Health inspection·December 9, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility Self-Reported Incidents (SRIs), review of the facility investigation, and facility policy review, the facility failed to ensure thorough investigations were completed regarding diversion of narcotics and a resident-to-resident altercation. The facility also failed to ensure preventative and corrective measures were in place. This affected three residents (# 11, #61 and #72) of four residents who were investigated for abuse and misappropriation. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 04/08/24 with diagnoses including kidney disease stage three, retention of urine, acute chronic respiratory failure, chronic obstructive pulmonary disease, anxiety, and other seizures. Significant orders included admit to hospice with a diagnosis of congestive heart failure dated 06/13/24, check fentanyl patch (opioid pain medication) placement every shift, morphine sulfate oral solution 20 milligrams (mg) per milliliter (ml) (opioid pain medication), give 0.5 ml by mouth every two hours as needed for severe pain, oxycodone 10 mg (opioid pain medication), give two tablets by mouth four times a day for pain, Ativan 1 mg (anxiety medication) four times daily for anxiety, fentanyl transdermal patch 72 Hour 50 micrograms (mcg) per hour, apply 1 patch transdermal every 72 hours for pain and remove per schedule. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. Review of the care plan dated 10/10/24 revealed Resident #11 had the potential for acute and or chronic pain related to colovesical fistula chronic obstructive pulmonary disease and decreased mobility. Interventions included administering analgesia (pain medication) as ordered, monitor record and report complaints of pain, and notify the physician if interventions are unsuccessful. Review of the narcotic count sheet for Resident #11 revealed on 11/08/24 there were two missing oxycodone 10 mg tablets. Review of the facility SRI tracking number (#) 253899 revealed on 11/08/24 the narcotic count for oxycodone 10 mg was off by two pills for Resident #11. Review of the facility investigation for SRI tracking #253899 revealed on the morning of 11/08/24 at change of shift, the narcotic count for oxycodone 10 mg was off by two pills for Resident #11. The missing medication was verified by Registered Nurse (RN) #160. The facility wanted Licensed Practical Nurse (LPN) #240 to go for a drug screen, but she refused. The investigation did not contain (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 3 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 12/09/2024 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)