Inspection·February 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because she had been sitting in urine. Resident #92 stated to STNA #203 that she didn't need to put her finger there. STNA #203 stated to the resident that there was a proper way of being cleaned and you could not just take the wash cloth over the perineal area and call it clean. She denied placing her finger in Resident #92's vagina. -Administrator's statement dated 02/27/24 revealed he had attended a family care conference for Resident #92 as they had concerns with the care being provided. Resident #92's daughter asked if the police were updated and he stated that they had not because Resident #92 said she did not feel it was abuse, but rather a care issue. Resident #92's daughter stated she felt it was abuse as the STNA had put her fingers into her mother's vagina without any use of wipes or Vaseline. The Administrator stated during his interview with STNA #203 she had stated she was using a washcloth and actually had asked Resident #92 on her preference to wipes or a washcloth. The Administrator stated STNA #203 was on administrative leave pending the outcome of his investigation. -Licensed Practical Nurse (LPN) #202 statement dated 02/27/24 stated an STNA reported to her that Resident #92 wanted to speak with her. She talked to the resident with the resident's daughter in the room. Resident #92 stated she did not like the way one of the STNA's cleaned her up and she did not wish for her to take care of her any longer. LPN #202 assured her that the STNA would not be placed on her assignment. LPN #202 stated the resident and family were in agreement and were satisfied. Interview on 02/27/24 at 9:15 A.M. with Resident #92 revealed she felt she had never been abused while at the facility. She stated she felt STNA #203 had taken liberties during care and that herself and her daughters were having a care conference with the facility regarding the issue. Resident #92 stated she did not tell staff for a couple of days about what had happened and then decided to speak to the nursing manager on 02/21/24. She stated on 02/21/24 she spoke to LPN #202 related to the care provided by STNA #203. She stated she told her that during incontinence care, STNA #203 put her finger into her vagina while cleaning her. STNA #203 had told her she had bowel there and she wanted to clean her properly. When this surveyor asked her if she felt the STNA did not know how to properly perform perineal care or if she felt it was sexual abuse, Resident #92 stated she never thought about it being sexual abuse. Resident #92 felt that STNA #203 did not know how to properly clean residents. Interview on 02/27/24 at 11:07 A.M. with LPN #202 revealed she had spoken to Resident #92 on 02/21/24 about care performed by an STNA. LPN #202 stated Resident #92 had stated to her that an aide (she did not know which STNA it was or her name) was attempting to clean her and perform perineal care and while doing so had put her finger into her vagina. Resident #92 had stated to LPN #202 she didn't think it was done purposely but did not like how she was cleaning her. LPN #202 stated she did not update the DON until 02/22/24 on this concern. Interview on 02/27/24 at 11:20 P.M. with the DON revealed she had spoken to Resident #92 on 02/22/24 and she felt it was more of a care concern because the resident did not like the way the STNA had cleaned her up. The DON stated she had been interviewing staff and residents related to care and abuse since 02/22/24 and ensured STNA #203 was not on the schedule. Although the DON was investigating the incident since 02/22/24, there was no evidence a SRI was submitted to the State Agency untin 02/27/24. Interview on 02/27/24 at 11:20 A.M. with the Administrator revealed he did not report the incident with Resident #92 to the police or the State Agency as Resident #92 did not state it was abuse. He believed it was more of a care concern with STNA #203 not performing appropriate perineal care. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366071 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Alverna Home Inc 6765 State Road Parma, OH 44134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator stated during the care conference held with the resident, family and other staff members earlier in the day, Resident #92's daughter stated she felt it was abuse and he was going to file an SRI with the State Agency and continue the investigation. Review of facility policy titled Abuse, Neglect and Exploitation, revised 03/07/18 revealed the facility response would be to complete a full body assessment of the resident, provide medical treatment if necessary, initiate an investigation immediately, notify the attending physician and resident's family and the medical director, obtain statements, place the accused associate on leave and contact the State Agency and local Ombudsman to report the alleged abuse. This deficiency represents non-compliance investigated under Complaint Number OH00151374. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366071 If continuation sheet Page 3 of 3