Health inspection·September 18, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #41's physician was notified timely on radiographic findings. This affected one (Resident #41) of four residents reviewed for notification. The facility census was 85. Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/11/22 with diagnoses including chronic kidney disease, diabetes mellitus and absence of left leg below the knee. Review of the fall investigation dated 08/26/23 at 6:00 A.M. revealed Resident #41 updated the nurse that his left wrist, hand and forearm had discomfort. He stated during a transfer prior to dialysis that morning, the mechanical hoyer lift was mistakenly released too quickly and he ended up on the floor. Resident #41's physician was updated, and an X-ray was ordered. The staff were educated on proper mechanical hoyer lift use. Review of the nursing progress note dated 08/26/23 at 12:05 P.M. revealed Registered Nurse (RN) #205 was updated upon Resident #41's return from dialysis that he had been dropped on the floor that morning by the State Tested Nurse Aide's (STNA) who were trying to get him into the wheelchair. On 08/29/23 at 7:41 A.M. it was noted Trident Care returned the results of a left wrist and forearm X-ray and the physician had been notified. Review of the X-ray for Resident #41's left hand, forearm and wrist revealed Trident Care Imaging came to the facility on [DATE]. The results were received by the facility on 08/27/23 at 1:11 P.M. and showed no fractures. On the results page it was noted that the physician had been faxed the results on 08/29/23 and he had given no new orders on 08/29/23. Interview on 09/14/23 at 2:13 P.M. with RN #205 verified Resident #41 had updated her after dialysis that he had fallen during the mechanical hoyer lift transfer in the morning prior to going to dialysis. She stated she assessed him, updated the physician and received an order to X-ray his left wrist, hand and forearm. Interview on 09/14/23 at 3:03 P.M. with the DON verified Resident #41's physician was not notified of the X-ray findings timely. Review of the facility policy titled, Change in Condition-Physician/Resident Representative Notification, revised October 2016, revealed notification to a physician of a change in a resident's (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 5 Event ID: 365412 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 365412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483 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)