Health inspection·September 27, 2023

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, policy review, and staff interview, the facility failed to ensure an allegation of physical abuse was reported to the state agency as required. This affected one resident (#9) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 113. Findings include: Record review for Resident #9 revealed an admission date of 08/17/22. Diagnoses included personal history of traumatic brain injury, anxiety disorder, dementia unspecified severity with mood disturbance, and muscle weakness. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed Resident #9 was rarely or never understood. Resident #9 required extensive assistants of one for bed mobility, transfers, dressings, eating, and personal hygiene. Resident #9 used a wheelchair for mobility. Resident #9 had no behavior towards others such as hitting, kicking, pushing, etc., and had no rejection of care. Record review of the care plan for Resident #9 dated 08/14/23 revealed Resident #9 was at risk for visual impairment related to age, cataracts, and dementia. Interventions included to announce yourself when entering the residents room or space and orient the resident to surroundings. Resident #9 also had an activity of daily living (ADL) self care performance deficit. Interventions included to allow the resident time to express feelings of frustration regarding the need for assistants in ADL tasks. Honor resident choice and preference whenever possible. Resident #9 also had potential for pain. Interventions included to monitor for changes in behavior that may be indicators of pain which included increased agitation and or refusals for treatment. Record review revealed no documentation in the nursing progress note for Resident #9 for 09/14/23. Record review of the skin assessment completed 09/20/23 completed by Licensed Practical Nurse (LPN) #260 revealed no new areas. Interview on 09/26/23 at 9:59 A.M. with Licensed Practical Nurse (LPN) #260 revealed she worked on 09/14/23 as the charge nurse for Resident #9. LPN #260 revealed on 09/14/23 (unsure of time) Former Housekeeper #347 went to her and revealed a State Tested Nursing Assistant (STNA) was in Resident #9's room and was removing Resident #9's shirt. When she was removing the shirt, Resident #9 was pulling back. LPN #260 revealed she went to Resident #9's room immediately and asked STNA #333 if she needed help. STNA #333 had Resident #9's shirt in her hand, Resident #9 was sitting in her wheelchair Page 1 of 3 365661 365661 09/27/2023 Heights Rehabilitation and Healthcare Center, The 2801 E Royalton Rd Broadview Heights, OH 44147

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with no shirt on. STNA #333 said it was under control, she was getting ready to take her to the bathroom to clean her, she just finished breakfast and had food on her clothes. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) asked her about it the same day and also did a head-to-toe assessment on Resident #9. STNA #333 continued to work on the floor, she was never suspended. Interview on 09/26/23 at 10:21 A.M. with STNA #333 revealed residents can be so combative. STNA #333 revealed Resident #9 drools food everywhere. On 09/14/23 at breakfast Resident #9 was in the dining room, she spilled food and liquids on her clothes. STNA #333 revealed she took Resident #9 to her room and requested to allow her to change her shirt and clean her up. STNA #333 revealed as she pulled Resident #9's shirt off, Resident #9 was resisting. Former Housekeeper #347 came in the room, and STNA #333 revealed she took Resident #9's shirt off even though she was resisting. STNA #333 revealed Former Housekeeper #347 asked what are you doing to her, why you doing this, she went to the nurse, STNA #333 had already cleaned her when the nurse came, the nurse came then the DON came and asked me what happened. STNA #333 told her she was taking her shirt off, she was resisting. STNA #333 revealed she was never sent home or removed from the assignment pending investigation. STNA #333 revealed that was the end because Resident #9 had no bruises, so nothing happened. STNA #333 revealed Housekeeping should be mopping the floors, not checking on staff, she was always suspicious she was abusing residents. Interview on 09/26/23 at 10:34 A.M. with ADON LPN #296 revealed there was one incident with a housekeeper and Resident #9. The housekeeper mentioned something with clothing. STNA #333 was assisting the resident with clothing, the housekeeper felt it was rough. ADON LPN #296 revealed she investigated the incident with the DON. The DON interviewed the staff member, we checked skin on all residents, STNA #333 was not suspended. Record review of SRI's revealed no SRI for September 2023 was completed prior to 09/20/23. Interview on 09/26/23 at 11:07 A.M. with Director of Human Resources #262 revealed he remembered Former Housekeeper #347 coming to him on 09/14/23 on or around midday 12:00 P.M. to 1:00 P.M. Former Housekeeper #347 expressed a concern regarding an STNA'S behavior towards a resident, she said she was doing housekeeping when she opened a resident's door, she saw an STNA (STNA #333) grabbing at a wheelchair bound resident, (Resident #9) pulling, the resident and was jerking her back and forth as she was holding the front of her shirt with both hands jerking her. She went on to say how that aid talked to her, the resident, aggressively. Director of Human Resources #262 revealed he had Former Housekeeper #347 narrate a report as he typed it, then immediately called the Administrator and e-mailed him the report, statement, from Former Housekeeper #347. Director of Human Resources #262 began rapidly jerking his shirt with both hands back and forth and revealed that was how Former Housekeeper #347 demonstrated what STNA #333 did to Resident #9. The surveyor reviewed the report, undated or timed with Director of Human Resources #262. The report revealed: Interviewer - Director of Human Resources #262 Interviewee - Former Housekeeper #347 Concern of possible abuse of resident 365661 Page 2 of 3 365661 09/27/2023 Heights Rehabilitation and Healthcare Center, The 2801 E Royalton Rd Broadview Heights, OH 44147

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Content interview: While cleaning my assigned hall I was walking into room [ROOM NUMBER], and I seen an aid grabbing the shirt of the resident. She was jerking the shirt back and forth. I asked the aid if she needed help and the aid said no. I left the door slightly opened and told the nurse then went to HR and told him what I seen. Director of Human Resources #262 revealed he let Former Housekeeper #347 go home on [DATE] after the interview, she was rattled, she said she couldn't perform she was so upset, so he let her go home and paid her. Director of Human Resources #262 revealed STNA #333 was never suspended or sent home. Director of Human Resources #262 revealed he punched Former Housekeeper #347's timecard out at 4:30 P.M. so she would get paid. Former Housekeeper #347 since resigned. Review of sent E-mail on Director of Human Resources #262 computer with Director of Human Resources #262 revealed on 09/14/23 at 11:29 A.M. Director of Human Resources #262 sent the completed form/documented interview with Former Housekeeper #347 to Administrator. Director of Human Resources #262 confirmed that was the date and time he sent the completed interview with Former Housekeeper #347 to the Administrator. Interview on 09/26/23 at 11:39 A.M. with DON revealed on 09/14/23 at approximately 3:00 P.M. she was made aware by Administrator Former Housekeeper #347 stated she saw an aid, STNA #333, taking Resident #9's shirt off, and it was too rough or something. The DON revealed she immediately spoke with STNA #333 to hear her side of the story. The DON confirmed STNA #333 was not removed from resident care during the investigation or at any time, she spoke with STNA #333 in the nursing station of the unit then STNA #333 returned to continue resident care. STNA #333 revealed the resident's clothes were dirty and she was attempting to remove her shirt over her head. Resident #9 was resistive to care, the nurse came in to offer help. The DON revealed she and the ADON went in to look at Resident #9's skin the same day after she spoke with STNA #333 and there were no concerns. The DON confirmed she did not document any of the findings or interviews for that day. The DON revealed on 09/14/23 she only spoke with LPN #260 and STNA #333 regarding the allegation, no other residents or staff were interviewed on 09/14/23. Interview on 09/26/23 at 11:58 A.M. with the Administrator revealed on 09/14/23 (unaware of time) he spoke with Former Housekeeper #347 who told him STNA #333 was trying to pull Resident #9's shirt off. The Administrator revealed there was not an allegation, Former Housekeeper #347 never used the word abuse and confirmed a Self Reported Incident was not completed. The Administrator revealed he did not recall when he saw the report from the HR. but that was not what Former Housekeeper #347 said to him. Review of the facility policy titled, Abuse Investigating and Reporting dated September 2021 revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported. This deficiency represents non-compliance investigated under Complaint Number OH00146729. 365661 Page 3 of 3