Health inspection·May 21, 2025

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 record review, observation, interview and policy review, the facility failed to ensure the treatment was completed as ordered for Resident #47's right lateral nose skin cancer. This finding affected one (Resident #47) of four residents reviewed for general skin conditions. The facility census was 72. Residents Affected - Few Findings include: Review of the medical record revealed Resident #47 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including malignant melanoma of the nose, cognitive communication deficit and weakness. Review of Resident #47's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #47's Wound Assessment Report form authored by Wound Nurse Practitioner (NP) #584 dated 04/25/25 revealed the resident had a right nostril melanoma wound identified on 04/02/25 which measured 2.0 centimeters (cm) length by 2.30 cm width by 0.10 cm depth. The treatment included cleansing the wound daily with normal saline and leave open to air (OTA). Review of Resident #47's Wound Assessment Report form authored by Wound NP #584 dated 05/05/25 revealed the resident had a right nostril melanoma wound which measured 2.0 cm length by 2.30 cm width by 0.10 cm depth. The treatment indicated cleansing the wound with normal saline daily and OTA. Review of Resident #47's Wound Assessment Report form authored by Wound NP #584 dated 05/19/25 revealed the resident had a right nostril melanoma which measured 2.0 cm length by 2.30 cm width by 0.10 cm depth. The treatment indicated cleansing the wound with normal saline daily and leave OTA. Review of Resident #47's medication administration records (MARS) and treatment administration records (TARS) from 04/25/25 to 05/20/25 did not reveal evidence the resident's right nostril was cleansed daily with normal saline as ordered by Wound NP #584. Interview on 05/20/25 at 7:46 A.M. with Registered Nurse (RN) Wound Nurse #562 confirmed Resident #47's medical record did not have evidence the resident's right nostril was cleansed daily with normal saline and left OTA. Review of the undated Skin Care and Wound Management Overview policy revealed the facility staff strived to prevent resident skin impairment and to promote the healing of existing wounds. 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: 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 05/21/2025 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)