Health inspection·November 3, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review, the facility failed to ensure Resident #55 was free from staff-to-resident physical abuse. This affected one resident (#55) of three residents reviewed for abuse. The facility census was 54. Findings include: Review of the medical record for Resident #55 revealed an admission date of 01/26/24 and a discharge date of 10/11/24. Diagnoses included sepsis, muscle weakness, epilepsy, bipolar disorder, anxiety, and paraplegia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed resident #55 was cognitively intact. He was completely dependent on staff for eating, oral care, personal hygiene, showering, toileting, and dressing. Review of the care plan dated 08/06/24 revealed Resident #55 had inappropriate behaviors such as agitation and combativeness, aggression with staff, cursing at staff, and refusing to lie down. Interventions included approaching the resident in a slow, calm manner, bringing the resident to a quiet environment as needed, and observing for possible environmental causes of behaviors. Review of SRI tracking number 252677 dated 10/06/24 at 10:41 A.M. revealed Resident #55 reported a facility nurse slapped him. The perpetrator was identified as Registered Nurse (RN) #205 who was suspended pending an investigation. Review of the facility investigation for SRI tracking number 252677 revealed Resident #55 reported RN #205 was providing care when he became verbally aggressive with RN #205. He alleged RN #205 slapped his mouth. Resident #55 reported RN# 205 left his room after the occurrence. Interview with RN #205 confirmed Resident #55's report, stating she utilized the back of her hand to slap Resident #55's mouth, then exited the room. An interview with Certified Nurse Aide (CNA) #206 revealed she was present in the room and confirmed both Resident #55 and RN #205's reports of what occurred. Like residents were interviewed as well as all staff working at the time of the incident, and no further issues were noted. Resident #55 was assessed, and no injuries were noted, vital signs were obtained and reported blood pressure was 110/75, pulse 88, respirations 16, temperature 97.5 degrees Fahrenheit (F) and oxygen saturation was 98%. (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: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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)