Health inspection·February 1, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, and staff interview, the facility failed to inform residents of new orders and treatment plans. This affected one (Resident #36) of three residents reviewed for change in condition. The facility census was 76. Residents Affected - Few Finding include: Review of the medical record for Resident #36 revealed an admission date of 01/23/24 with diagnoses including pleural effusion, cirrhosis of the liver, hepatitis C, hypertension, esophageal varices, diabetes, obstructive pulmonary disease, traumatic stress disorder, schizophrenia, and ascites (a condition in which fluid collects in spaces within your abdomen). Review of the progress note for Resident #36 dated 01/25/24 timed at 11:40 P.M. revealed the resident requested to go to the hospital to have immediate paracentesis (a procedure performed in patients with ascites, during which a needle is inserted into the abdomen to drain excess fluid), because she had increased abdominal pain, and she felt her liver was leaky. The nurse assessed the resident and noted the resident's abdomen was slightly distended. The nurse told Resident #36 she would notify the resident's physician the next day and they would make the decision regarding paracentesis. Review of the physician's order for Resident #36 dated 01/26/24 revealed the physician gave an order for the following lab tests to be completed: complete blood count (CBC), basic metabolic panel (BMP) and hemoglobin A1C. Review of the progress notes for Resident #36 dated 01/26/24 to 01/29/24 revealed the notes did not include documentation of notification to the resident that her provider had been contacted regarding her concerns and/or that laboratory tests had been ordered for her. Review of the progress note for Resident #36 dated 01/30/24 timed at 9:16 A.M. revealed the laboratory tests for Resident #36 were not drawn as ordered and had to be rescheduled. There was no documentation in the note that Resident #36 was notified the lab had to be rescheduled. Observation on 1/31/24 at 4:55 P.M. revealed Resident #36 told the nurse she was upset because she felt like she was filling up with fluid and drowning due to her abdominal ascites. Interview on 02/01/24 at 1:45 P.M. with Resident #36 confirmed staff did not provide information to her about her care for her abdominal ascites. Resident #36 confirmed staff did not tell her NP #235 was notified of her concerns and that the NP had ordered laboratory testing to be completed on 01/29/24. Resident #36 further confirmed the staff did not tell her that the lab work had to be rescheduled for the next lab day. (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 2 Event ID: 365324 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 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 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)