Health inspection·September 12, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure Resident #140 was free from abuse. This affected one resident (#140) of two residents two residents reviewed for physical abuse. The facility census was 138. Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed Resident #32 had a history of physical aggression. Resident #32 was standing inside another resident's room near the doorway. Resident #32 was told by another resident to get out of his room and started walking towards Resident #32. Resident #32 stepped into the hallway and pushed the other resident back into his doorway, and both residents started to hit each other. Review of Resident #32's medical record revealed no evidence Resident #32's physical aggression was addressed or new interventions were implemented after being physically aggressive with another resident on 07/10/23. Review of Resident #32's nursing note dated 08/25/23 at 1:21 A.M. revealed Resident #32 was an aggressor in hitting and kicking the roommate (Resident #140) in the face. Review of the care plan dated 08/25/23 revealed Resident #32 had a diagnosis of altered mental status unspecified and has a history of behaviors that can be both verbal and physical. Interventions included attempt to reduce stressors, observe for and report to the nurse any behavior issues and remove any items that could be used during behaviors. Resident #140's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, atrial fibrillation, chronic kidney disease, Page 1 of 15 365832 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0600 depression, and psychoactive substance abuse. Level of Harm - Minimal harm or potential for actual harm Review of Resident #140's progress note dated 08/25/23 at 2:57 A.M. revealed Resident #140 stated he sat up in bed ad Resident #32 told him to lay down and go to sleep. Resident #140 stated he told his roommate he does not have to lay down, then Resident #32 walked over and began assaulting him. The progress note indicated the residents were separated. Residents Affected - Few Review of the facility incident report dated 08/25/23 at 12:30 A.M. revealed a resident to resident altercation occurred, and staff witnessed Resident #140 lying on the floor and Resident #32 kicking him in the face. The report noted an injury occurred to the face but the injury type was undeterminable. The incident report stated that the resident was alerted to person and place in the mental status category. Review of facility Self-Reported Incident (SRI) tracking number 238644 dated 08/29/23 (late submission) revealed Resident #32 punched Resident #140 in the face due to Resident #140 sitting up in bed because Resident #140 could not breathe. Resident #140 stated in the early morning hours of 8/25/23 his roommate punched and kicked him while he was in bed. The residents were separated, physician and families were notified. Head to toe assessments were completed and new rooms were assigned. Resident #140 had a minor injury. When interviewed by the social worker on the morning of 08/25/23, Resident #140 stated that he was okay, was happy with the room move, was a retired [NAME], felt okay and felt safe. Later in the day Resident #140 developed complications related to his heart condition and pacemaker, which was his admitting diagnosis, and was sent to the hospital for further evaluation. The resident had not returned to the facility. Interview on 09/05/23 at 2:10 P.M. with Licensed Practical Nurse (LPN) #568 revealed that Resident #140 was on the third floor before her shift on 08/25/23 and didn't get report anything happened from the outgoing nurse. LPN #568 remembered him having swollen lips. Interview on 09/05/23 at 2:23 P.M. with LPN #470 revealed that she was off the floor for supplies when Resident #32 assaulted Resident #140. LPN #470 moved Resident #140 to the third floor because he couldn't breathe when laying. LPN #470 was not able to contact Resident #140's physician, so she left a message. LPN #470 remembered Resident #140 red around the eye. The supervisor and security walked him up to the third floor. Interview on 09/06/23 at 5:25 A.M. with State Tested Nursing Assistant (STNA) #436 revealed the power went out and the generator went on. STNA #436 stated that she and the other aide were doing room checks, heard Resident #140 screaming with Resident #32 kicking him. She told the nurse and took Resident #32 to the dining room and security took Resident #140 to another floor. Review of the facility policy titled Ohio Abuse Policy, dated 05/2008 with a revision date of 10/03/22 revealed revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The facility would ensure the immediate safety of the resident and means of providing protection included but were not limited to moving the resident to another room/unit, providing increased supervision and/or monitoring. This deficiency represents non-compliance investigated under Master Complaint Number OH00146166 and Complaint Number OH00145964. 365832 Page 2 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure their abuse policy was implemented to prevent abuse toward Resident #140, to ensure Resident #140 was assessed properly after being abused, and to ensure the allegation of abuse was reported to the state agency. This affected one resident (#140) of two residents two residents reviewed for abuse. Residents Affected - Few Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed Resident #32 had a history of physical aggression. Resident #32 was standing inside another resident's room near the doorway. Resident #32 was told by another resident to get out of his room and started walking towards Resident #32. Resident #32 stepped into the hallway and pushed the other resident back into his doorway, and both residents started to hit each other. Review of Resident #32's medical record revealed no evidence Resident #32's physical aggression was addressed or new interventions were implemented after being physically aggressive with another resident on 07/10/23. Review of Resident #32's nursing note dated 08/25/23 at 1:21 A.M. revealed Resident #32 was an aggressor in hitting and kicking the roommate (Resident #140) in the face. Review of the care plan dated 08/25/23 revealed Resident #32 had a diagnosis of altered mental status unspecified and has a history of behaviors that can be both verbal and physical. Interventions included attempt to reduce stressors, observe for and report to the nurse any behavior issues and remove any items that could be used during behaviors. Resident #140's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, atrial fibrillation, chronic kidney disease, depression, and psychoactive substance abuse. Review of Resident #140's progress note dated 08/25/23 at 2:57 A.M. revealed Resident #140 stated he sat up in bed ad Resident #32 told him to lay down and go to sleep. Resident #140 stated he told his roommate he does not have to lay down, then Resident #32 walked over and began assaulting him. The progress note indicated the residents were separated. Review of the facility incident report dated 08/25/23 at 12:30 A.M. revealed a resident to resident altercation occurred, and staff witnessed Resident #140 lying on the floor and Resident #32 kicking 365832 Page 3 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few him in the face. The report noted an injury occurred to the face but the injury type was undeterminable. The incident report stated that the resident was alerted to person and place in the mental status category. Review of facility Self-Reported Incident (SRI) tracking number 238644 dated 08/29/23 (late submission) revealed Resident #32 punched Resident #140 in the face due to Resident #140 sitting up in bed because Resident #140 could not breathe. Resident #140 stated in the early morning hours of 8/25/23 his roommate punched and kicked him while he was in bed. The residents were separated, physician and families were notified. Head to toe assessments were completed and new rooms were assigned. Resident #140 had a minor injury. When interviewed by the social worker on the morning of 08/25/23, Resident #140 stated that he was okay, was happy with the room move, was a retired [NAME], felt okay and felt safe. Later in the day Resident #140 developed complications related to his heart condition and pacemaker, which was his admitting diagnosis, and was sent to the hospital for further evaluation. The resident had not returned to the facility. Review of Resident #140's medical record revealed an admission assessment dated [DATE] at 6:20 A.M. for an admission on [DATE] at 6:10 A.M. Although the SRI indicated a head to to assessment was completed the medical record contained no evidence Resident #140 was thoroughly assessed following the physical altercation with Resident #32. The electronic medical record noted an admission assessment dated [DATE] at 6:20 A.M. for his admission on [DATE] at 6:10 A.M., but no further assessments were completed including periodic neurological checks after head trauma. Interview on 08/30/23 at 2:49 P.M. with Medical Director (MD) #556 revealed he remembered the altercation between Resident #32 and Resident #140 but he was not told that one resident was kicked in the face. MD #556 stated that any injury to head, neurological checks would have been ordered and the resident would most likely be sent to the hospital for observation. Interview on 08/30/23 at 4:34 P.M. with Administrator confirmed the facility did not implement their abuse policy as the SRI was not submitted until four days after the incident. Interview on 09/05/23 at 2:10 P.M. with Licensed Practical Nurse (LPN) #568 revealed that Resident #140 was on the third floor before her shift on 08/25/23 and didn't get report that anything happened from the outgoing nurse. LPN #568 remembered the resident having swollen lips. Interview on 09/05/23 at 2:23 P.M. with LPN #470 revealed that she was off the floor for supplies when Resident #32 assaulted Resident #140. LPN #470 moved Resident #140 to the third floor because he couldn't breathe when laying. LPN #470 was not able to contact Resident #140's physician, so she left a message. LPN #470 remembered Resident #140 red around the eye. The supervisor and security walked him up to the third floor. LPN #470 stated she would have done neuro checks if Resident #140 stayed on the second floor. Interview on 09/06/23 at 5:25 A.M. with State Tested Nursing Assistant (STNA) #436 revealed the power went out and the generator went on. STNA #436 stated that she and the other aide were doing room checks, heard Resident #140 screaming with Resident #32 kicking him. She told the nurse and took Resident #32 to the dining room and security took Resident #140 to another floor. Interview on 09/07/23 at 11:20 A.M. with Regional Director of Clinical #560 confirmed Resident #140 was assessed on 08/24/23 and neurological checks were done on 08/24/23 but the facility could not produce any other assessments completed after abuse occurred on 08/25/23. 365832 Page 4 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility Neurological Checks Policy dated 05/2008, revised 03/21/23, revealed neurological checks are indicated to monitor for potential irregularities in neurological status in the event of known or unknown head trauma as the result of a resident event, change in resident condition, or physician's order. A initial neurological check will be performed by a licensed clinician for all resident who have sustained a witnessed, unwitnessed, alleged, reported, or suspected head trauma following and unusual occurrence of change in resident neurological condition. Any signficant change in vitals or neurological status in a previously stable resident will be reported to the provider promptly. Upon initiation of the schedule or as triggered by a qualifying event, the neurological event check assessment in the electronic health record or on paper will be imitated to conduct periodic checks and to document the results of the neurological checks or physicians' orders. Elements to be assessed include level of consciousness, mental status, ability to communicate, movement/coordination, reflexes, change in behavior, vital signs: blood pressure, pulse, and respirations. Review of the facility policy titled Ohio Abuse Policy, dated 05/2008 with a revision date of 10/03/22 revealed revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The facility would ensure the immediate safety of the resident and means of providing protection included but were not limited to moving the resident to another room/unit, providing increased supervision and/or monitoring. To protect the resident if the resident is injured, the facility should take immediate action to treat the resident. A nurse should perform an initial assessment of the resident. The assessment should generally include the following: range of motion, full body assessment for signs of injury, and vital signs. All allegation of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing and to the applicable State Agency. If the event that caused the allegation involved as allegation of Abuse or serious bodily injury, it should be reported to the DOH immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Master Complaint Number OH00146166 and Complaint Number OH00145964. 365832 Page 5 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

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 and staff interview, the facility failed to ensure an allegation of physical abuse was reported to the State Agency timely. This affected one resident (Resident #140) of two residents reviewed for abuse. Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed Resident #32 had a history of physical aggression. Resident #32 was standing inside another resident's room near the doorway. Resident #32 was told by another resident to get out of his room and started walking towards Resident #32. Resident #32 stepped into the hallway and pushed the other resident back into his doorway, and both residents started to hit each other. Review of Resident #32's medical record revealed no evidence Resident #32's physical aggression was addressed or new interventions were implemented after being physically aggressive with another resident on 07/10/23. Review of Resident #32's nursing note dated 08/25/23 at 1:21 A.M. revealed Resident #32 was an aggressor in hitting and kicking the roommate (Resident #140) in the face. Review of the care plan dated 08/25/23 revealed Resident #32 had a diagnosis of altered mental status unspecified and has a history of behaviors that can be both verbal and physical. Interventions included attempt to reduce stressors, observe for and report to the nurse any behavior issues and remove any items that could be used during behaviors. Resident #140's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, atrial fibrillation, chronic kidney disease, depression, and psychoactive substance abuse. Review of Resident #140's progress note dated 08/25/23 at 2:57 A.M. revealed Resident #140 stated he sat up in bed ad Resident #32 told him to lay down and go to sleep. Resident #140 stated he told his roommate he does not have to lay down, then Resident #32 walked over and began assaulting him. The progress note indicated the residents were separated. Review of the facility incident report dated 08/25/23 at 12:30 A.M. revealed a resident to resident altercation occurred, and staff witnessed Resident #140 lying on the floor and Resident #32 kicking him in the face. The report noted an injury occurred to the face but the injury type was 365832 Page 6 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few undeterminable. The incident report stated that the resident was alerted to person and place in the mental status category. Review of facility Self-Reported Incident (SRI) tracking number 238644 dated 08/29/23 (four days after the incident) revealed Resident #32 punched Resident #140 in the face due to Resident #140 sitting up in bed because Resident #140 could not breathe. Resident #140 stated in the early morning hours of 8/25/23 his roommate punched and kicked him while he was in bed. The residents were separated, physician and families were notified. Head to toe assessments were completed and new rooms were assigned. Resident #140 had a minor injury. When interviewed by the social worker on the morning of 08/25/23, Resident #140 stated that he was okay, was happy with the room move, was a retired [NAME], felt okay and felt safe. Later in the day Resident #140 developed complications related to his heart condition and pacemaker, which was his admitting diagnosis, and was sent to the hospital for further evaluation. The resident had not returned to the facility. Interview on 08/30/23 at 4:34 P.M. with Administrator revealed the facility did not submit a SRI on the date of occurrence because it was resident to resident abuse and no real injury occurred. The administrator stated that an SRI was created after the Ombudsman came to the facility with a concern about the altercation. Review of the facility policy titled, Ohio Abuse Policy, dated 05/2008 with a revision date of 10/03/22 revealed all allegation of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropiration of resident property must be reported immediately to the Administrator, Director of Nursing and to the applicable State Agency. If the event that caused the alelgation involved as allegation of Absue or serious bodily injury, it should be reported to the DOH immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Master Complaint Number OH00146166 and Complaint Number OH00145964. 365832 Page 7 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews, the facility failed to provide adequate supervision and individualized and comprehensive interventions to prevent Resident #101 from eloping from the facility. This resulted in Immediate Jeopardy and the likelihood of actual harm on 08/29/23 at approximately 9:48 A.M. when Resident #101, who was cognitively impaired and assessed to be at high risk for elopement, exited the facility grounds without staff knowledge, during a supervised smoke break. Staff failed to identify Resident #101 was missing until approximately 12:15 P.M. when the resident was not available for lunch. On 08/29/23 at 5:14 P.M. Resident #101 was found by police, approximately 2.8 miles away from the facility on a street corner. The resident was transported to the hospital for evaluation. This affected one resident (#101) of three sampled residents reviewed for accidents. This facility identified 14 residents (#3, #24, #27, #45, #46, #76, #86, #90, #98, #101, #124, #130, and #131) who were smokers and elopement risks. The facility census was 138. On 08/30/23 at 5:11 P.M. the Administrator, Regional Nurse Consultant, Director of Nursing and Administrator in Training were notified Immediate Jeopardy began on 08/29/23 when Resident #101, who was cognitively impaired, exited the facility grounds without staff knowledge during a supervised smoke break. Resident #101 was found on a street corner approximately 2.8 miles from the facility by police and was transferred to the local hospital for evaluation. The Immediate Jeopardy was removed on 08/31/23 when the facility implemented the following correction actions: • On 08/29/23 at 12:15 P.M. Resident #101 was identified as having eloped from the facility when he was not present in the dining room for lunch. Licensed Practical Nurse (LPN) #558 informed Licensed Social Worker (LSW) #403, immediately had the receptionist call Code [NAME] 512W. LSW #403 immediately notified the Administrator and Director of Nursing (DON). The administrator notified the Regional [NAME] President of Operations (RVPO) #559 and the Regional Director of Clinical Services #560. • Upon hearing the Code Green, facility staff conducted a head count on all floors and a facility sweep as well as the immediate area outside the facility. Several other staff members used their vehicles to begin searching for the residents in the surrounding neighborhoods, checking bars, convenient stores, and other areas of interest. All residents were accounted for by 12:30 P.M. except for Resident #101. • On 08/29/23 at 12:30 P.M. the DON notified the physician of Resident #101 leaving the facility. Attempts were made to notify the family of Resident #101; however, the attempts were not successful until 08/30/2023 at 2:00 P.M. • 365832 Page 8 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety On 08/29/23 at approximately 12:30 P.M. all local hospitals and satellite emergency rooms were notified by clinical leadership. The receptionist contacted Cleveland Police Department (CPD) third district and Regional Transit Authority (RTA) police. LSW #403 called University Circle police and Case Western police. The Cleveland Police Department contacted all other local affiliate police departments and emergency medical services (EMS). Residents Affected - Few • On 08/29/23 at 12:30 P.M. Administrator and Human Resource Director (HR) #495 reviewed camera footage. Resident #101 was last observed outside smoking in a supervised smoking group that was being conducted by State Tested Nursing Assistant (STNA) #526. Resident #101 was last seen on camera at 9:48 A.M. smoking with other residents. Resident #101 was not observed entering the facility when smoke break was over. • On 08/29/23 at 12:45 P.M. LSW #403 and the Administrator provided CPD a description of Resident #101, full body picture of Resident #101 and Resident #101's face sheet for pertinent contact information. • On 08/29/23 at 5:14 P.M. CPD located Resident #101 at 5:14 P.M. at Forty Fifth Street and Cedar Avenue, approximately 2.8 Miles from the facility, and took Resident #101 to the hospital for evaluation. LPN #515 and Assistant Director of Nursing (ADON) #492 met the resident at the emergency room (ER). ADON #492 stayed at the ER until 11:15 P.M. when informed by personnel at the ER that they would watch the resident until his transportation arrived back to the facility at approximately 3:00 A.M. or 4:00 A.M. on 8/30/2023. • On 08/29/23 at 1:00 P.M. until 2:00 P.M, RDCS #560 reviewed progress notes for the last 72 hours for any resident changes in condition with no negative findings. • On 08/29/23 from 2:00 P.M. to 10:00 P.M. the DON and/or Designee completed new elopement assessments for all current residents. Residents who were identified as high risk for elopement had their care plan and [NAME] information updated. The facility ensured appropriate interventions were put in place if needed. • On 8/29/2023 at 3:20 P.M. the Administrator and RDCS #560 updated the process of outdoor group activities for residents with supervised leave of absences (LOAs) to reflect two staff must accompany residents for outdoor activities, no more than 15 residents at a time, and residents must be signed out and signed in when returning inside. This process went into effect on 8/31/2023. There was no outdoor supervised smoking after the event on 8/29/2023 and 8/30/2023. All residents were assisted smoking inside. 365832 Page 9 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 08/29/23 and 08/30/23 education was provided to all staff on the facility's elopement policy, outdoor smoking policy for residents with supervised leave of absences (LOA), and the new process on expectations of signing residents in and out when they are participating in an outdoor supervised group as well as clarifying the expectations of staff members who are taking responsibility for the security and safety of an outside group. Training was completed in person, telephone, email, and via text message system. Residents Affected - Few • On 08/29/23 at 11:45 P.M., Licensed Practical Nurse (LPN) Supervisor # 431 completed an elopement drill. LPN Supervisor #431 noted staff response was very good. Staff searched and followed the policy properly. • On 08/29/23 at 5:00 P.M. a Quality Assurance Performance Improvement (QAPI) was held via telephone with the Administrator, DON, Regional [NAME] President of Operations (RVPO) #559, Regional Director of Clinical Services (RDCS) #560 and Medical Director (MD) #556. The QAPI minutes and findings were reviewed with the facility interdisciplinary team (IDT) and Medical Director during clinical morning meeting on 8/30/2023 at 9:45 A.M. • Beginning 08/29/23 the administrator/or designee would conduct elopement drills, one on each shift weekly for four weeks and then monthly for two months. Elopement drills will be evaluated, and education would be completed as needed. • Beginning 08/29/23 the Director of Nursing (DON) /or designee would complete audits of five residents who were at high risk for elopement or have had a change of condition three times per week for four weeks then monthly for two months. The Director of Nursing (DON) /or designee would review assessments, care plans and [NAME] information to ensure that orders were accurate, and revisions made as needed. • Beginning 08/29/23 the Administrator/or Designee would conduct audits three times weekly for four weeks and then monthly for two months for new admissions and re-admissions to ensure elopement risks were completed appropriately. Residents who were identified at risk would have their face sheet and picture placed in the elopement binders located on each unit and reception desk. • On 08/30/23 at 5:45 A.M. Resident #101 returned to facility. Resident #101 was assessed with no signs of pain or discomfort. For safety the resident was kept on his secured unit and smoking opportunities were provided on the unit. The facility arranged for an interpreter to interview the resident 365832 Page 10 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few regarding the incident and during the interview the resident voiced suicidal ideations. The nurse practitioner was notified, and an order was received to send the resident to the hospital for psychological evaluation. One to one (1:1) was provided for safety to resident until he was transferred at 2:00 P.M. on 8/30/2023. • Beginning 08/30/23 the Administrator/or designee would complete an audit five times per week for four weeks and then monthly for two months for all residents taken out to smoke are signed out/in by staff and are accounted for upon returning to the unit. The results of all audits would be forwarded to the facility QAPI committee for review and correction actions would be made. • On 08/30/23 at 10:00 A.M., Registered Nurse (RN) #501 completed an elopement drill and noted staff did an excellent job. A suggestion was made to add color code to the back of name tags. • On 08/30/23 at 12:00 P.M. the facility elopement binder was updated and placed on each floor and at the receptionist desk. • On 08/30/23 at 3:30 P.M., Registered Nurse (RN) #501 completed an elopement drill. RN #501 noted staff searched appropriately inside and outside. • On 08/30/23 at 11:45 P.M. Licensed Practical Nurse (LPN) Supervisor #431 completed an elopement drill. Licensed Practical Nurse (LPN) Supervisor #431 noted staff overall did a good job. A list of common codes was to be given to staff to place with name tags. • On 08/31/23 at 9:30 A.M. Registered Nurse (RN) #540 completed an elopement drill. Registered Nurse (RN) #540 noted staff were very responsive and went through all rooms and areas. Staff given copies of policy. • Interviews on 08/31/23 from 8:00 A.M. through 11:30 A.M. with State Tested Nursing Assistant (STNA) #507, Licensed Practical Nurse (LPN) #491, STNA #480, Housekeeper #443, STNA #550, LPN #517, Physical Therapist Aide (PTA) #561 and LPN #504 confirmed they were educated and knowledgeable of the elopement and smoking policies and procedures. Although the Immediate Jeopardy was removed on 08/31/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and 365832 Page 11 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 monitoring to ensure on-going compliance. Level of Harm - Immediate jeopardy to resident health or safety Findings include: Residents Affected - Few Review of the medical record for Resident #101 revealed an admission date of 04/17/23 with diagnoses including dementia without behavioral disturbance, alcohol dependence, epilepsy, and human immunodeficiency virus (HIV) disease. Review of the elopement assessment dated [DATE] at 4:32 P.M. revealed Resident #101 was at high risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/23 revealed Resident #101 had severely impaired cognition and was independent for mobility, transfers, and ambulation. Review of Resident #101's comprehensive care plan revealed no evidence goals and/or interventions were identified to address the resident's high risk of elopement or exit seeking behaviors. Review of the physician's orders for August 2023 revealed an order indicating Resident #101 may go on leave of absence (LOA) with supervision. Review of the smoking assessment dated [DATE] at 9:44 A.M. revealed Resident #101 required supervision by staff, volunteer, or family member always when smoking. Review of the nurse's note dated 05/06/23 at 4:03 P.M. revealed Resident #101 had previous exit seeking behavior after being moved from the facility fifth floor to the fourth floor. Resident #101 stated I want to leave and go home during the shift, and was standing near the elevator, got on the elevator as the doors opened and went to the main floor lobby. The resident was encouraged by staff to return to the assigned unit, he finally agreed, and was seen flicking a lighter. The resident agreed to hand it (the lighter) to this nurse. The family of the resident came in for a visit and voiced concerns about the resident's current room and requested he be transferred back to the fifth floor. The resident agreed to the move, and a supervisor and Director of Nursing (DON) were made aware. Resident #101 moved then moved back to the fifth floor. Review of the nurse's note dated 08/29/23 at 12:36 P.M. revealed Resident #101 was not in the dining area and not in his room. An overhead page was sent, and staff surveyed the facility. Resident #101 was noted to be out of the building. The physician was notified and attempted to notify the family but there wasn't a working number. Review of the nurse's note dated 08/29/23 at 7:32 P.M. revealed during lunch tray pass at/or around 12:45 P.M. Resident #101 was unable to be located on the unit. The DON and Administrator were made aware, and complete search of facility and surrounding grounds was completed by staff. Local police departments were notified and given description of resident, surrounding hospitals called, staff out in vehicles searching area. On 08/29/23 at approximately 5:15 P.M. CPD notified facility that Resident #101 was located and taken to hospital for medical evaluation. Review of the care plan dated 08/30/23 revealed Resident #101 was at risk of elopement because he believed he was in Philadelphia instead of Cleveland. Interventions included but were not limited to complete elopement assessments upon admission, quarterly and as needed, resident information in elopement binder, and staff to follow procedures for elopements, if applicable to ensure safe return. 365832 Page 12 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility investigation dated 08/30/23 at 10:53 A.M. revealed Resident #101 exited the facility grounds while out on 08/29/23 during the 9:18 A.M. supervised smoke break without staff knowledge and was found by police, approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. Interview on 08/30/23 at 7:15 A.M. with State Tested Nursing Assistant (STNA) #526 revealed on 08/29/23 she took Resident #101 outside to smoke and get fresh air. She stated she did not realize Resident #101 was not with the group when they re-entered the building. STNA #526 revealed she regularly took Resident #101 outside for smoke breaks without difficulty. Observation on 08/30/23 at 7:20 A.M. confirmed Resident #101 returned to the facility. Resident #101 was observed walking the halls with a towel around his waist. Security Officer #545 observed Resident #101 and got an aide to assist him back to his room for a shower. Interview on 08/30/23 at 8:56 A.M. with LSW #403 confirmed Resident #101 eloped from the facility after not receiving adequate supervision during a smoke break. LSW #403 revealed he was notified at approximately 12:30 P.M. Resident #101 got away from the smoking group at approximately because he was not available for meal pass. LSW #403 called surrounding police departments, gave description of the resident, and reported Resident #101 missing. Human Resources (HR) #495 reviewed camera footage and Resident #101 was last seen at 9:48 A.M. on 08/29/23. The facility staff searched the facility and grounds as well as started driving around. Police came to the facility and were given Resident #101's medical record face sheet. The Police Department called the facility on 08/29/23 at 5:14 P.M. and stated Resident #101 was found approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. A nurse went to the hospital and brought the resident back. Interview on 08/30/23 at 11:21 A.M. with the Assistant Director of Nursing (ADON) revealed when he received notification Resident #101 was at the hospital the ADON retrieved fresh clothes and went to the hospital. The hospital wanted the ADON him to stay with Resident #101. The ADON stated he waited until 11:00 P.M. and that transportation would not be there for a couple more hours, but the hospital stated the ADON could leave. The ADON indicated Resident #101 had no bruises, and all tests completed came back negative. Interview on 08/31/23 at 8:54 A.M. with Receptionist #527 revealed smokers who required a supervised leave of absence (LOA) must be accompanied by staff. The list gets updated weekly and Resident #101 was on the list. Receptionist #527 stated she assisted in calling places looking for Resident #101 after the resident was noted to be missing. Review of Resident #101's progress notes revealed on 08/30/23 at 11:06 A.M. Resident #101 was interviewed by LSW #403, LPN #515 and a phone interpreter (OPI) to understand Resident #101's thoughts on why he left the facility unsupervised on 08/29/23. Resident #101 could state his basic needs but when dialogue was more complex, he understood better with his native language. According to LSW #403, Resident #101 stated he was unsatisfied with the facility, and they were not providing for him the amenities he felt that he should have (cigarettes). Resident #101 was unfamiliar with his diagnoses but did identify he was forgetful and that his memory fails him often. Resident #101 stated he left the facility because he wanted more cigarettes because he was not given any more by the facility. Resident #101 was not oriented to place or time during the conversation and insisted he was in Philadelphia. The resident insisted he was in a prison during the interview. Resident #101 did make homicidal and suicidal statements during the interview. LPN #515 notified the resident's physician, and the resident was sent for a psychological evaluation and admitted . 365832 Page 13 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the sign out sheet dated 08/29/23 revealed STNA #526 signed out Resident #63, #75, #86, #88, #98, #124 and a resident that was not residing in the facility. The sign out sheet had no time out or time in documented. Resident #101 was not included on the sign out sheet. On 09/07/23 at 9:50 A.M. observation of the smoking area for residents revealed there were chairs and a bench located on the side of the building. Human Resources Director # 495 was outside and stated they believed Resident #101 went around the building and exited on the driveway that connected the facility and condominiums next door. Review of facility policy dated 09/2008 with a revision date of 03/18/22 titled, Elopement/Unauthorized Absence Policy, revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility would implement its policies and procedures promptly to locate the resident in a timely manner. This deficiency is an example of noncompliance investigated under Master Complaint Number OH00145983 and Complaint Number OH00145980. 365832 Page 14 of 15 365832 09/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide behavior health training consistent with the requirements and as determined by a facility assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training on hire. This had the potential to affect all 138 residents in the facility. Findings include: Review of the facility's Facility assessment dated [DATE] included under staff training, education and competencies training would be provided for caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder and implementing non-pharmacological interventions. Review of personnel record for State Tested Nursing Assistant (STNA) #526 revealed a hire date of 12/21/22 with no documentation of behavioral training. Review of personnel record for State Tested Nursing Assistant (STNA) #439 revealed a hire date of 08/28/23 with no documentation of behavioral training. Review of personnel record for State Tested Nursing Assistant (STNA) #550 revealed a hire date of 02/06/23 with no documentation of behavioral training. Review of personnel record for Nursing Assistant (NA) #143 revealed a hire date of 08/08/23 with no documentation of behavioral training. Review of personnel record for Housekeeper #514 revealed a hire date of 010/12/22 with no documentation of behavioral training. Interview on 09/06/23 at 9:10 A.M. with Human Resource Director (HR) #495 revealed that behavioral training is done by [NAME] President of Social Services (VPSS) #567, who trained only nursing staff quarterly. HR #495 stated that training for staff is done through a facility on-line training program, which the program populates which training must be done at what time. HR #495 stated that there is no training just for orientation. Interview on 09/07/23 at 12:01 P.M. with VPSS #567 revealed that she does behavioral training for facilities, but the facility should be doing some kind of training at orientation. This deficiency represents non-compliance investigated under Master Complaint Number OH00146166. 365832 Page 15 of 15