Health inspection·September 21, 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI) and abuse investigation, review of employee files and review of facility in-services, the facility failed to ensure a resident was free from physical abuse. This affected one (Resident #24) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record of Resident #24 revealed an admission date of 12/05/22. Diagnoses included altered mental status, anemia, chronic obstructive pulmonary disease, and restlessness and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severely impaired cognition and required extensive assistance of one for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment indicated she utilized a wheelchair. Review of the progress notes dated 08/22/23 at 7:41 A.M. revealed Registered Nurse (RN) #170 was called to Resident #24's room. Stated Tested Nursing Aide (STNA) #320 reported she was transferring Resident #24 from the bed to the wheelchair and the resident scrapped her left lower extremity on the side of wheelchair causing a skin tear to left lower extremity. Blood was noted on the floor next to the wheelchair. Resident #24's skin area was cleansed, and steri-strips were applied, and the area was covered with border gauze. The area measured 6.0 centimeters (cm) in length, 2.0 cm in width, and 0.3 cm in depth. Review of the facility's SRI control number 238367 revealed an allegation of physical abuse towards Resident #24 was made on 08/22/22. STNA #340 alleged that STNA #320 was aggressive with the care provided to Resident #24. STNA #320 roughly put Resident #24 into a wheelchair, and it caused a skin tear to the resident's leg. The allegation of physical abuse was substantiated and STNA #320's employment was terminated. Review of the typed statement from STNA #340 revealed on 08/22/23 around 7:10 A.M., STNA #320 and herself were getting Resident #24 ready for the day when several incidents happened that ended up causing Resident #24 to have a skin tear. STNA #320 helped STNA #340 with another resident in Resident #24's room. During that time, STNA #320 decided to get Resident #24 dressed in clean clothes for the day. STNA #320 made a comment to STNA #340 to watch her and then STNA #340 observed STNA #320 throw Page 1 of 3 366184 366184 09/21/2023 Elizabeth Scott Community 2720 Albon Rd Maumee, OH 43537

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clean clothes and a brief at Resident #24 who was sitting on the edge of the bed. STNA #320 then aggressively handled Resident #24's legs onto the bed and had her lying flat on the bed. She forced Resident #24's pajama bottoms and panty hose off her legs. At this moment, STNA #320 told STNA #340 that this was how you must handle Resident #24 in order to get anything on her, Resident #24 was clearly upset at this time in the way she was getting handled by STNA #320. STNA #340 was moving the bed back to the wall, Resident #24 and STNA #320 were bickering again at this moment. STNA #320 reached over Resident #24's head to get to the shoe and that was when Resident #24 grabbed STNA #320's hand and bit her. STNA #320 retaliated by hitting Resident #24 on top of the head, then proceeded to hit her on the head several times after that but not as hard as the initial hit. The shoe was finally grabbed and put on the resident's foot. STNA #340 was still standing at the end of the bed trying to position it back to normal and this was when STNA #320 decided to transfer Resident #24. STNA #320 leaned over and did a hugging motion on Resident #24 and stood her up with no warning. In this process, Resident #24 fought back a little bit causing STNA #320 to throw the resident down into her wheelchair. During this time, a lot of commotion happened, and Resident #24's leg hit the metal side of the chair. Resident #24 then complained STNA #320 scratched her leg. STNA #340 pulled Resident #24's pant leg up and saw a large skin tear on her left shin and a lot of blood. Around 7:20 A.M., STNA #340 hit the staff call assist light and handed STNA #320 a towel to be placed on Resident #24's leg. STNA #320 started to panic, and STNA #340 told her she would go grab the nurse. STNA #340 walked out of the room and found Registered Nurse (RN) #170 at the B hall nurse cart and she told her they needed her help with Resident #24 due to a skin tear. RN #170 then asked how it had happened and STNA #340 said during STNA #320's transfer of Resident #24, the resident hit her leg on the wheelchair. STNA #340 walked with RN #170 to the supply room in A hall where the nurse grabbed some supplies. RN #170 then walked in the room and assessed the skin tear; STNA #340 did not report the allegation of abuse to RN #170 during this time. Review of the employee file for STNA #320 revealed a hire date of 05/12/21. A Corrective Action form dated 08/22/23 revealed STNA #320 had been suspended related to the incident reported earlier by STNA #340. STNA #320 was then terminated on 08/23/23. Interview on 09/21/23 at 2:50 P.M. with the Assistant Director of Nursing (ADON) #120 confirmed she received an email from STNA #340 on 08/22/23 at 8:30 A.M. and the email contained allegations that STNA #320 physically abused Resident #24 during the morning care. ADON #120 stated she telephoned STNA #340 on 08/22/23 at 3:50 P.M. regarding the delay in reporting and STNA #340 stated she had feared retaliation from STNA #320 and that was the reason she had not reported until the email sent to ADON #120 at 8:30 A.M Review of the facility policy titled Resident Abuse, updated 10/27/21, revealed the facility will not tolerate abuse of any manner to residents. The deficient practice was corrected on 08/23/23 when the facility implemented the following corrective actions: • On 08/22/23 at 8:30 A.M., STNA #340 reported the allegation of physical abuse by email to ADON #120. • 366184 Page 2 of 3 366184 09/21/2023 Elizabeth Scott Community 2720 Albon Rd Maumee, OH 43537

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/22/23 at 8:45 A.M., ADON #120 notified the Administrator and DON of the allegation of physical abuse. • On 08/22/23 at 9:00 A.M., STNA #320 was pulled off the floor and met with DON and ADON #120 regarding the abuse allegation and STNA #320 was notified of her suspension pending an investigation of abuse. On 08/23/23, STNA #320 was terminated from employment effective immediately. • On 08/23/23, all residents residing in the facility were assessed for any signs of abuse and there were no negative findings. • On 08/23/23, all staff were inserviced on the facility's abuse policy and timely reporting of allegations of abuse. 366184 Page 3 of 3