Health inspection·January 22, 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** Based on record review, review of the facility reported incident, review of facility policy and interview, the facility did not ensure Resident #52 was free from physical abuse by Resident #46. This affected one resident (#52) out of four residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/06/23 and a discharge date of 11/10/23. Diagnoses included depression, bipolar disorder, anxiety disorder, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/19/23, revealed Resident #52 was severely impaired mentally and exhibited physical and verbal behavioral symptoms for one to three days. Review of progress notes for Resident #52, dated 10/09/23 through 10/19/23, revealed Resident #52 had documented behaviors of wandering into other resident's rooms, confusion, aggression and cursing directed towards others. Resident #52 was noted to be urinating in front of other resident's room, wandering into other resident rooms and refusing to leave as well as taking other residents clothing. Review of the medical record for Resident #46 revealed an admission date of 02/24/23. Diagnoses included end stage renal disease, altered mental status, and cognitive deficit. Review of the quarterly MDS 3.0 assessment, dated 12/27/23, revealed Resident #46 was cognitively intact. Review of a progress note, dated 10/19/23, revealed Resident #46 sprayed [NAME] on another resident's (Resident #52) face due to he wandered into my room again while I was in bed and urinated on my floor, refused to leave when I asked him to. Resident #46 was alert and oriented to person, place, and time. Review of the facility reported incident dated 10/19/23 and the related facility investigation revealed Resident #52 went into the room of Resident #46, exposed his genitals, began urinating on the walls and towards Resident #46 who was lying in bed. Resident #46 sat up and told Resident #52 to get the Hell out of his room. Resident #52 refused to leave, so Resident #46 grabbed [NAME] he kept at his bedside and began spraying it towards Resident #52 ultimately spraying him in the face with the [NAME]. Resident #52 then left his room to enter another room and began stating I can't see there is Page 1 of 2 366377 366377 01/22/2024 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bleach in my eyes. Following all the yelling Resident #46 said two to three staff members then came into his room to see what was going on. Resident #46 stated he pissed in my room. This is the second time he has done this, the first time he was outside my door. Staff explained Resident #46 was not allowed to have the [NAME] in his room. Resident #46 was willing to give up the [NAME] but said he would obtain more because he did not feel safe with Resident #52 wandering around exposing himself and had intrusive behavior. The facility determined abuse had occurred due to Resident #46 spraying Resident #52 with [NAME]. Treatment to Resident #52 consisted of staff showering him, flushing his eyes, and notifying the physician who ordered for him to be sent out to the hospital for a psychiatric evaluation due to being unsafe and dangerous to the community at the facility. Interview on 01/22/24 at 2:05 P.M. with the Administrator revealed the facility substantiated abuse of Resident #52 because Resident #46 admitted to spraying [NAME] in Resident #52's face. Review of facility policy Abuse, Neglect and Exploitation, revised 01/01/24, revealed the facility would provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The policy also indicated abuse prevention included identifying behaviors and providing interventions for those behaviors which could lead to conflict. 366377 Page 2 of 2