Health inspection·June 26, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation review, self-reported incident review, facility policy review, and interviews, the facility failed to timely report an allegation of sexual abuse. This affected three (Resident #7, #10, and 14) of four residents reviewed for abuse. The facility census was 77. Findings include: Medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following cerebral infarction, schizophrenia, history of substance abuse, muscle weakness, dysphagia, and chronic obstructive pulmonary disease. Further review of the medical record revealed the resident was severely cognitively impaired. Medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, bipolar disorder, panic disorder, and history of cocaine abuse, and chronic obstructive pulmonary disease. Further review of the medical record revealed the resident was moderately cognitively impaired. Medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including chronic heart failure, acute pancreatitis, depression, anxiety disorder, personal history of trauma, other stimulant abuse, and muscle weakness. Further review of the medical record revealed the resident was cognitively intact. Review of Self-Reported Incident (SRI) #248991, dated 06/24/24, revealed on 06/23/24 Licensed Practical Nurse (LPN) #58 reported to the Director of Nursing (DON) that she had been told by a resident, who heard from another resident, that there was fornication on the smokers' patio with a couple of residents. The residents alleged to be involved were Resident (#7, #10, and #14). The allegation was immediately reported to the Administrator and an investigation was immediately initiated. Following the allegation, the smoking patio was supervised by staff during smoking breaks for all residents. The three residents in question were interviewed with no concerns, and there were no witnesses who confirmed that fornication had occurred on the patio. Interview on 06/27/24 at 1:00 P.M. with the Administrator confirmed the sexual abuse allegation indicated in SRI #248991 was not reported to the State Agency within two hours as required. Review of the facility's policy titled, Ohio Abuse, Neglect, and Misappropriation, dated 10/27/21, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property, are reported immediately, but no later (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 5 Event ID: 365862 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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)