Health inspection·February 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure Residents #31, #32, and #55 were treated with dignity and respect. This affected three residents (#31, #32 and #55) of six residents reviewed for dignity and respect and had the potential to affect all residents. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #31 revealed an admission date of 02/16/24. Diagnoses included chronic obstructive pulmonary disease (COPD), asthma, adult failure to thrive, sleep apnea, and high cholesterol. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 required substantial or maximum assistance for showering or bathing, partial or moderate assistance for toileting and personal hygiene, and set up help for eating and oral hygiene. 2. Review of the medical record for Resident #32 revealed an admission date of 02/13/24. Diagnosis included acute respiratory failure, Parkinson's disease, shortness of breath, muscle atrophy, and prostate cancer. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #32 was cognitively intact. He was totally dependent on staff for toileting and required substantial or maximum assistance for showering or bathing and personal hygiene. 3. Review of the medical record for Resident #55 revealed an admission date of 01/12/24. Diagnosis included arthritis, diabetes, pancreatitis, pain and swelling of the left knee, and asthma. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #55 was totally dependent on staff for toileting and showering or bathing, required partial or moderate assistance for personal hygiene, and setup help for eating and oral hygiene. Interview on 02/28/24 at 9:07 A.M. with Resident #55 revealed she felt like State Tested Nurse's Aide (STNA) #204 was constantly picking on her and demeaning her. STNA #204 told her they promoted independence in the facility and did not consider Resident #55's limitations due to her knee immobility and pain. STNA #204 referred to her as honey or baby which was inappropriate. Page 1 of 2 366010 366010 02/28/2024 The Pinnacle Rehabilitation and Nursing Center 330 Southwest Ave Tallmadge, OH 44278

F 0550 Level of Harm - Minimal harm or potential for actual harm Interview on 02/28/24 at 9:15 A.M. with Resident's #31 and #32 as well as Resident #32's wife, revealed staff working on the night shift were especially rude. Staff came in at night and turned off the call light without addressing concerns. Resident #32's wife reported she had an issue with one employee who made a nasty comment to her husband. She reported the incident to the Director of Nursing (DON), and it was handled. Residents Affected - Few Interview on 02/28/24 at 9:42 A.M. with the Administrator and DON revealed they were aware of Resident #55's concerns regarding STNA #204. They revealed they had provided verbal counseling to STNA #204. They confirmed they were aware of the concerns with Resident #32 and his wife; they did not have knowledge of Resident #31's concerns. Interview on 02/28/24 at 11:53 A.M., STNA #204 denied Resident #55 reported any concerns to her about disrespect or mistreatment. Review of the personnel file for STNA #204 revealed a hire date of 11/09/15. The file contained an annual employee evaluation dated 10/27/23 with an action plan to work on her attitude and anger. The date of completion for the action plan was 11/30/23. The file contained verbal education dated 04/02/19 for a resident who felt his bath was not completed in an appropriate amount of time, a written warning dated 04/14/19 for arguing with another STNA in the hallway, and a written warning dated 07/31/15 for threatening a fellow employee with bodily harm. The progressive discipline policy was reviewed with STNA #204 on 10/09/23, highlighting behavior that was offensive to residents, visitors, or fellow employees, arguing or engaging in disruptive behavior with fellow employees in resident care areas, using foul or abusive language, threatening a fellow employee, resident, or visitor, or instigating a physical confrontation with a fellow employee, resident, or visitor. Review of the facility policy titled Resident Rights, dated December 2016, revealed residents have the right to be treated with kindness, respect, and dignity. Review of the facility policy titled Quality of Life-Dignity, dated August 2009, revealed residents would be treated with dignity and respect at all times, enhancing their self-esteem and self-worth. Staff would speak respectfully to residents and all the times including addressing resident by name. This deficiency represents noncompliance investigated under Complaint Number OH00150977. 366010 Page 2 of 2