Health inspection·March 19, 2024

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure Resident #8 was free from resident-to-resident physical abuse by Resident #59. This affected one resident (#8) of three residents reviewed for abuse. The facility census was 104. Findings include: Review of the medical record for Resident #8 revealed an admission date is 10/06/23. Diagnoses included diabetes, dementia, muscle weakness, liver cancer, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. He required supervision for showering and personal hygiene and setup help for eating, oral hygiene, and toileting. He displayed no behaviors. Review of the progress note dated 02/18/24 at 3:21 P.M. revealed Resident #8 obtained several scratches on his face as the result of an altercation with another resident. Resident #8 requested to go to the hospital for evaluation. The resident returned to the facility at 9:28 P.M. with no new orders. Review of the SRI tracking number 244303 dated 2/18/24 revealed the Administrator was informed of an incident that occurred on 02/17/24 between Residents #8 and #59. Resident #59 scratched Resident #8 on his face. Staff immediately intervened and separated the residents. Resident #8 was assessed, and scratches were noted to his face. Resident #8 requested to go to the hospital for evaluation. The physician was notified and placed an order for Resident #8 to be sent to the hospital for evaluation and Resident #59 to be sent to the hospital for a psychiatric evaluation. All responsible parties were notified. Interview on 03/18/24 at 2:37 P.M. with Resident #8 revealed he was attacked by another resident (Resident #59). He revealed he was scratched in the face and went to the hospital. He confirmed the resident no longer lived on the same floor. Interview on 03/19/24 at 9:02 A.M. with the Administrator confirmed Resident #59 assaulted Resident #8. Page 1 of 2 365879 365879 03/19/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse, neglect, exploitation and misappropriation of resident property which included situations observed or reported by staff, residents, relatives, visitors or others that had not yet been investigated and could result in noncompliance with federal requirements related to mistreatment, neglect or abuse. Residents Affected - Few As a result of the incident, the facility took the following actions to correct the deficient practice by 02/28/24: Immediately following the incident on 02/18/24, Residents #8 and #59 were assessed for injuries and separated. • On 02/18/24 at 3:06 P.M. an investigation regarding the residents involved began. Interviews and skin observations were completed on all residents who resided on the secured unit. There were no other concerns identified regarding abuse. • On 02/18/24, Resident #8 was transported at his request and evaluated at a local hospital and received treatment for the scratches he obtained. • On 02/18/24, Resident #59 was evaluated for psychiatric hospitalization. • On 02/19/24, all nursing staff were reeducated on the de-escalation policy. • Interviews on 03/18/24 with Licensed Practical Nurses (LPNs) #202 and #203, and State Tested Nurse's Aides (STNAs) #204 and #205 revealed they were able to identify types of abuse and procedures for escalating behaviors and abuse allegations. They reported they received training on abuse policies and procedures and escalating behaviors. • On 03/18/24, two additional residents (#79 and #93) were sampled and reviewed for abuse. No concerns were identified. • On 03/18/24, review of the facilities SRIs revealed there were no further concerns identified regarding abuse. This deficiency represents noncompliance investigated under Complaint Number OH00151344. 365879 Page 2 of 2