Health inspection·November 4, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview the facility failed to ensure Resident #65's concern was addressed promptly. This affected one resident (#65) of three residents reviewed for grievances. The facility census was 87. Findings Include: Review of the medical record for Resident #65 revealed an admittance date of 06/29/20. Diagnoses included dementia, depressive disorder, bipolar, psychosis, schizoaffective disorder, alcohol abuse. Review of the concern log form dated 03/11/24 through 10/30/24 revealed no identified concerns for Resident #65. Review of the email correspondences dated 10/10/24 at 10:49 A.M. through 10/29/24 at 10:59 A.M. between Resident #65's sister, Resident #65's Power of Attorney (POA), the Director of Nursing (DON), Administrator, and the ombudsmen revealed Resident #65's sister emailed the above recipients regarding concerns that occurred on 10/05/24 when Resident #14 threw a dish towards Resident #65 and on 10/08/24 when Resident #14 pulled Resident #65's private caregiver's hair. The email stated Resident #65's sister and Resident #65's POA would be available for a group call. On 10/25/24 at 10:26 P.M. Resident #65's sister sent a second email stating she was following up with concerns expressed on 10/10/24 and had not received a response by email or nor phone call. On 10/26/24 at 7:31 P.M. the Administrator responded stating she was sorry it took some time to respond but she been in and out of the building due to the Jewish holiday this month. Resident #65's sister and POA are welcome to call the facility next time and request to speak with someone if needed a timelier response. The incident was reported to the Resident #14's representatives and the facility was dealing with them regarding the next step. Interview on 10/31/24 at 11:00 A.M. with the Administrator stated due to the Jewish holiday she was in and out of the facility. Resident's 56's sister could have called the facility to talk to someone or she could have texted if she needed a timely response. The Administrator did verify the email was received on 10/10/24 and she did not respond until 10/26/24. Interview on 11/03/24 at 11:05 A.M. with the Director of Nursing (DON) stated she did not want to respond to the email in fear it would exoculate Resident #65's sisters concerns. Review of the facility policy titled Resident Rights dated January 2022, stated voiced grievances to the facility or those agency/entity that hears grievances without discrimination or reprisal, including those with respect to care and treatment which has been furnished as well as that which has Page 1 of 2 365845 365845 11/04/2024 Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145

F 0585 Level of Harm - Minimal harm or potential for actual harm not been furnished, the behavior of staff and of other resident, and other concerns regarding their long-term care facility stay. The facility must make prompt efforts to resolve grievance. This deficiency represents non-compliance investigated under Complaint Number OH00158843. Residents Affected - Few 365845 Page 2 of 2