Inspection·May 10, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, interviews, and facility policy review the facility failed to report an alleged incident of abuse against Resident #76. This affected one resident (#76) of three residents reviewed for abuse reviewed. The facility census was 75. Findings include: Review of the medical record for Resident #76 revealed an admission date of 07/25/22 and a discharge date of 02/24/23. Diagnoses included benign neoplasm of meninges, need for persona assistance, weakness, dysphagia, type two diabetes mellitus, major depressive disorder, schizoaffective disorder bipolar type, and anxiety. Review of the care plan dated 10/05/22 revealed a goal for Resident #76's behaviors. Interventions included offering positive encounters rather than only talking to him when he needed something and medicating as ordered. Interview on 05/08/23 with the Director of Nursing (DON) revealed she was made aware of Resident #76 having been verbally aggressive with State Tested Nurse Aide (STNA) #118 on 01/14/23. She stated she received a call from the manager on duty stating STNA #108 alleged STNA #118 flipped off Resident #76. The DON had staff get a statement from STNA #118 before walking her out until the investigation was over. The DON stated Resident #76 did not remember or complain about the situation. The DON said there were dynamics between STNA #108 and STNA #118 and the DON and Administrator felt it was a beef between staff. The DON said it was STNA #108's word against STNA #118's word. The DON stated they felt it was not reportable incident because no one witnessed it and that Resident #76 did not recall it. The facility verified they did not complete a self-reported incident. Interview on 05/08/23 at 4:45 P.M. with STNA #127 revealed she was in the doorway of Resident #76's room when the incident occurred. She stated she did not witness STNA #118 flip off Resident #76 as her back was to her. STNA #127 said she was blocking Resident #76's view and did not believe he saw anything. Interview on 05/08/23 at 4:48 P.M. with STNA #108 revealed she was getting a shower chair along with STNA #127 when they were at the doorway of Resident #76. She stated she saw STNA #118 flip off Resident #76. STNA #108 stated she reported it immediately to her supervisor and then the manager on duty. Interview on 05/08/23 at 4:55 P.M. with STNA #118 revealed Resident #76 had been screaming at her all day long. Resident #76 was reassigned to another STNA, but STNA #118 stayed on the hallway. STNA (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 3 Event ID: 365665 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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)