Inspection·August 9, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure a safe discharge for residents requiring durable medical equipment including a tube feed pump. This affected one (Resident #5) of four residents reviewed for discharge. The facility census was 104. Findings include:Review of the medical record for Resident #5 revealed an admission date of 04/25/25 and a discharge date of 06/24/25. Diagnoses included need for assistance with personal care, anxiety disorder, dysphagia oropharyngeal phase, and moderate protein-calorie malnutrition. Review of the plan of care dated 04/27/25 noted Resident #5 had the potential for fluid deficit related to receiving nutrition via a gastrostomy tube (G-tube). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #5 had intact cognition. Resident #5 received nutrition via G-tube. Review of the physician order dated 05/29/25 noted Resident #5 was receiving Fibersource (tube feeding supplement) 1.2 continuous at 65 milliliters (ml) per hour. Review of the discharge order/summary dated 06/21/25 noted Resident #5 was to receive Fiber source 1.2 at 65 ml with auto flush of 30 ml every hour. The discharge summary did not indicate Resident #5 would be bolus feeding herself until a tube feed pump was available. The summary indicated no other instructions related to tube feeding or the tube feeding pump. Review of the nursing progress note dated 06/23/25 at 4:15 P.M. noted Resident #5 had received extensive training on preparing and administering medications via G-tube. Resident #5 received education on working the tube feed pump including how to unhook and hook self and start pump. Review of the nursing progress note dated 06/24/25 at 3:22 P.M. noted staff explained to Resident #5 that the feeding supplies were not yet ordered due to insurance not returning a call. Review of the nursing progress note dated 06/26/25 at 5:28 P.M. noted calls were made to several home service agencies who did not offer home services or did not provide tube feeding supplies. The facility would still search for providers. Review of the nursing progress note dated 06/30/25 at 3:00 P.M. noted calls were made to several home service agencies who did not offer home services or did not provide tube feeding supplies. The facility would still search for providers. Resident #5's insurance sent a month's supply of feeding at that point. Review of the nursing progress note dated 07/18/25 at 3:42 P.M. noted the facility was still trying to contact a home health company to provide tube feed and supplies. Interview on 08/09/25 at 9:34 A.M., a family member stated Resident #5 was not able to receive nutrition after being discharged due to not having the pump and being nauseated from the bolus (a method of delivering liquid nutrition into the stomach through a feeding tube using a syringe or gravity) feed. Interview on 08/09/25 at 11:00 A.M., the Director of Nursing (DON) and the Administrator noted there was a slight delay in getting everything for Resident #5. The DON stated staff were going to educate Resident #5 on giving herself a bolus; but Resident #5 left the facility before the education could be provided. The Administrator stated Resident #5 was getting sick from the bolus feeds. Interview on 08/09/25 at 11:36 A.M., Licensed Practical Nurse (LPN) #201 stated she worked the (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: 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 08/09/2025 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)