Inspection·September 17, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, review of the Self-Reported Incidents (SRI) database, facility investigation, review of hospital records, resident interviews, and staff interviews, the facility failed to prevent resident-to-resident physical abuse. This resulted in actual harm when Resident #01, a resident with known history of resident-to-resident abuse incidents, struck Resident #02 in the face causing a hematoma (a pool of clotted blood that forms in the tissue) to her face and a closed fracture of the right orbital floor (one or more bones around the eyeball break, often from a blow to the face). Additionally, the facility failed to ensure Resident #03 was free from resident-to-resident physical abuse when Resident #01, who was supposed to be on one-to-one monitoring, struck Resident #03 in the back several times, while Resident #03 was asleep. This affected three (#01, #02 and #03) of six residents reviewed for abuse. The current census is 79. Findings include: 1. Review of the SRI dated 08/14/24 revealed the incident was reported on 08/09/24 at 6:35 P.M., when Resident #01 was seen grabbing Resident #02's hair and punching her in the face. Per the SRI, the facility separated the residents, sent Resident #02 to the hospital, then upon return placed both residents in 15-minute checks until Resident #02 was transferred to another unit. Per the SRI report, the police were notified but no report was made, and no charges were filed. The SRI was unsubstantiated for abuse due to Resident #01's diagnosis of dementia. Review of the facility's investigation into the alleged resident-to-resident abuse dated 08/09/24 to 08/16/24 revealed per the investigation, two nurses and one aide were interviewed after the incident, and there was no information regarding what led up to the incident noted in the interviews. Per the aide's written statements dated 08/09/24, Resident #01 and Resident #02 were sitting in their wheelchairs in the hallway and the aide witnessed Resident #01 grabbing Resident #02 by the hair and punching her in the face. Per the nurses' interviews the aide reported the incident immediately and Resident #02 was able to report to one nurse she was punched by Resident #01 in the face. No other resident interviews were included in the investigation reports. An assessment of Resident #02 revealed the resident had facial swelling and bruising to the right side of her face. Per the investigation Resident #02 was sent to the hospital and was diagnosed with facial swelling and an orbital fracture to her right eye. a. Review of Resident #01's medical record revealed an admission date of 01/24/24. Diagnoses for Resident #01 included: bipolar disorder, vascular dementia, delirium, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident (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 8 Event ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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)