Health inspection·September 3, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility Self-Reported Incident (SRI), hospital record review and interview, the facility failed to provide adequate supervision to Resident #25, who required placement on the facility secured unit, frequent monitoring, and had a history of verbal, physical and/or combative aggressive behaviors, to prevent an avoidable resident injury.Actual Harm occurred on 08/22/25 at approximately 6:00 A.M when Resident #25 was found on the floor with two bruised and swollen eyes, reported pain rated a nine (out of ten with ten being the worst possible pain) and stated someone hit her. Resident #25 was transferred to a local hospital and found to have a subdural hematoma (bleeding the subdural space between the arachnoid membrane and dura mater of the brain), subarachnoid bleed (bleeding in the subarachnoid space between the brain and the arachnoid membrane), and intraparenchymal hematoma (a collection of blood within the brain tissue) of the brain, with unknown loss of consciousness and was admitted to the intensive care unit (ICU). This affected one (Resident #25) of three residents reviewed for abuse. The facility census was 160.Findings include:Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, dementia, and anxiety. Resident #25 discharged to the hospital on [DATE]. As of 08/26/25 the resident had not returned to the facility. Review of the physician orders dated 05/20/25 revealed Resident #25 had an order to reside on the secured unit to stabilize medical symptoms of psychiatric illness and/or dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of two indicating the resident had severely impaired cognition. Resident #25 was noted to have both short- and long-term memory impairment. Review of the MDS assessment revealed Resident #25 required supervision or touching assistance from staff for activities of daily living (ADLs). Review of the care plan dated 05/29/25 revealed Resident #25 was at risk for falls due to a history of falls, impaired balance, impaired mobility, dementia, and restlessness, required special care unit related to dementia with behaviors, wandered aimlessly and/or elopement risk. Interventions included, but were not limited to, assist with all transfers, locomotion, mobility, call light within reach, and reminders, and provide one-on-one supervision as needed and that Resident #25 required frequent monitoring. The care plan did not define what frequent monitoring required. Further review of the care plan revealed Resident #25 displayed resistive behaviors and was hard to direct related to verbal and physical aggression toward staff and other residents with interventions that included, but were not limited to, administering medications as ordered, monitor and document, allowing to make decisions to provide a sense of control, and encourage interaction and participation during care. Review of the progress note dated 08/02/25 at 12:31 P.M. revealed Resident #25 and an unknown resident were noted to be arguing over the restroom and were able to be redirected and the situation diffused. Resident #25 reported the other resident hit her, but staff were present the whole time and no physical contact Page 1 of 5 365757 365757 09/03/2025 Broadview Multi Care Center 5520 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few was made. Review of the progress note dated 08/05/25 at 6:45 P.M. revealed Resident #25 was yelling, cursing and agitated with another unknown resident. Resident #25 was redirected, separated, and calm. Review of the notes revealed Resident #25's son was left a message. Review of the progress note dated 08/0825 at 7:58 P.M. revealed Resident #25 was getting into it with another unknown resident about the bathroom. Resident #25 refused to go into the room and was arguing with other residents. Review of the progress note dated 08/19/25 at 11:08 A.M, revealed Resident #25 yelled at staff, was redirected, and was resting at the table. The note referenced Resident #25 would continue to be monitored. Review of the progress note dated 08/20/25 at 10:54 P.M. revealed Resident #25 was having behaviors. Resident #25 was standing in the doorway talking about other residents and saying stuff to them. Resident #25 started getting loud with staff and going back and forth. Resident #25 was asked to return to her room and after a few moments of being mouthy and loud, Resident #25 returned to her room. Half an hour later, Resident #25 was observed resting in her room with no more issues noted during the shift. Review of the progress notes revealed no documented notes from 08/20/25 at 10:54 P.M. to 08/22/25 at 6:00 A.M. regarding frequent monitoring and/or behaviors. Review of the progress note dated 08/22/25 at 6:00 A.M revealed Resident #25 had a transfer to a local hospital related to a trauma ( fall-related or other) with bruising of the eyes. Review of the progress note dated 08/22/25 at 6:02 A.M. revealed Resident #25 had an unwitnessed fall with bilateral eye bruising and was swollen shut with a treatment plan to be sent emergently sent to the emergency room (ER) of a local hospital. Review of the progress note dated 08/22/25 at 7:14 A.M. revealed Resident #25 was found on her hands and knees in the doorway of her room. Resident #25 was assessed from head to toe and noted to have severe bruising around both eyes with a change of level of cognition. Resident #25 was assisted back into bed and was observed grimacing in pain. Resident #25 required assistance from one staff member to be lifted off the floor. Resident #25 reported pain on a level of 9 out of 10 beginning after the fall. Resident #25 revealed she was hit while sleeping. Review of the note revealed the resident was transferred to the emergency room (ER) for evaluation and a Certified Nurse Assistant (CNA) stayed with Resident #25 until the emergency medical services (EMS) squad arrived. Review of the note revealed Resident #25 family was notified and physician. Review of the progress note dated 08/22/25 at 9:48 A.M. revealed Resident #25 was in the hospital. Review of a facility self-reported incident (SRI) dated 08/22/25 at 7:40 A.M. revealed the facility initiated an investigation, regarding an allegation of abuse involving Resident #25. Review of the SRI revealed Resident #25 resided on the memory care unit and stated someone had struck her. The SRI revealed Resident #25 was unable to provide any details and staff present on the unit denied seeing or being involved in any abuse. The SRI revealed all residents residing on the memory care unit were assessed with no signs of an altercation occurring. The SRI also revealed Resident #25 roommate, identified as Resident #139, stated Resident #25 was on the floor when she woke up. Review of the SRI revealed Resident #25 was sent out for evaluation with a BIMS score of two and diagnosis of dementia. Further review of the facility's SRI investigation revealed an undated handwritten statement that revealed Registered Nurse (RN) #803 was caring for Resident #25 when she sustained an unwitnessed fall. RN #803 was informed by Resident #139 at 5:40 A.M. that Resident #25 fell. RN #803 stated upon entering Residents #25 and #139 room, Resident #25 was found on the floor and an assessment was performed. Review of the statement revealed Resident #25 was noted to have severe bruising around both eyes as well as a change in mental status and then emergency medical services (EMS) were called. Further review of the statement revealed RN #803 noted no prior changes in condition or mental status and the unit presented calm with no agitation or outbursts. Review of an undated handwritten statement by CNA #824 revealed she had just 365757 Page 2 of 5 365757 09/03/2025 Broadview Multi Care Center 5520 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few started charting when an unidentified resident came knocking at the door stating someone had fallen. CNA #824 revealed she did not see what happened. Review of a handwritten statement dated 08/22/25 by CNA #864 revealed she did not see the fall or anything and Resident #25's roommate (Resident #139) came to the nurse's station saying Resident #25 was on the floor with her eyes swollen shut. CNA #864 revealed while doing rounds, she didn't hear anything. CNA #864 revealed when both herself and RN #803 got to the room, Resident #25 was laying there. CNA #864 revealed she helped Resident #25 up and Resident #25 would not say anything. Continued review of the SRI investigation revealed an incident report dated 08/22/25. Review of the document revealed on 08/22/25 RN #803 was the nurse and CNA #864 was the CNA assigned to Resident #25, with CNA #824 also on the unit. Resident #25 was found on the floor with a picture drawn that indicated she was on both hands and knees in her room at the time of the observation. Resident #25 was alone, unattended, gripper socks in place and the resident stated someone hit me. Review of the document revealed all other pages were left blank in the areas designated for details related to the incident such as the last time Resident #25 was seen, including but not limited to, at least 3 hours prior. Review of the EMS run sheet from the local Fire Department dated 08/22/25 revealed EMS received a call from the facility at 6:02 A.M., 22 minutes after Resident #25 was found on the floor. The run sheet revealed the chief complaint was a fall victim (injury) with a provider impression of traumatic injury and the mechanism of injury being sexual abuse and/or assault suspected. The run sheet revealed Resident #25 had bruising and swelling to both eyes. Once on scene, EMS was delayed and unable to make patient contact due to no staff at the door or at the other line of the phone. Once patient contact was made, Resident #25 was laying supine (flat on her back) in her bed alert but confused. Staff present reported Resident #25 was alert and oriented to person, place, time, and event until 6:00 A.M. this morning but was now confused. Upon examination, Resident #25 had significant swelling and bruising to both of her eyes. Staff present stated Resident #25 might have gotten into an altercation with her roommate, Resident #139, but did not hear or see the fight. Staff provided EMS staff paperwork, and Resident #25 was transferred to a local hospital ER's trauma bay for evaluation. Review of the Police Report dated 08/22/25 revealed the police were called to the facility for a resident who had a fall and injuries that did not make sense. The narrative referenced Resident #25 had extremely bruised eyes that were swollen shut. Resident #25 was previously alert and oriented times four (to person, place, time, and situation) but now was alert and oriented times one (to person). Resident #25 stated she was struck, but did not say by who. The police spoke with Resident #25's roommate who stated the two had a verbal altercation during the night, but she denied striking Resident #25. Review of the hospital paperwork dated 08/22/25 revealed Resident #25 arrived at the ER with diagnoses of assault (primary), subdural hematoma, a subarachnoid bleed, and intraparenchymal hematoma of the brain, with unknown loss of consciousness. Resident #25 was deemed a trauma patient from the facility and was found with bruising to her face, her eyes were bruised and swollen shut, with concerns of assault with the nursing home knowing nothing about it. Resident #25 was sent to trauma intensive care unit because of an injury that acutely impaired one or more vital organs systems that such was a high probability of imminent or life-threatening deterioration in Resident #25's condition. Per EMS, Resident #25 was normally alert and oriented to person, place, time, and event. EMS reported concern for possible assault as Resident #25 roommate, Resident #139, also had injuries present but staff was overall unsure of what happened, and time incident occurred. The hospital staff attempted to reach the facility but was unable to reach staff due to the phone ringing without being answered. Resident #25 was admitted into the trauma ICU for further care and monitoring. Interview on 08/26/25 at 12:21 P.M. with Unit Manager (UM) #884 revealed 365757 Page 3 of 5 365757 09/03/2025 Broadview Multi Care Center 5520 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #25 had a fall prior to the start of her shift. UM #884 revealed Resident #25 was a little aggressive, alert and oriented to person and place, and was verbally combative due to multiple residents sharing the same bathroom but never physically at the same time. Interview on 08/26/25 at 12:37 P.M. with the Administrator revealed Resident #25's incident investigation (from 08/22/25 at approximately 6:00 A.M.) was still ongoing as of this time. The Administrator revealed at the time of the incident RN #803 went and got Unit Manager (UM) #861 and Resident #25 was found on her hands and knees with bruising to her forehead and nose area. The Administrator revealed Resident #25 appeared to have had an unwitnessed fall, was assessed, and assisted back to bed. Resident #25 stated someone hit her and staff immediately called the police and the resident's family. Resident #25 was then sent to the hospital with the police on scene. The Administrator revealed Resident #25 roommate, Resident #139, had no indication of being involved and reported Resident #25 was on the floor when the roommate woke up. The Administrator revealed he was still waiting on RN #803 to provide a timeline of when Resident #25 was last seen. Interview on 08/26/25 at 12:54 P.M, with UM #861 revealed when she arrived to work on 08/22/25 at 6:00 A.M., RN #803 came and got her and nine-one-one (911) had already been called to summon emergency medical services. UM #861 revealed upon observing Resident #25, the resident's bruising was unique and she informed the Administrator right away. UM #861 revealed Resident #25 was already up with the squad, she didn't see her on the floor, and was unsure how she was found. Interview with CNA #864, identified as one of the aides on duty when the incident occurred, was attempted on 08/27/25 at 8:51 A.M. However, surveyor was unable to leave a message as the voicemail was not set up. Interview with CNA #824, identified as one of the aides on duty when the incident occurred, was attempted on 08/27/25 at 8:56 A.M. A message was left requesting a call back. A return call was returned on 08/27/25 at 10:01 A.M. indicating that the person called was not CNA #824 and the number listed was wrong. Interview on 08/27/25 at 3:04 P.M. with Licensed Practical Nurse (LPN) #832 revealed Resident #25 and her roommate, Resident #139 would get into it bad and be confrontational with each other due to differences with each other. LPN #832 revealed Resident #25 did not like that Resident #139 snored while asleep but LPN #832 had never witnessed the two being physically abusive towards each other. Interview on 08/28/25 at 3:44 P.M. with a family member of Resident #25 revealed he received a call on 08/22/25 at 7:06 A.M. from the local hospital informing him Resident #25 was at the local hospital after an incident at the facility. The family member reported the facility did not call Resident #25's family member until 11:23 A.M. to inform them of Resident #25's hospital transfer and indicated he was told an investigation was ongoing. The family member revealed he had not received any additional phone calls or information since 08/22/25 at 11:23 A.M. Interview on 08/28/25 at 5:49 P.M. with RN #803 revealed on the day of the incident (08/22/25) he was doing medication pass when CNA #864 told him Resident #25 had a fall. RN #803 revealed when he arrived at Resident #25 room, the resident was observed on her hands and knees in front of the door with really bad bruising around her eyes. RN #803 revealed at that moment he felt there had been an altercation between Resident #25 and her roommate, Resident #139. RN #803 revealed Resident #25's injuries did not make sense or align with a fall. RN #803 revealed he did not witness or hear an altercation or fall. RN #803 revealed Resident #139 had a little bruise on her face near her cheek but denied any physical altercation. RN #803 revealed he last saw Resident #25 between approximately 2:00 A.M. and 3:00 A.M. prior to the incident. Review of an email correspondence from the Administrator dated 09/02/25 at 3:23 P.M. revealed the facility did not have a policy for supervision or monitoring. The facility reported depending on the situation, levels of supervision could vary including one-on-one care, 15-minute checks, up to the routine every two-hour checks. A follow up correspondence timed 4:11 P.M. 365757 Page 4 of 5 365757 09/03/2025 Broadview Multi Care Center 5520 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few revealed prior to the incident, Resident #25 had not been on any increased supervision (even though the resident had a plan of care for frequent monitoring in place at the time of the incident. Following the incident, clinical staff remained with Resident #25 until she was transferred to a local hospital. Review of the policy Abuse, Neglect, Exploitation and Misappropriation of resident Property dated 06/08/22 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents noncompliance investigated under Complaint Number 2598483. 365757 Page 5 of 5