Health inspection·September 22, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 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** 2. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including schizophrenia, major depressive disorder, anxiety, pulmonary disease, high cholesterol, osteoporosis, polyosteoarthritis, extrapyramidal and movement disorder, vitamin D deficiency, and insomnia. Resident #45 was unsteady on feet with difficulty walking, muscle weakness, and had low back pain. Review of a facility Self-Reported Incident (SRI), tracking number 234468 dated 04/28/23, indicated an allegation of physical abuse. The SRI indicated at approximately 11:15 P.M. on 04/27/23 a staff member (unnamed) heard two residents speaking in loud volumes on the west hallway in the facility. The staff member entered Resident #45's room and Resident #45 informed the staff member that Resident #91 had entered her room and struck her on the left side of her face near her eye. Both residents were separated, and a skin assessment was completed for Resident #45. Resident #45 had suffered a 0.1 centimeter (cm) scratch on the inner canthus region of her left eye. The SRI indicated Resident #91 had a diagnosis of paranoid schizophrenia, schizoaffective disorder, severely impaired cognition, dementia with behavioral disturbance and impulse control disorder. Resident #91 was unable to state why she had struck Resident #45. Resident #45 informed the facility that she was sleeping when Resident #91 walked in her room and punched her in the left eye and wanted to file a police report. Resident #45 was moderately cognitively impaired and did not know why Resident #91 had punched her in the eye. A police report was filed, and the local police department investigated the incident. Record review revealed there was no documentation in Resident #45's progress notes of the incident dated 04/27/23. Resident #45's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she needed extensive assistance with dressing, toileting and personal hygiene, one-person physical assistance with ambulation, had unsteady balance when walking, turning around and facing the opposite direction, moving on and off the toilet and during surface-to-surface transfers. An interview with State Tested Nursing Assistant (STNA) #194 on 09/18/23 at 8:49 A.M. indicated (on 04/27/23) she heard Resident #45 screaming for help and went to investigate the cause of the problem. STNA #194 stated Resident #45 informed her Resident #91 had hit her in the left eye. STNA #194 stated Resident #45's left eye was bleeding and red and she reported the incident to the nurse and wrote a statement of the incident during the facility investigation. STNA #194 stated the police were notified and did talk to both residents regarding the incident. An interview with Resident #45 on 09/18/23 at 10:15 A.M. revealed she had no memory of the incident with Resident #91. Page 1 of 9 366323 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #91's MDS 3.0 assessment dated [DATE] indicated Resident #91 exhibited behaviors including hallucinations, delusions, physical symptoms (e.g., hitting, kicking, pushing scratching, grabbing, abusing others sexually), verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others). The MDS assessment indicated the behaviors exhibited had an impact on others by putting others at significant risk for physical injury, significant intrusion on the privacy or activity of others, and significantly disrupting the care or living environment. Residents Affected - Many Review of Resident #91's nursing progress note dated 04/28/23 indicated Resident #91 had struck Resident #45 in the left eye causing slight bleeding in the inside corner of her eye. A cold compress was applied, and neurological checks were implemented. A review of Resident #91's plan of care revised on 05/22/23 indicated Resident #91 had potential to demonstrate physical behaviors related to dementia, schizoaffective disorder, impulse control disorder and delusional disorder. Interventions on the plan of care included monitoring and documenting her behavior and report, document and notify physician of danger to self and others. Resident #91 was discharged from the facility and not available to interview. A review of Registered Nurse (RN) #197's written statement regarding the incident where Resident #91 hit Resident #45 in the left eye on 04/27/23 at 11:15 P.M. indicated STNA #194 had reported Resident #91 hit Resident #45 in the left eye causing Resident #45's eye to bleed and the eye was reddened. RN #197 assessed Resident #45 and found the inner corner of her left eye was bleeding and applied a cold compress and notified the Director of Nursing (DON) and physician. 3. Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including morbid obesity, lymphedema, seizures, mental disorder, intermittent explosive disorder, obsessive compulsive disorder, psychotic disorder, anxiety, moderate intellectual disability, personality disorder, bipolar disorder and major depressive disorder. Resident #46's medical record revealed she had lack of coordination, muscle weakness, and cervical disc disorder with myelopathy. Resident #46's nursing progress note dated 05/29/23 indicated Resident #46 was in the north hallway day area with other residents. Resident #46 allegedly pushed Resident #85 and Resident #85 retaliated by hitting Resident #46 in the mouth. Resident #46 was assessed, and care provided for her mouth until the bleeding stopped. Resident #46's MDS 3.0 assessment dated [DATE] indicated extensive assistance was needed for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #46 was not steady during transitions and walking including moving from seated to standing position, walking, turning and facing the opposite direction, and moving on and off the toilet. An interview with Resident #46 on 09/18/23 at 10:10 A.M. revealed a few weeks ago Resident #85 had punched her in the mouth causing her mouth to bleed. Resident #46 stated the incident occurred in the dining room and the facility sent her to the hospital for treatment. Resident #46 was unable to state why Resident #85 had physically hit her in the mouth. Medical record review revealed Resident #85 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorder with hallucinations, dementia with behavioral disturbance, anxiety, major depressive disorder, and drug induced subacute dyskinesia (uncontrolled involuntary movements). 366323 Page 2 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety A review of SRI tracking number 235507 dated 05/30/23 indicated the charge nurse (unnamed) heard yelling from the north day room. Upon investigation Resident #85 reported that when he attempted to stand from a seated position, Resident #46 grabbed him attempting to make him sit back down. Resident #85 stated he almost fell so he hit Resident #46. Resident #46's mouth was assessed, and first aid provided. Both residents were separated, and the day room was monitored for behaviors. The facility substantiated the allegation that physical abuse had occurred. Residents Affected - Many Resident #85's progress note dated 05/29/23 indicated Resident #85 hit Resident #46 in the mouth after Resident #46 pushed him almost making him fall to the ground. An interview with Licensed Practical Nurse (LPN) #106 on 09/18/23 at 8:24 A.M. revealed she was aware of the incident when Resident #85 hit Resident #46 in the mouth. LPN #106 stated she heard screaming in the north hall day room and went to investigate. LPN #106 stated she found Resident #46 and Resident #85 and asked them to explain what had happened. LPN #106 did not witness the interaction but Resident #46's mouth was bleeding and she stated Resident #85 had hit her in the mouth. LPN #106 stated apparently Resident #85 tried to move past Resident #46. Resident #46 pushed his arm and Resident #85 hit Resident #46 in retaliation. Resident #85 hit the part of her mouth that had a chronic sore and the area started bleeding. LPN #106 separated the residents and cleaned Resident #46's mouth. The administrator, guardian and physician were notified of the incident. An interview with Resident #85 on 09/18/23 at 10:20 A.M. indicated Resident #46 was antagonizing him by teasing him and imitating his movements and Resident #85 had warned Resident #46 to stop mimicking his movements. Resident #85 stated he would hit her again if she continued to antagonize him. 4. Medical record review revealed Resident #77 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including intracranial injury with loss of consciousness, degenerative diseases of the nervous system, intractable epilepsy, left sided hemiplegia, major depressive disorder, and nonpsychotic mental disorder. Resident #77's medical record indicated she had abnormal posture, lack of coordination, need for assistance with personal care, cognitive communication deficit, muscle weakness, dependence on wheelchair, and had a history of falling. Review of SRI tracking number 234459, dated 04/28/23 indicated on 04/27/23 at 2:08 P.M. Resident #91 walked into Resident #77's room and hit her on the head unprovoked. Charge nurse (unnamed) assessed Resident #77 and found no injury. Resident #77 complained of acute pain to her head and was offered pain medication. Mental Health Consultant (MHC) #198 witnessed the incident and informed the facility Resident #91 walked into Resident #77's room and hit Resident #77 with a closed fist on the back of her head. Resident #91 indicated Resident #77 verbalized a racial slur and threw a bottle of lotion at her and she hit Resident #77 in retaliation. MHC #198 stated there were no words exchanged between Resident #77 and Resident #91 prior to the incident. Resident #77's MDS 3.0 assessment dated [DATE] indicated she was totally dependent on staff for assistance with dressing, transfers and locomotion on/off the unit, toilet use, personal hygiene, extensive assistance for bed mobility and eating. Resident #77 had impairment on one side of upper and lower extremities and used a wheelchair for mobility. Resident #77 was not available during the survey on 09/14/23 and 09/18/23 to conduct an interview. An interview with MHC #198 on 09/14/23 at 2:40 P.M. revealed MHC #198 was conducting a therapy session with Resident #77 in her room. Resident #77 was seated with her back towards the door. Resident 366323 Page 3 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many #91 entered Resident #77's room through the shared bathroom connecting the two rooms. Resident #91 had difficulty navigating a path through the room and became frustrated and hit Resident #77 on the back of the head. Resident #91 then proceeded to exit the room without exchanging any words. MHC #198 reported the incident to the staff and completed a witness statement regarding the incident. Review of the facility Abuse Prevention Program policy, revised December 2016, revealed residents had the right to be free from abuse. The policy indicated the administration would protect residents from abuse by anyone, including facility staff and other residents. Review of the document titled Behavior Modification Program, revised 05/2022, revealed the program was designed to reward good behaviors. Positive behaviors were awarded points, and negative behaviors result in a deduction of points. Each resident had a separate point card. Points could be redeemed for smoke breaks or an account credit. Points were lost for instances that included physical or verbal abuse, refusing ancillary services, or inappropriate touching. This deficiency represents non-compliance investigated under Complaint number OH00146133. Based on observation, record review, review of facility Self-Reported Incidents (SRIs), local police report review, review of the facility's Abuse policy and procedure and interviews, the facility failed to ensure Resident #28 was free from resident-to-resident physical abuse. This resulted in Immediate Jeopardy and actual harm beginning on 08/28/23 at 4:30 P.M., when Resident #37, who was cognitively intact and known to be verbally and physically aggressive, was observed by Licensed Practical Nurse (LPN) #123 entering Resident #28's room, where he squeezed Resident #28's hands in a forceful manner. Resident #28, who was non-verbal, was heard screaming in pain, LPN #123 responded and removed Resident #37 from Resident #28's room. Resident #28 was assessed to have bilateral hand edema, bruising and pain. X-rays of Resident #28's hands revealed Resident #28 had a left (hand) fifth proximal phalanx (finger) fracture and fractures to the right hand second through fifth proximal phalanges (fingers). The resident was subsequently transported to the hospital for evaluation and treatment. Following the incident, the facility failed to develop and implement effective and planned safety measures to protect Resident #28 and other residents from situations of abuse by Resident #37. The lack of adequate and necessary supervision and interventions for Resident #37 placed all residents at risk for actual harm or serious life-threating injuries up to and including death as a result of resident-to-resident abuse. On 09/10/23 State Testing Nursing Assistant (STNA) #114 reported to LPN #174 a verbal confrontation between Resident #37 and Resident #47. Resident #37 attempted to push Resident #47 into his bathroom. Resident #47 was able to grab the door handle to prevent Resident #37 pushing him in the bathroom after Resident #37 entered his room. On 09/10/23 Resident #76 was heard saying stop squeezing my hand and Resident #37 was observed in the day room squeezing Resident #76's hands. On 09/11/23 at a beverage break, Resident #37 had a physical altercation with Resident #85, where Resident #37 was antagonizing Resident #85 by preventing him and blocking him from moving out of the area. Additionally, the facility failed to prevent additional situations of resident-to-resident abuse that did not rise to the level of an Immediate Jeopardy for Residents #45 and #77 who were abused by Resident #91 and for Resident #46 who was abused by Resident #85. This affected seven residents (#28, #45, #46, #47, #76, #77 and #85) reviewed for resident-to-resident abuse and had the potential to affect all residents residing in the facility who Resident #37 could potentially have contact with. The facility census was 91. On 09/14/23 at 1:49 P.M. the Administrator and Director of Nursing (DON) were notified Immediate 366323 Page 4 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Jeopardy began on 08/28/23 at approximately 4:30 P.M. when Resident #28 was physically abused by Resident #37 when Resident (#37) forcefully squeezed Resident #28's hands causing swelling, bruising, pain and bone fractures and the safety measures put in place to protect Resident #28 and other residents were not thoroughly and timely implemented or effective. The Immediate jeopardy was removed on 09/14/23 when the facility implemented the following corrective action: On 09/13/23 at 5:34 P.M. Resident #37's physician was notified of Resident #37's behaviors with no new orders. Resident #37's physician deferred to psychiatry. On 09/14/23 at 3:30 P.M. Resident #37 was moved to a private room. On 09/14/23 at 3:30 P.M. one-to-one staff monitoring was implemented for Resident #37. The one-on-one supervision was scheduled to continue for a duration of one week, after which time Resident #37 would be reassessed by the physician, psychiatrist, and the interdisciplinary team. Based on this assessment, a decision would be made regarding Resident #37's supervisory needs. On 09/14/23 at 3:42 P.M. the psychiatrist completed a medication review of Resident #37's medications and adjusted Resident #37's antipsychotic medication due to disruptive behaviors. On 09/14/23 at 4:00 P.M. Resident #37's care plan was updated to include an individualized behavior plan. The behavior plan addressed physical and verbal abuse, staying out of other residents' rooms, and the facility's behavior modification program. The behavior plan was signed by Resident #37, the Administrator, Director of Nursing (DON), Unit Manager Registered Nurse (UM RN) #180 and Social Service Assistant (SSA) #132 and was to be implemented immediately. On 09/14/23 at 5:30 P.M. the unit manager nurses audited all facility residents for similar behaviors and care plans were updated if needed. On 09/14/23 at 5:32 P.M. all staff were in-serviced through a web-based program on abuse, elder abuse and neglect: preventing, recognizing and reporting abuse; de-escalation strategies; and doing and completing in services. On 09/14/23 at 6:30 P.M. the unit manager nurses completed a facility wide audit for pain and injury for all residents. No concerns were identified. Starting on 09/18/23, Human Resources Coordinator (HRC) #135 or designee would audit in-service completion records weekly for the next four weeks. Following the weekly audits, HRC #135 would complete random monthly auditing of in-service completion for three months. Results of the audits would be reviewed monthly in Quality Assurance Performance Improvement (QAPI) meetings and an action plan implemented if not in compliance. Starting on 09/18/23, Director of Nursing (DON) or designee would audit incident reports and investigations weekly for the next four weeks. Following the weekly audits, the DON would complete monthly auditing of incident reports and investigations for three months. The audits were to include assurances that residents were protected from further occurrences and that corrective actions were implemented as necessary. The results of the audits would be reviewed monthly in QAPI meeting, and an action plan implemented if not in compliance. 366323 Page 5 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Interviews completed on 09/18/23 between 10:00 A.M. and 11:00 A.M. with Registered Nurse (RN) #182, LPN #106, and State Tested Nursing Assistant (STNA) #188 verified staff were knowledgeable on recognizing and reporting abuse and de-escalation strategies. Interviews completed on 09/18/23 between 1:30 P.M. and 3:11 P.M. with RN #101, LPN #167, Housekeeper #103 and STNA #194 verified staff were knowledgeable on recognizing and reporting abuse and de-escalation strategies. Observations on 09/14/23 at 4:00 P.M., 09/18/23 at 7:00 A.M., 11:00 A.M. and 2:38 P.M. revealed a staff member was seated in Resident #37's room or directly outside Resident #37's room for one-to-one supervision. Review of staff schedules from 09/14/23 at 3:30 P.M. through 09/18/23 confirmed a staff member was assigned to always provide one to one supervision for Resident #37. Although the Immediate Jeopardy was removed on 09/14/23, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 01/09/17 with diagnoses including cerebral palsy, cerebrovascular accident (stroke) with hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) affecting right dominant side, aphasia (loss of ability to understand or express speech) and reduced mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/09/23, revealed Resident #28 was rarely/never understood, with a Brief Interview for Mental Status (BIMS) score of a 00, indicating severely impaired cognition. The assessment revealed Resident #28 required extensive to dependent assistance of one to two staff members for activities of daily living (ADLs). Review of Resident #28's progress note dated 08/28/23 revealed at approximately 4:30 P.M., Resident #28 had his hands forcefully squeezed by another resident and was screaming in his room. LPN #123 assessed Resident #28 for injuries and noted edema and bruising to bilateral hands and updated the physician and facility leadership. Review of Resident #28's mobile radiology report, dated 08/28/23, revealed Resident #28's left hand had an acute appearing fifth proximal phalanx fracture. The report noted the right hand examination was a limited study for which fracture could not be excluded and recommended a repeat study with additional diagnostic views. Review of Resident #28's progress note dated 08/29/23 timed 8:30 A.M. revealed Resident #28's physician was notified of the inconclusive radiology results and Resident #28's status. Resident #28 was observed to have facial grimacing, indicative of pain, with manipulation of the right hand. Resident #28's right hand was observed to be grossly edematous (swollen). The physician ordered a STAT (immediate) repeat x-ray examination of Resident #28's right hand and an order for Tramadol, an oral opioid analgesic, as needed. Review of Resident #28's mobile radiology report, dated 08/29/23, of the right hand revealed acute appearing fractures in the second through fifth proximal phalanges. Review of Resident #28's progress notes dated 08/29/23, revealed Resident #28's physician was 366323 Page 6 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many updated on the STAT radiology results and ordered Resident #28 to be transferred to the hospital for evaluation. Resident #28 was sent to the hospital on [DATE] at 7:35 P.M. and returned to the facility on [DATE] at 2:30 A.M. Review of Resident #28's hospital records, dated 08/29/23, revealed Resident #28 presented to the hospital with injuries after he was the victim of an assault at a nursing facility. The medical record revealed outside x-rays revealed metacarpal fractures to the right hand. Ecchymosis (bruising) and blisters were noted to Resident #28's right hand. Due to the patient being non-verbal, multiple radiological examinations were performed to identify injuries. In addition to the hand injuries identified pre-hospital, Resident #28 was additionally found to have a closed nondisplaced fracture of the phalanx (toe) of right foot, and a closed fracture of one rib on the right side. Hospital records further revealed that the guardian was contacted by the hospital staff who was agreeable for Resident #28 to return to the facility. Review of Resident #28's physician's orders, dated 08/30/23, revealed new orders for two staff members to be present for all care due to acute injuries, and for a mechanical lift with two staff members to be used for all transfers. Resident #28 was referred to an orthopedic physician for consultation. Review of a facility SRI, tracking number 238619 revealed the facility reported an incident of resident-to-resident physical abuse on 08/28/23. The SRI indicated on 08/28/23 LPN #123, who was in a resident room across the hall, heard Resident #28 yell. Upon entering Resident #28's room, the nurse saw Resident #28 lying in bed with Resident #37 seated in his wheelchair next to Resident #28's bed, forcefully squeezing Resident #28's hands. LPN #123 intervened and removed Resident #37 from Resident #28's room. Resident #28 was assessed for injury and found to have bilateral hand swelling and bruising. Resident #28's physician was notified and ordered bilateral hand x-ray examinations. The SRI contained staff statements and identified only one staff member, LPN #123, witnessed the incident. As a result of the investigation, the facility moved Resident #37 to a different hallway, away from Resident #28's room, implemented every 15-minute safety checks for Resident #37 for a period of 72 hours, and all staff were to be in-serviced on abuse and resident rights. Review of the document titled Accident or Incident Report dated 08/28/23 and timed 4:30 P.M. revealed another resident was forcefully squeezing Resident #28's hands. The incident appeared to be non-consensual and caused discomfort or distress to Resident #28. The incident report was completed by LPN #123. Review of local police report, reported on 08/29/23, revealed the DON reported the incident and stated an assault occurred between two residents of the facility on 08/28/23. The victim, Resident #28 suffered multiple fractures. The report noted Resident #28's guardian was unable to be reached but facility staff reported the guardian wished to pursue charges. The report indicated the case was closed on 09/11/23. No disposition or rationale was listed. Observation on 09/13/23 at 1:19 P.M. revealed Resident #28 lying in bed. His bilateral arms were on top of a blanket. Resident #28's right and left hands were observed to be edematous, with the right side more edematous than the left. Resident #28 was awake, but unable to answer questions or meaningfully engage in conversation. Review of Resident #37's medical record revealed an admission date of 08/10/23 with diagnoses including bipolar disorder, psychoactive substance use, opioid abuse, anxiety, depression, and a history 366323 Page 7 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 of suicidal ideations. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #37's hospital medical records prior to admission to the facility, dated 07/19/23, revealed Resident #37 presented to the hospital requesting detox from methamphetamines, cocaine, and fentanyl. He had not taken his prescription medications for the past two weeks since he was kicked out of another nursing home and taken to a park near a homeless shelter. Resident #37 had not been able to secure housing, and had a lifetime ban, for unknown reasons, at homeless shelters in the area. Hospital records indicated Resident #37 had poor impulse control and his insight and judgement were impaired. Residents Affected - Many Review of Resident #37's care plan, dated 08/11/23, revealed a focus on Resident #37's adjustment issues to the facility. Resident #37's care plan also identified he participated in the facility's behavior modification plan. Review of Resident #37's admission MDS 3.0 assessment, dated 08/18/23, revealed he was cognitively intact with a BIMS score of 14. Resident #37 experienced delusions and was identified to have verbal behavior symptoms directed towards others on four to six days, and other behavioral symptoms not directed towards others on one to three days during the seven-day lookback period. Resident #37 was identified to require the use of a wheelchair for mobility. He required extensive assistance of one staff for personal hygiene and required supervision of one staff for all other activity of daily living (ADL) care. Review of progress notes dated 08/15/23 through 09/11/23 revealed instances of Resident #37 being up all night self-propelling through the hallways, verbal and physical aggression towards staff, staffing closing a door to prevent Resident #37 from becoming physically aggressive with the staff, verbal threats of physical aggression, use of profane language, calling staff obscene names, kicking and throwing a trash can down the hallway, ramming his wheelchair into LPN #107's shins and punching LPN #107 in the abdomen, banging on the glass surrounding the north nurses station with a closed fist, going in and out of other resident rooms when they did not consent, verbal confrontations with other residents, pushing another resident (Resident #47) upon entering the resident's room without consent, squeezing Resident #28 and Resident #76 hands forcefully, and preventing and blocking Resident #85 from moving out of an area. Interview on 09/13/23 at 1:26 P.M. with State Tested Nursing Assistant (STNA) #144 revealed Resident #28 was almost completely non-verbal. Occasionally he was able to verbalize a one-word phrase, and he frequently used sounds, like a short yell, to communicate discomfort. STNA #144 stated Resident #28 required extensive assistance of one to two staff members for ADL's. STNA #144 revealed she knew Resident #37 to have frequent verbal behaviors directed at staff members and other residents. Interview on 09/13/23 at 1:40 P.M. with LPN #136 revealed Resident #37 to be verbally aggressive. LPN #136 stated there had been instances where he had attempted physical aggression, but staff were able to intervene and de-escalate the situation before situations progressed. LPN #136 recalled an incident that occurred on 09/11/23 where Resident #37 and Resident #85 were both outside at a beverage break. Resident #37 antagonized Resident #85 repeatedly by blocking Resident #85's path which prevented Resident #85 from removing himself from Resident #37. Resident #85 was observed to strike Resident #37 in his head, which knocked his hat off. LPN #136 stated Resident #37 was identified to be the aggressor who initiated the altercation. LPN #136 stated she documented behavior incidents in the medical record and kept nursing leadership informed of behavior patterns. LPN #136 stated both Resident #37 and Resident #85 were known to be verbally aggressive but receptive to redirection. 366323 Page 8 of 9 366323 09/22/2023 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/13/23 at 2:08 P.M. with STNA #105 revealed she cared for Resident #28 on 08/28/23. The nurse on duty had informed her of the incident that occurred around dinner time on 08/28/23 and to be careful when performing care or moving his upper extremities. STNA #105 stated she was cautious when she provided evening care and got Resident #28 ready for bed that evening. STNA #105 stated Resident #28 had edema to both of his hands, including his fingers but she did not recall any bruising or verbal or non-verbal signs of pain. Residents Affected - Many Observation on 09/13/23 at 2:19 PM revealed Resident #37 was seated in a manual wheelchair in the west hall common area. Resident #37 was awake, alert and dressed appropriately. During an interview, Resident #37 stated he had never had a physical incident with another resident at the facility and questioned who said that he did. Resident #37 stated that all the staff at the facility were liars and denied getting physical. Resident #37 stated he had only gone to Resident #28's room to visit as he had tried to be friendly. Resident #37 ended the conversation, raised his hands up in the air and self -propelled his wheelchair down the hallway towards his room. Interview on 09/13/23 at 2:28 P.M. with unit manager (UM) LPN #141 revealed she had seen Resident #37 enter other resident rooms uninvited. Resident #37 was cognitively intact, and staff had attempted to educate and redirect him, but Resident #37 was quick to become verbally aggressive. LPN UM #141 stated she was familiar with the incident between Resident #28 and Resident #37 but had no firsthand knowledge of the event. She stated an additional incident happened on 09/10/23 when Resident #37 was observed to squeeze Resident #76's hands in a common area. LPN UM #141 stated she was concerned about Resident #37's continued stay in the facility and stated he was unpredictable, and it bothered her to see another vulnerable resident who Resident #37 gravitated towards. LPN UM #141 revealed upon returning from the hospital on [DATE], Resident #28 returned to a room on the same hall as Resident #37. Resident #37 was moved to another unit midday on 08/30/23. LPN UM #141 stated when incidents occurred, the facility nursing staff completed an incident report that first went to the unit manager, and then was turned into and reviewed by the DON. Interview on 09/13/23 at 2:58 P.M. with the DON verified Resident #37 had a room change to the opposite side of the facility, but not until 08/30/23 at 11:30 P.M., approximately 43 hours after the incident between Resident #28 and Resident #37 occurred. The DON stated Resident #37 primarily had only been aggressive with staff and had a rough adjustment to the facility. Resident #37 was mouthy and rude, but had only been aggressive with one staff member, LPN #107. The DON further stated 366323 Page 9 of 9