm - Minimal harm or potential for actual harm • Transfer or discharge of resident from center. Residents Affected - Few • Change in roommate assignment. When a change in condition was noted, the nursing staff would contact the resident's representative, notify the physician, and the resident if they were their own responsible party. This deficiency represents non-compliance investigated under Complaint Number OH00154257. 365633 Page 5 of 5