Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review, and facility policy review the facility failed to ensure Resident #78's
immediate care and service needs were assessed and orders initiated at the time of admission. This
affected one resident (#78) of two residents reviewed for admissions. In addition, the facility failed to ensure
Resident #55 received wound treatments according to physician orders. This affected one resident (#55) of
four residents reviewed for wound treatments. The facility census was 80.
Residents Affected - Few
Finding included:
1. Review of the closed medical record for Resident #78 revealed an admission date of 03/08/25 at 6:07
P.M. and a discharge from the facility per resident request on 03/10/25 at 12:45 P.M Diagnoses included
local infection of the skin, subcutaneous tissues, non-pressure ulcer of the right and left lower legs with fat
layer exposed, peripheral vascular disease, type II diabetes, hypertension, Chronic Obstructive Pulmonary
Disorder (COPD), and major depressive disorder.
Review of Resident #78's progress notes dated 03/08/25 to 3/10/25 revealed there was no evidence of an
admission note to the facility, no evidence the physician was notified of arrival and no evidence the
admitting staff verified admission orders with the physician.
Review of Resident #78's Hospital After Visit Summary (AVS) dated 03/08/25 revealed Resident #78 had
been hospitalized from [DATE] to 03/08/25 with a diagnosis of foot infection. Resident #78 was discharged
from the hospital with the following medication orders: Daptomycin (antibiotic) 800 milligram (mg)
Intravenously (IV) every 24 hours for 14 days (next dose due to be given on 03/09/25),
Oxycodone-acetaminophen (narcotic pain medication) 5-325 mg one tablet daily as needed for pain for
three days (last dose given on 03/08/25 at 9:56 A.M.), Humulin (insulin to treat diabetes) R U-500 Kwik Pen
500 Unit/milliliter (ml) inject 120 units with breakfast, 50 units with lunch and 120 units with dinner (last
dose given on 03/08/25 at 11:50 A.M.), albuterol sulfate 108 microgram (mcg)/Actuation (act), inhale two
puffs into lungs every six hours as needed, apixaban (blood thinner) 5 mg take one tablet by mouth once a
day starting on 03/09/25, bumetanide (diuretic) one mg tablet by mouth every day in the morning,
citalopram (antidepressant) 20 mg tablet take one tablet daily (last dose given on 03/08/25 at 9:51 A.M.,
lisinopril (high blood pressure treatment) 10 mg tablet daily (last dose given on 03/08/25 at 9:51 A.M.),
metoprolol (blood pressure treatment) 100 mg tablet by mouth daily (last dose given on 03/08/25 at 9:51
A.M.), mometasone-formoterol 200-5 mcg/act inhale 2 puffs in the morning and in the evening, Mujaro 2.5
mg once a week, multivitamin with minerals one tablet by mouth daily, pregabalin (anti-convulsant) 300 mg
capsule by mouth twice a day for convulsions twice a day (last dose given on 03/08/25 at 9:51 A.M.),
tamsulosin 0.4 mg take two capsules daily to equal 0.8 mg (last dose given on 03/08/25 at 9:51 A.M.) .
There were also orders for wound care treatments to the bilateral lower extremities, rehabilitation therapy
order and infectious disease protocol for
(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 13
Event ID:
365732
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0684
IV therapy including standing orders for laboratory work, IV flushing orders, and IV dressing change orders.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #78's physician orders revealed it was not until 03/10/25 that the following were initiated
as orders: all facility standing orders for monitoring oxygen saturation and documenting results every shift
due to COPD, Physical Therapy (PT) eval, Occupational Therapy (OT) eval, height, weight times four weeks
upon admission, vital signs every shift times 72 hours then daily, COVID-19 testing as needed/may use
PCR or POC testing, weekly skin assessment to be completed and documented, read tuberculosis (TB)
skin test number one and number two with documentation of results on Medication Administration Record
(MAR), ensure the resident is on a pressure reducing/relieving mattress every shift, consults with
Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed, monitor for pain every shift, and a
wound care consult.
Residents Affected - Few
Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated
March 2025 confirmed the aforementioned orders were not initiated until 03/10/25.
Further review of Resident #78's physician orders revealed medications were not reconciled at the time of
admission and the following orders were not initiated until 03/09/25: Daptomycin 500 mg IV, Oxycodone
5-325 mg, bumetanide 1 mg, metoprolol 100 mg, albuterol 108 mcg/act, tamsulosin 0.4 mg give two
capsules to equal 0.8 mg, Mounjaro 2.5 mg/0.5 ml injection, pregabalin 300 mg two times a day for
convulsions, and citalopram 20 mg for depression.
Further review of Resident #78's Medication Administration Record (MAR) dated March 2025 confirmed
Daptomycin, Oxycodone, bumetanide, metoprolol, albuterol, tamsulosin, Mounjaro, pregabalin and
citalopram were not initiated until 03/09/25.
Interview on 06/10/25 at 4:03 P.M. with the Director of Nursing (DON) revealed Licensed Practical Nurse
(LPN) #631 was the admitting nurse for Resident #78 and did not complete any of the admission
assessments required for new admissions, nor did they initiate any of the admitting physician orders from
the hospital.
Interview on 06/11/25 at 9:23 A.M. with the DON revealed they confirmed on admission, nursing staff were
to complete a medication reconciliation, implement all orders obtained from the hospital, and notify the
physician of resident arrival. The DON confirmed admission orders for Resident #78 were not initiated on
the day of admission of 03/08/25 and were completed between 03/09/25 and 03/10/25 by Registered Nurse
(RN) #712 causing medications, treatments and assessments to be missed for Resident #78. The DON
also confirmed LPN #631 was issued an Employee Corrective Action final written warning for
Performance/Policy Violation and Safety/Carelessness, due to: the staff member failing to comply with the
admission policy of initial assessment and order entry in a timely manner of first hour of admission,
interfering with medication delivery for treatment, initial assessment of wound and IV site not completed,
and no orders for care entered. No admit vital signs were obtained, or height and weight. admission was not
touched by shift change. This occurrence led to delay in medications and treatments being administered.
Review of the undated facility policy titled admission Evaluation, revealed it was the policy of the facility to
provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns
of the residents. A systematic evaluation is completed by a licensed nurse upon admission/readmission to
assist in determining the most effective and appropriate care needs of each resident admitted to the center.
Under the Procedure section staff are to complete the admission
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 2 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Initial UDA and appropriately triggered assessments electronically as soon as feasible but within 24 hours.
Second, staff were to prioritize resident needs with appropriate interventions to include but not limited to,
meeting immediate physical needs including assessment of pain, provide social and emotional support,
identify any culturally specific needs, consider elopement risk, consider pressure injury risk, provide
toileting needs, complete medication reconciliation, and consider last meal eaten and provide hydration.
Residents Affected - Few
2. Review of the medical record for Resident #55 revealed an admission date of 02/01/24 with diagnoses
including chronic embolism and thrombosis of right and left femoral veins (blood clots to the legs), varicose
veins of the left lower extremity with ulcer, peripheral vascular disease (PVD) (disorder that restricts the
blood flow to the arms, legs and other parts of the body) and diabetes mellitus.
Review of the physician's orders for June 2025 revealed Resident #55 had an order to cleanse the wound
to his right posterior lower leg with normal saline and apply collagen (wound treatment) particles, cover with
xeroform (non-adhering wound dressing), pad and wrap with kerlex (gauze wrap) daily and as needed
dated 06/05/25. There were no physician's orders for wound care to the left leg.
Review of treatment administration record (TAR) for June 2025 for Resident #55 revealed the nursing staff
had documented on 06/08/25 that his treatment to his right lower leg was completed. There were no orders
for wound treatments to the left leg.
Review of the nursing progress notes from 06/07/25 through 06/09/25 for Resident #55 revealed there was
no documentation related to his left lower leg having an open area, the physician being updated or a
treatment being ordered.
Observation on 06/09/25 at 1:43 P.M. of Resident #55 revealed he had wound treatments to bilateral lower
legs. The dressings were dated 06/07/25.
Observation and interview on 06/09/25 at 1:45 P.M. with Licensed Practical Nurse (LPN) #600 verified
Resident #55 had a venous ulcer to the back of his right lower leg. She stated his treatment should have
been completed daily and was not done on 06/08/25 as ordered. LPN #600 stated she did not know why he
had a dressing on the left lower leg. She verified the dressings to bilateral lower extremities were dated
06/07/25. Resident #55 stated nursing staff had not performed the treatment to his right lower leg on
06/08/25.
Interview and observation on 06/09/25 at 1:53 P.M. with Registered Nurse (RN) #609 revealed the dressing
to the right lower leg was adaptic (non-adhering wound dressing) with a dry dressing and rolled gauze to
secure the treatment in place. RN #609 stated Resident #55 previously had scabs to the front of his left leg
due to his PVD. Observation revealed an open area to the front of his left leg. RN #609 stated the scabs
must have come off and the nurse placed a dressing. She verified she was not updated on the resident's
open area to his left leg.
Interview on 06/09/25 at 1:59 P.M. with LPN #600 verified her initials were on the TAR on 06/07/25 and she
had placed the dressing on Resident #55's left lower leg. She stated she placed the same treatment that
was on the right lower extremity. LPN #600 stated she had not updated the physician, received an order for
the left lower extremity or documented in the resident's medical record.
Review of the facility policy titled, Skin Care and Wound Management Overview, undated, revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 3 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
the facility should review and select the appropriate treatment, obtain a physician's order and document
treatment in the treatment administration record.
This violation represents non-compliance investigated under Master Complaint Number OH00164793 and
Complaint Number OH00163639.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 4 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review and review of facility policy, the facility did not ensure wound
assessments accurately identified date of onset of a pressure ulcer and wound treatments were
implemented as ordered by the physician for Resident #77. This affected one resident (Resident #77) of
four residents reviewed for pressure ulcers. The facility census was 80.
Residents Affected - Few
Findings include:
Review of the closed medical record for Resident #77 revealed an admission date of 12/13/24 with
diagnoses including osteomyelitis (infection of the bone) of the left foot and ankle, peripheral vascular
disease (disorder that restricts the blood flow to the arms, legs and other parts of the body) and cellulitis
(skin infection where the skin is swollen, painful and warm to the touch).
Review of the hospital After Visit Summary, dated 12/13/24, revealed at the time of discharge from the
hospital, Resident #77 had no pressure ulcers, but did have treatments in place for surgical incisions to his
femoral left leg, left leg and left toe.
Review of the nursing admission evaluation dated 12/13/24 for Resident #77 revealed he had no pressure
ulcers. It was noted he had surgical incisions to the groin, left thigh, left lower leg and left toes.
Review of the nursing notes for Resident #77 dated from 12/13/24 through 12/16/24 revealed the nursing
staff had not documented any information to identify a pressure ulcer on right buttocks.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #77
revealed he had one Stage III pressure ulcer that was present upon admission.
Review of the care plan for Resident #77, dated initiated 12/27/24 revealed he was admitted to the facility
with a stage III pressure ulcer to his right buttock. Interventions included administer medications and
treatments as ordered by medical provider, apply barrier creams post incontinence episodes, complete
weekly skin checks and daily wound assessments.
Review of the Wound Assessment Report, dated 12/17/24 by Nurse Practitioner (NP) #714 revealed she
saw Resident #77 for the first time for a Stage III pressure ulcer (Full-thickness loss of skin, in which
subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are
often present) to the right buttocks. NP #714 stated it was 5.0 centimeters (cm) in length, 1.0 cm in width
and 0.10 cm in depth and was present on admission. She ordered the facility nursing staff to cleanse the
right buttock with normal saline, apply Triad Cream (wound care product designed to treat and protect skin
from damage due to pressure ulcers) and leave open to air twice daily and as needed.
Review of the Wound Assessment Report, dated 12/26/24 by NP #714 revealed she saw Resident #77
again for his right buttocks Stage III pressure ulcer. NP #714 stated the wound was now 4.0 cm in length,
2.0 cm in width and .2 cm in depth. NP #714 provided a new order for the nursing staff to cleanse the right
buttock with normal saline and apply Triad Cream and a bordered foam daily and as needed.
Review of the physician's orders and treatment administration record from December 2024, revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 5 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
NP #714's orders were not implemented for Resident #77's pressure ulcer of the right buttocks until
12/26/24.
Interview on 06/11/25 at 2:37 P.M. with Registered Nurse (RN) #609 revealed she rounded with NP #714
and saw Resident #77 on 12/17/24. She verified NP #714 provided an order for treatment to Resident #77's
right buttocks Stage III pressure ulcer. RN #609 stated NP #714 entered her own treatment orders in the
computer and must have missed putting Resident #77's order in for his right buttocks. RN #714 verified that
prior to NP #714 initially seeing Resident #77's right buttock pressure ulcer on 12/17/24 there had been no
skin assessment nor other documentation in the medical record to reflect Resident #77 had a pressure
ulcer upon admission yet it was documented as present upon admission in the MDS and wound
assessment report.
Interview on 06/12/25 at 11:28 A.M. with NP #714 verified she assessed Resident #77 on 12/17/25 and
provided an order for Triad Cream to his right buttocks. She stated she had forgot to enter his order for the
Stage III pressure ulcer into the computer until she returned again on 12/26/24. She stated his wound
mildly worsened, however, due to his medical condition worsening could be expected as unavoidable and it
was not due to the lack of treatment with the Triad Cream from 12/17/24 to 12/25/24. NP #714 stated she
was notified Resident #77 was admitted with the pressure ulcer and she assessed him four days later.
Review of the facility policy titled, Skin Care and Wound Management Overview, undated, revealed the
facility should review and select the appropriate treatment, obtain a physician's order and document
treatment in the treatment administration record.
This violation represents non-compliance investigated under Master Complaint Number OH00164793 and
Complaint Number OH00163639.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 6 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observation, interview, record review and review of facility policy, the facility failed to ensure
Resident #184's enteral feedings were administered as ordered. This affected one resident (Resident #184)
of two residents reviewed for enteral nutrition. The facility census was 80.
Findings include:
Review of the medical record for Resident #184 revealed an admission date of 05/23/25 with diagnoses
including cerebral infarction (stroke), hemiplegia affecting right side (paralysis), dysphagia (difficulty
swallowing) and cognitive communication deficit.
Review of the physician's orders for June 2025 for Resident #184 revealed she had an order for enteral
feedings every shift at 60 milliliters (mL) an hour for 20 hours via the pump dated 06/03/25.
Review of the Medication Administration Record (MAR) for June 2025 for Resident #184 revealed
Registered Nurse (RN) #625 signed off her enteral feed order on 06/09/25 prior to 10:47 A.M. as
administered as ordered.
Observation on 06/09/25 at 10:40 A.M. of Resident #184 revealed her enteral feeding was running at 50 mL
per hour.
Observation and interview on 06/09/25 at 10:52 A.M. with RN #625 verified Resident #184's enteral feeding
was running at 50 mL per hour and should be at 60 mL per hour.
Review of the facility policy titled, Enteral General Nutritional (tube feeding) Guidelines, undated, revealed
feeding the enteral feed through the electronic pump, nursing staff should verify the practitioner's order
including the volume and rate to be infused.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 7 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and review of facility policy, the facility failed to ensure dialysis residents were
monitored before and after dialysis treatments, and daily weights were obtained according to physician
order for Resident #4. This affected one resident (Resident #4) out of two residents reviewed for dialysis.
The facility census was 80.
Residents Affected - Few
Findings include:
Review of Resident #4's medical record revealed an admission date of 12/08/23. Diagnoses included end
stage renal disease, dependence on renal dialysis, chronic diastolic congestive heart failure,
hyperlipidemia, disorders of bone density, Gastro-Esophageal Reflux Disease (GERD), hypertensive heart
and Chronic Kidney Disease (CKD), type II diabetes mellitus, anxiety, and major depressive disorder.
Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the
resident had impaired cognition. They required setup or clean up assistance for eating, substantial to
maximal assistance for oral hygiene, upper body dressing, personal hygiene, and bed mobility. They were
dependent on staff for toileting hygiene, showers, and lower body dressing.
Review of Resident #4's care plan date 10/05/24 revealed the resident was on dialysis therapy related to
CKD three times a week. Interventions and goals indicated the resident would be free from signs and
symptoms of complications from hemo-dialysis. Staff were to administer medications per medical provider's
orders including monitoring weights daily and completing a pre and post dialysis assessment every dialysis
treatment day.
Review of Resident #4's physician orders dated June 2025 revealed there were orders for staff to obtain
daily weights related to congestive heart failure and dependency on renal dialysis. There was an order for
pre and post dialysis assessments to be completed every Tuesday, Thursday, and Saturday.
Review of Resident #4's pre dialysis assessments revealed there were no pre dialysis assessments
completed on 04/01/25, 04/03/25, 04/10/25, 04/15/25, 04/17/25, 04/22/25, 04/29/25, 05/01/25, 05/06/25,
05/13/25, 05/15/25, 05/20/25, and on 06/07/25.
Review of Resident #4's post dialysis assessments revealed there were no post dialysis assessments
completed on 04/15/28, 04/22/25, 04/29/25, 05/10/25, 05/15/25, 05/17/25, 05/29/25, and on 06/07/25.
Review of Resident #4's daily weights from 04/01/25 through 06/05/25 revealed daily weights were not
completed on 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/09/25, 04/10/25, 04/14/25, 04/15/25,
04/16/25, 04/20/25, 04/21/25, 04/23/25, 04/24/25, 04/25/25, 04/27/25, 04/28/25, 04/30/25, 05/01/25,
05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/10/25, 05/11/25, 05/12/25, 05/13/25,
05/14/25, 05/15/25, 05/16/25, 05/17/25, 05/18/25, 05/19/25, 05/21/25, 05/22/25, 05/26/25, 05/28/25,
05/29/25, 05/30/25, 06/01/25, 06/02/25, 06/03/25, 06/04/25, and on 06/05/25.
Interview on 06/09/25 at 1:52 P.M. with Registered Nurse (RN) #610 revealed the Certified Nursing
Assistants (CNA) obtain the resident's weight and notify the nurse of results so they can be documented.
RN #610 stated there was no other place they would document the weights except for in the Electronic
Medical Record (EMR) under the weight/vitals tab.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 8 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 06/11/25 at 3:51 P.M. with Dietician #715 revealed they confirmed Resident #4 was on daily
weights related to their diagnosis of congestive heart failure and the need for hemo-dialysis. Dietician #715
confirmed the daily weights are not being done per physician orders.
Interview on 06/12/25 at 11:57 A.M. with the Regional Director of Clinical Operations (RDCO) revealed they
confirmed there were multiple missing pre and post dialysis assessments for Resident #4 as well as
multiple missing daily weights from 04/01/25 to 06/12/25 with no explanation given as to why. The RDCO
stated staff are to complete a pre and post dialysis assessment on each dialysis day and the daily weights
should be completed and documented daily per physician orders.
Review of the undated facility policy titled Hemodialysis Care and Monitoring, revealed the facility uses this
policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and
concerns of the residents. The facility is responsible to provide resident centered care to meet the resident's
need for dialysis, provide a method for coordination and collaboration between the nursing home and the
dialysis facility, provide outside dialysis services with an agreement between the facility and a Medicare
Certified Dialysis facility, Provide a method for on-going communication and collaboration for the
development and implementation of dialysis care plan. The facility will provide pre and post dialysis
assessments and weights per physician orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 9 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on record review and interview, the facility failed to ensure medications were obtained timely from
the pharmacy to meet resident needs. This affected two residents (Resident #64 and #78) of eight residents
reviewed for medication administration. The facility census was 80.
Findings include:
1. Review of Resident #64's medical record revealed an admission date of 05/03/25 with diagnoses
including local infection of the skin and subcutaneous tissue, cellulitis of Left Lower Extremity (LLE),
displaced bicondylar fracture of left tibia, type II diabetes mellitus, hypertension, major depressive disorder,
and acute embolism and thrombosis of deep vein of left lower extremity.
Review of Resident #64's admission Minimum Data Set (MDS) 3.0 assessment revealed the resident had
intact cognition, was independent with eating, required setup or clean up assistance with oral hygiene,
partial to moderate assistance with upper dressing,, personal hygiene, and bed mobility. Resident #64
required substantial to maximal assistance with toileting hygiene and showers and was dependent on staff
for lower body dressing.
Review of the Medication Administration Record (MAR) for May 2025 for Resident #64 revealed nursing
staff documented not administered/not available from the pharmacy on 05/03/25 for the following
medications: Amlodipine 10 Milligrams (mg), Atorvastatin 40 mg for lipids daily, Colace 100 mg for
constipation, Duloxetine 90 mg daily for depression, Hydrochlorothiazide (HCTZ) 12.5 mg for hypertension
daily, Lisinopril 40 mg daily for hypertension, Oxybrutrin 5 mg daily for urinary health, protonix 40 mg daily
for GERD, Pioglitazone 30 mg daily for diabetes, Synthroid 88 micrograms (mcg) daily for hypothyroidism,
Vitamin D 50 mcg for supplement, metformin 500 twice a day for diabetes, and Ceftriaxone 2 gm IV daily
for soft tissue infection.
Interview on 06/11/25 at 10:01 A.M. with Resident #64 revealed her medications were not available to be
administered to her on the date of admission to the facility. She stated she had to wait a day to a day and a
half before all her medications were available to be administered. Resident #64 stated because she did not
receive her medications, she just felt like laying in bed, not going to therapy and not taking a shower
because she felt nauseated and had some pain.
2. Review of the closed medical record for Resident #78 revealed an admission date of 03/08/25 at 6:07
P.M. and discharged from the facility per resident request on 03/10/25 at 12:45 P.M Diagnoses included
local infection of the skin, subcutaneous tissues, non-pressure ulcer of the right and left lower legs with fat
layer exposed, peripheral vascular disease, type II diabetes, hypertension, Chronic Obstructive Pulmonary
Disorder (COPD), and major depressive disorder.
Review of Resident #78's MAR dated March 2025 revealed on 03/09/25 the resident did not receive their
Citalopram 20 mg daily for depression, pregabalin 300 mg twice a day for convulsions, and Daptomycin 500
mg IV daily for infection due to not being available from the pharmacy.
Interview on 06/11/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #513 revealed LPN #513 did not
always have the resident medications to give the residents because the medications were not being made
available from the pharmacy and were not in the Nexus system (automated pill dispenser). LPN #513
stated they must make multiple phone calls to the pharmacy to inquire about where the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 10 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
medications are. LPN #513 stated with new admissions it is not uncommon if their medications are not
available to give for approximately a day to a day and a half due to not arriving from the pharmacy in a
timely manner. LPN #513 verified medications not administered as ordered for Resident #64 due to not
being available to give to Resident #64.
Interview on 06/11/25 at 9:23 A.M. with the DON verified Resident #78 had missed physician ordered
medications due to the medications not being available to give to Resident #78.
Interview on 06/11/25 at 1:02 P.M. with LPN #510 revealed there are times when medications do not arrive
from the pharmacy timely. LPN #510 stated it can take up to a day and a half to get certain meds, including
IV antibiotics and any medications not available in the Nexus system.
Review of the facility policy titled, Pharmacy Services, revised 09/01/21, stated the pharmacy would supply
medications that were needed and deliver the medications to the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00163639.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 11 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure Enhanced Barrier
Precautions (EBP) were followed when administering Intravenous (IV) medications for Resident #64. This
affected one resident (Resident #64) out of three residents reviewed for Enhanced Barrier Precautions. The
facility census was 80.
Residents Affected - Few
Findings include:
Review of Resident #64's medical record revealed an admission date of 05/03/25 with diagnosis including
local infection of the skin and subcutaneous tissue, cellulitis of Left Lower Extremity (LLE), displaced
bicondylar fracture of left tibia, type II diabetes mellitus, hypertension, major depressive disorder, and acute
embolism and thrombosis of deep vein of left lower extremity.
Review of Resident #64's admission Minimum Data Set (MDS) 3.0 assessment revealed the resident had
intact cognition, was independent with eating, required setup or clean up assistance with oral hygiene,
partial to moderate assistance with upper dressing, personal hygiene, and bed mobility. Resident #64
required substantial to maximal assistance with toileting hygiene and showers and was dependent on staff
for lower body dressing.
Review of Resident #64's care plan dated 05/21/25 revealed a care plan initiated related to Resident #64
had an infection, cellulitis of the LLE and was on IV antibiotics. Goals and interventions included the
resident would be free from signs and symptoms of complications related to the infection. Staff were to
administer antibiotics per medical providers orders, observe for side effects and effectiveness and report
abnormal findings to medical provider. Additionally, there was a care plan for Enhanced Barrier Precautions
(EBP) due to providing care to the resident with a history or colonized multi-drug-resistant organism. The
care plan also consisted of Resident #64 was currently on IV therapy for antibiotics. The resident would be
free of signs and symptoms of infection at IV insertion site, staff to administer IV medications and flushes
per medical providers orders and report any abnormal findings.
Review of Resident #64's physician orders dated June 2025 revealed the resident was in EBP related to
Peripherally Inserted Central Catheter (PICC) when administering medication, dressing or bathing,
showering, transferring in room or therapy gym, personal hygiene, changing linen, providing hygiene,
changing briefs or assisting with toileting. Staff to administer Ceftriaxone Sodium 2 grams (gm) IV every 24
hours for soft tissue infection until 06/12/25 at 11:59 P.M.
Observation on 06/11/25 at 9:54 A.M. of IV antibiotic administration for Resident #64 by Licensed Practical
Nurse (LPN) #513 revealed LPN #513 did not wear proper Personal Protective Equipment (PPE) including
a gown and gloves.
Interview on 06/11/25 at 10:03 A.M. with LPN #513 revealed they verified Resident #64 was in EBP and
stated they should have worn proper PPE including a gown and gloves to administer Resident #64's IV
antibiotics.
Review of the undated facility policy titled Enhanced Barrier Precautions revealed Enhanced Barrier
Precautions is an infection control intervention designed to reduce transmission of multi-drug-resistant
organisms. Personal Protective Equipment required is a gown and gloves. EBP are indicated for residents
with any of the following including indwelling medical devices for example central lines
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 12 of 13
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
365732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Austintown Healthcare Center
650 S Meridian 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)
F 0880
such as PICC lines.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled Intermittent Infusion, last revised 12/2014 revealed under General
Guidance number three Administration sets used for intermittent therapy will be changed every 24 hours.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365732
If continuation sheet
Page 13 of 13
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the June 12, 2025 survey of AUSTINTOWN HEALTHCARE CENTER?
This was a inspection survey of AUSTINTOWN HEALTHCARE CENTER on June 12, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AUSTINTOWN HEALTHCARE CENTER on June 12, 2025?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.