Health inspection·August 15, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations and interviews, the facility failed to ensure all agency staff were oriented to the call light system to assist residents timely. This affected 13 residents (Resident #8, #13, #27, #36, #49, #57, #83, #88, #91, #95, #106, #121 and #123) of 58 residents reviewed for resident call system. Finding Include: Interview on 08/14/23 at 2:10 P.M. with agency State Tested Nurses Assistant (STNA) #307 revealed she was the only aide on the 600-Hall, for 13 residents. STNA #307 stated she has been in all of her resident's rooms every two hours. STNA #307 was asked if call lights were being answered timely and she responded, no call lights have gone off. STNA #307 verified she did not realize the lights above the resident doors did not work and that she was supposed to have a call light phone with her. STNA #307 stated this was her first day in the building as she was contracted through a staffing agency, and no one told her that she was to have a call light phone with her and that the lights above resident doors do not work. STNA #307 stated she just found out about the call light phone a few minutes ago (12:00 P.M.) and she has been on the floor since 9:00 AM. STNA #307 stated the nurse on the 500-Hall came over to her to see why her call lights were not being answered. STNA #307 revealed there was a monitor on the 500-Hall nurses' station that will show when a call light came on and if it had not been answered, she did not know this prior to the nurse telling her. When the call light phone was given to her by STNA #306, she was unable to get the phone to work properly due to the reception in the facility was spotty. STNA #307 stated STNA #306 took her personnel cell number and was texting her when a call light on her hall, was on, so she could answer the call light. Observation of the call light monitor on the 500-Hall revealed three call lights on the 600-Hall had been on for more than 30 minutes from 9:00 A.M. to 1:00 P.M. Resident #36 call light had been on 48 minutes; Resident #95 call light had been on for one hour and three minutes and Resident #27 call light had been on for 41 minutes. Interview on 08/14/23 at 2:30 P.M. with Licensed Practical Nurse (Licensed Practical Nurse (LPN) #309 verified that on the 500-Hall call light monitor, showed 600-Hall had three call lights that had not been answered. Interview on 08/14/23 at 3:39 P.M. with the Director of Nursing (DON) stated there was two different call lights in the facility. The call lights system on the 500, 600, 700 and 800 halls use the same call light system. The aide is to carry the call light phone, that shows if a call lights is ringing and that there was only one call light monitor for the four hall, on the 500-Hall. The DON stated the wifi does not always work well and the aide will have to go to the 500 hall to see if she has a (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: 365289 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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)