Health inspection·April 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure a thorough investigation of Resident #120 who claimed he hit his head on the ceiling of the van when the transport driver drove over speed bumps while on an appointment on 01/28/25. This affected one resident (#120) of three residents reviewed for accidents. The facility census was 119. Findings include: Review of the medical record for Resident #120 revealed an admission date of 01/09/25 and a discharge date of 01/31/25. Diagnoses included malnutrition, osteomyelitis (infection of the bone), muscle weakness, arthritis, kidney disease, and diabetes. Review of the comprehensive Minimum Dat Set (MDS) assessment dated [DATE] revealed Resident #120 was cognitively intact. He was independent with eating, oral hygiene, toileting and showering. Review of the health progress noted dated 01/28/15 revealed Resident #120 had an appointment with the Blood and Cancer Center. Review of the social services progress note dated 01/29/25 revealed Resident #120 reported he hit his head on the ceiling of the van while driving over speed bumps at the prior days' appointment. He also reported he had to bend far to the side, so his head did not hit the ceiling. Interview on 04/14/25 at 2:34 P.M. with Licensed Social Worker (LSW) #404 confirmed she was told by Transport Aide #393 that Resident #120 did not have much space in the facility van between his head and the ceiling, and Resident #120 hit his head during transportation to his appointment on 01/28/25. Interview on 04/14/25 at 2:38 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence in the medical record that Resident #120 was assessed for injury upon hearing him hitting his head on the ceiling of the van on 01/28/25, and no investigation had been completed. He provided two witness statements, not part of the medical record, dated 01/29/25 from LSW #404 and Licensed Practical Nurse (LPN) #414 referencing the incident. LSW #404's witness statement stated, Transport Aide #393 reported that Resident #120 bumped his head while going over speed bumps. Transport Aide #393 and LSW #404 reported this to the nurse on the [NAME] Wing. LPN #414's statement stated, Resident #120 complained of pain to the right hip which is not new. Resident #120 complained of a bumpy ride to and from his appointment the prior day. No visible injuries noted per head-to-toe assessment. Neuro checks were within normal limits. (There was no documented evidence of neurological checks (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: 365433 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 04/16/2025 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)