Inspection·May 16, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure physician's orders were followed for Residents #69 and #83. This affected two residents (#69 and #83) of three residents reviewed for following physician's orders. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 03/27/24 and a discharge date of 04/27/24. Medical diagnoses included hypertensive heart and chronic kidney disease with heart failure with stage five chronic kidney disease, type two diabetes mellitus with diabetic chronic kidney disease, unspecified severe protein-calorie malnutrition, and end stage renal disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was severely cognitively impaired. Resident #83 was dependent on staff with toileting, and lower body dressing, and required substantial to maximal assistance with oral hygiene, shower/bathing, upper body dressing, and personal hygiene. Review of the physician orders for Resident #83 revealed an order dated 03/30/24 for Lidocaine pain relief patch four percent, to be applied to the low back and knees topically every 12 hours as needed for pain once daily, on for 12 hours and off for 12 hours. Review of the Medication Administration Record (MAR) for April 2024 revealed Resident #83 had Lidocaine patch documented as administered on 04/25/24 at 12:45 A.M. Further review of the MAR revealed there was no documented evidence that the lidocaine patch was removed after 12 hours. Review of progress notes for Resident #83 revealed a Medication Administration Note dated 04/25/24 at 6:08 A.M. that revealed the Lidocaine patch that was administered effectively treated pain. Interview on 05/15/24 at 11:15 A.M. with Assistant Director of Nursing (ADON) #349 stated that Lidocaine patch orders should have documentation for time the Lidocaine patch was administered and the time that the Lidocaine patch was removed. ADON #349 further confirmed there was no documented evidence that Resident #83's Lidocaine patch was removed on 04/25/24. 2. Review of the medical record for Resident #69 revealed an admission date of 07/13/18. Medical diagnoses included borderline personality disorder, acute embolism and thrombosis of unspecified beep veins of lower extremity, essential primary hypertension, primary osteoarthritis, and lymphedema. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365275 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 365275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista Nursing and Rehab 1216 5th Ave Youngstown, OH 44504 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)