Health inspection·May 31, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and policy review, the facility failed to notify the family/representative of changes in a resident's condition and when there was a change in room. This affected one resident (Resident #85) of three residents reviewed for change in status and notification. The facility census was 86. Findings Include: 1. Resident #85, was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, chronic respiratory failure, congestive heart failure, high blood pressure, post traumatic stress disorder, tracheostomy, a gastrostomy, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and methicillin resistant staph aureus (MRSA) pneumonia. The resident was transferred to the hospital on [DATE] and did not return to the facility. Review of the room changes for Resident #85 revealed he was admitted to room [ROOM NUMBER]. On [DATE] he was transferred to room [ROOM NUMBER] and moved again on [DATE] he was moved to room [ROOM NUMBER]. There was no documentation regarding the room changes or why they were made. Interview with the Administrator on [DATE] at 1:15 P.M. revealed he thought the facility was no longer required to notify families of room changes due to a waiver issued by the federal government during the world wide pandemic. The Administrator indicated he thought the waiver expired on [DATE]. He confirmed the family should still have been notified of the room changes. Review of the Centers for Medicare and Medicaid Services (CMS) QSO-21-17-NH letter dated [DATE] and updated on [DATE], revealed the emergency blanket waivers related to notification of Resident Room or Roommate changes ended in [DATE]. 2. Review of the progress notes for Resident #85 revealed on [DATE] he was sent to the local emergency room (ER) for respiratory distress. The was no documentation found notifying the family regarding Resident #85's transfer to the hospital. An interview with the Administrator on [DATE] at 3:20 P.M. confirmed whenever a resident experiences a change in condition, the family/responsible party were to be notified. An interview with the Director of Nursing (DON) on [DATE] at 4:10 P.M. revealed Licensed Practical Nurse (LPN) #131 was the nurse providing care to Resident #85 on [DATE] when he was transferred to the hospital. The DON said she was unaware the family was not notified of the transfer. The DON (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: 365539 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE 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)