Health inspection·June 22, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's Self-Reported Incidents (SRI), and policy review the facility failed to investigate and report an injury of unknown origin to the state agency. This affected one resident (#5) out of one resident reviewed for abuse. The facility census was 39. Findings include: Observation on 06/20/23 at 11:53 A.M. revealed Resident #5 was noted to have a quarter size purple bruise with slight edema directly under her left eye. Interview at this time with Resident #5 revealed she was unsure of what happened to her eye. Review of the facility's SRIs revealed the last reported SRI was reported to the state agency on 03/27/18. Review of Resident #5's medical record revealed an admission date of 12/08/22. Diagnoses included dementia with behavioral disturbance, age related cognitive decline, hallucinations, anxiety disorder, and muscle weakness. A complete review of the medical record revealed a skin assessment of the residents bruising was never documented into the medical record. Review of Resident #5's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. Review of Resident #5's nursing progress note dated 06/06/23 at 5:50 P.M. Licensed Practical Nurse (LPN) #247 charted, Resident #5 was sitting at dining room table with another resident and was asked how she got the black eye. Resident #5 responded she poked herself with a pencil. Later LPN #247 asked the resident what happened, and she responded she poked her eye with a razor blade. The resident also had a bruise on the top of her shoulder which was yellow in color, and her left forearm black in color. Review of Resident #5's Nursing progress note, entered as a late entry, the note was created by the Director of Nursing (DON) on 06/20/23 at 11:28 A.M. and noted to be effective on 06/07/23 at 11:26 A.M. stated this was the investigation of bruise to the residents left eye. The note continued to state a nurse observed a bruise under Resident #5's left eye and a fading bruise on her shoulder. The resident was alert and oriented to person only and was unable to recall any incidents that resulted in the injuries. She was overheard by staff one day telling another staff member that she poked Page 1 of 2 366449 366449 06/22/2023 Park Village Hc NP LLC 1019 Oldtown Valley Road SE New Philadelphia, OH 44663

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few herself with a pencil, but then told the nurse that she poked herself with a razor. Staff were interviewed and all stated the only thing they can think of would be her recent falls. The resident does have confusion and hallucinations and has had a steady decline. She does sit in her room a lot per her choice. Spoke to the resident's son who agreed these injuries were more than likely a result of her recent falls. He also stated she may have gotten the bruise from her glasses as he noted that she is constantly messing with her glasses when he was visiting with her. The resident denied pain to the areas, and they appear to be healing. The Medical Director is aware and gave no new orders other than to notify if the area worsens. Interview on 06/21/23 at 9:35 A.M. the DON revealed on 06/07/23 she initiated an investigation into Resident #5's left eye bruising. She stated she interviewed two State Tested Nurses Assistants (STNAs) (STNA #207 and STNA #211) and one nurse (LPN #247) but did not document these interviews. After the three interviews it was assumed that the resident received the bruising during her recent falls. She also stated she spoke to the resident's son, and he stated it was hard to tell what could have happened and she was always fighting with her glasses. She stated a skin assessment was not completed on the bruising to the resident's eye or shoulder. She went on to say she did not interview any other staff or residents in the facility regarding the bruising. She stated the Abuse policy was not retrained due to the facility staff just receiving education in April 2023. She confirmed at this time a full investigation was not done into Resident #5's bruising and stated she did not report the bruising to the state agency because she did not believe it was a result of abuse. Interview on 06/21/23 at 2:15 P.M. the Administrator confirmed the facility did not complete a full and timely investigation into Resident #5's bruising. She stated she did not feel like the injury needed to be reported to the state injury because it was not in a suspicious location. Review of the facility policy, Resident Abuse Policy, dated 10/21/22, revealed injuries of unknown source is defined by when all the following criteria are met: The source of the injury was not observed by any person and the source of the injury could not be explained by the resident: And the injury is suspicious because of the extent of the injury or the location if the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. 366449 Page 2 of 2