Health inspection·February 14, 2026

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS DEFICIENCY IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, Self-Reported Incident (SRI) review and interview, the facility failed to ensure residents were free from misappropriation. This finding affected four (Residents #49, #55, #56 and #57) of four residents identified during the investigation of diversion of narcotics. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including quadriplegia, chronic pain syndrome and anemia. Review of Resident #49's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #49's physician orders revealed an order dated [DATE] for Oxycodone 10 milligrams (mg) give one tablet every four hours as needed for pain.Review of Resident #55's medical record revealed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the left breast, morbid obesity, and generalized anxiety disorder. Review of Resident #55's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #55's physician orders revealed an order dated [DATE] for Oxycodone 4 mg one tablet every four hours as needed for moderate to severe pain. Review of Resident #56's closed medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged on [DATE] with diagnoses including malignant neoplasm of the bronchus, bipolar disorder and disorder of the brain. Resident #56 expired in the facility on [DATE].Review of Resident #56's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem.Review of Resident #56's physician orders revealed an order dated [DATE] for Oxycodone 5 mg one tablet four times a day for moderate to severe pain; and an order dated [DATE] for Oxycodone 10 mg every four hours as needed for increased pain. Review of Resident #57's closed medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including chronic obstructive pulmonary disease, essential hypertension, and muscle wasting. Resident #57 was discharged home on 0721/25.Review of Resident #57's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #57's physician orders revealed an order dated [DATE] for Oxycodone 5 mg give one to tablets by mouth every four hours as needed for pain.Review of the Misappropriation SRI Tracking #263185 dated [DATE] revealed LPN Agency #812 misappropriated narcotics from Residents #49, #55, #56 and #57. The investigation determined Resident #49 was missing an unknown amount of Oxycodone narcotic pain tablets due to LPN Agency #812 forging signatures of other nursing staff on the resident's narcotic flow record; Resident #55 was missing seven Oxycodone narcotic pain tablets; Resident #56 was missing 30 Oxycodone narcotic pain tablets; and Resident #57 was missing an unknown amount of Oxycodone narcotic pain tablets because LPN Agency #812 took the remaining Oxycodone card and narcotic flow record from the facility.Interviews on [DATE] at 12:23 P.M. with Regional Administrator #811 and Registered Nurse (RN) #813 confirmed the above findings.Review of the Resident Abuse Prevention Practices policy revised 10/2022 revealed it was the policy of the Residents Affected - Some (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: 365460 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 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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)