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 (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 3 Event ID: 365661 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 365661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heights Rehabilitation and Healthcare Center, The 2801 E Royalton Rd Broadview Heights, OH 44147 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)