Health inspection·June 4, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interviews the facility failed to ensure wound care was documented as ordered. This affected two residents (Resident #61 and #101) of three residents reviewed for wound care. The facility census was 117. Findings Include: 1. Medical record review for Resident #61 revealed an admission date of 04/17/23. Resident #61's current diagnoses include congestive heart failure, cerebral infarction (stroke), myocardial infarction (heart attack), neuromuscular dysfunction of the bladder, colostomy, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the 04/02/24 Minimum Data Set (MDS) revealed Resident #61 to be cognitively intact. Review of Resident #61's physician orders revealed an order dated 02/13/24 through 04/23/24 for the sacrum to be cleansed with normal saline, apply drawtec (a dressing that promotes moist wound healing) in a single layer and cover with coversite plus (a waterproof composite dressing that can replace gauze and tape) every shift. A new treatment order was written and completed from 04/24/24 through 04/30/24. Review of the corresponding treatment administration record (TAR) for February 2024 through April 2024 revealed no documentation the treatment was completed on day shift the following dates: 03/02/24, 03/08/24, 03/16/24, 03/23/24, 03/25/24, 03/27/24, 04/02/24, 04/04/24, 04/08/24, 04/11/24, 04/12/24. Further review of the physician orders revealed an order written 04/30/24 to cleanse the sacrum with saline, apply a single layer of drawtec, and cover with coversite plus every shift. Review of the May 2024 TAR revealed the treatment was not documented as completed on day shift 05/02/24, 05/03/24, and 05/05/24 and nightshift 05/06/24. An interview with Resident #61 on 05/09/24 at 11:26 A.M. revealed wound care was performed daily as ordered. An interview with Registered Nurse #501 on 05/09/24 at 2:03 P.M. verified the the treatments/wound care were not documented on the dates indicated. 2. Medical record review for Resident #101 revealed an admission date of 04/12/23. Current diagnoses include pressure ulcer of the sacral region, neuromuscular dysfunction of the bladder, chronic respiratory failure, dementia, heart failure, mild cognitive impairment, hypertension, and chronic pain syndrome. Review of Resident #101's physician orders revealed an order dated 03/12/24 through 04/02/24 for the sacrum to be cleansed with normal saline, apply durafiber and coversite every shift. Review of the March TAR revealed no documentation the treatments were completed on 03/14/24 and 03/24/24 dayshift and on 03/28/24 night shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 2 of 3 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the physician orders revealed an order dated 04/02/24 through 04/23/24 to cleanse the sacrum with normal saline, apply a single layer of drawtec, cover with a single 4 x 4 filling and coversite plus every shift. Review of the April 2024 TAR revealed no documentation the treatment was completed on 04/04/24, 04/05/24, 04/18/24, and 04/19/24 day shift and 04/15/24, 04/20/24 and 04/21/24 night shift. Review of the physician orders dated 04/23/24 through 04/30/24 revealed an order to cleanse the sacrum with acetic acid, apply drawtec in a single layer, 4 x 4 filling and coversite plus every shift. Review of the April 2024 TAR revealed no documentation the treatment was completed on 04/26/24. Review of the physician orders dated 04/30/24 revealed an order to cleanse the sacrum with acetic acid and apply durafiber AG (silver containing antimicrobial gelling dressing), gauze and coversite plus change every shift. Review of the May TAR revealed no evidence the treatment was documented on 05/02/24, day shift. An interview on 05/09/24 at 1:30 P.M. with Resident #101 verified the treatments were completed as scheduled. An interview with the Registered Nurse # 501 on 05/09/24 at 2:03 P.M. verified wound treatments were not documented as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 3 of 3