Inspection visit
Health inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interview, family interview, staff interview and policy review, the facility failed to ensure Resident
#49 was always treated with respect and dignity. This affected one resident (Resident #49) of 32 residents
reviewed in the initial sample.
Findings include:
Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with the
diagnoses of Parkinson's disease, dysphagia, pneumonia, dementia, delusional disorder, low back pain,
major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, atherosclerotic heart
disease, congestive heart failure, atrial fibrillation, hypertension, and psychotic disorder with delusions.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had
moderately impaired cognition and required supervision after being set-up for eating.
Interview on 03/02/20 at 4:29 P.M. with Resident #49 and Family Member #500 revealed, the staff was not
very nice at times. Resident #49 indicated a couple weeks ago she had an incident with a State Tested
Nursing Assistant (STNA) who brought her breakfast tray in and set it down on her over the bed table. The
resident stated she had attempted to pull the table over to her but she could not move it so she asked the
STNA who was walking out of her room if she could move it closer for her, and the STNA told her, you have
two hands you can do it yourself, and left the room. Resident #49 stated she had reported it and was told in
a care conference meeting, you are not going to let that ruin your day are you. Family Member #500 verified
what was said in the care conference meeting because she attended the meeting on 02/18/20. The resident
did not think the incident was abuse, and the resident felt safe in the facility.
Review of the care conference notes dated 02/18/20 revealed Resident #49 and her daughter attended.
Interview on 03/05/20 at 1:38 P.M. the Administrator indicated she had gone and spoken to Resident #49,
and the resident indicated a couple weeks ago she had an incident with a STNA who brought her breakfast
tray in and set it down on her over the bed table. The resident stated she had attempted to pull the table
over to her but she could not move it so she asked the STNA who was walking out of her room if she could
move it closer for her, and the STNA told her, you have two hands you can do it yourself, and left the room.
Resident #49 stated she had reported in and was told in a care conference meeting, you are not going to
let that ruin your day are you. The Administrator indicated they
(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 19
Event ID:
366078
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
had started an investigation and submitted a Self-Reported Incident for verbal abuse. The Administrator
indicated she had narrowed it down to the aides that normally work on that unit and was able to find out
who was working that day. She indicated STNA #412 stated she was at the door when Resident #49 had
asked her to move the table closer to her, but the resident had her hands on the table moving it closer to
herself, so she just left the room. STNA #412 indicated to the Administrator she never said anything to the
resident. However, STNA #412 was suspended pending the investigation outcome. She indicated she was
still investigation the care conference concern. The Administrator indicated she spoke with Family Member
#500 and she confirmed what was said in the care conference meeting, but no staff members could
remember what had been said at the meeting.
Interview on 03/05/20 at 2:11 P.M. the Administrator indicated Resident #49 had told the nurse working the
floor the day of the incident. Licensed Practical Nurse (LPN) #406 verified Resident #49 indicated to her
she had asked STNA #412 to move the tray table closer to her, and STNA #412 told her she had two
hands, she could do it herself. The Administrator stated LPN #406 had taken STNA #412 aside and asked
her what had happened, and STNA #412 stated to her Resident #49 had both her hands on the tray table
when she asked her to move the table, so she thought she could get it herself and left the room. The nurse
told STNA #412 if a resident asked you to do something you just do it. The Administrator verified LPN #406
was aware of the incident and should have reported the incident, but she had not reported the incident to
any one to be investigated because she did not think there was an issue. The Administrator indicated when
she spoke to the resident and her daughter, they both did not think the incident was abuse, and the resident
felt safe in the facility.
Review of the facility policy, Abuse Prohibitions, Investigation, and Reporting, dated 07/19, revealed it was
the facility policy to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation
of guest/resident property or resources. The facility would not allow verbal, mental, sexual, or physical
abuse, corporal punishment, involuntary seclusion, or exploitation and all facility personnel would promptly
report any incident or suspected incident of guest mistreatment, injuries of unknown source or
misappropriation of property/resources. Reports of alleged abuse and/or misappropriation would be
immediately reported to the Administrator and thoroughly investigated. Allegations of
abuse/misappropriation and the investigative conclusion would be reported to the appropriate State
regulatory agency, Law Enforcement agency, licensing, and/or certification board as required by State and
Federal law.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 2 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review and policy review, the facility failed to ensure Resident #43's concerns regarding
missing property were resolved timely. This affected one (Resident #43) of one residents reviewed for
missing property.
Residents Affected - Few
Findings include:
Resident #43 was admitted on [DATE] with diagnoses including polyneuropathy, need for assistance with
personal care, anxiety disorder, and major depressive disorder. Resident #43's quarterly Minimum Data Set
(MDS) 3.0 assessment dated [DATE] revealed her cognition was intact.
Interview on 03/03/20 at 2:31 P.M. with Resident #43 revealed she was missing cell phone accessories and
a gift care around Christmas time. Resident #43 revealed the concern was reported, and she had not hear
anything back.
Review of the facility grievance log for the last six months revealed no evidence Resident #43 had a
concern regarding missing items.
Review of Resident #43's Guest Satisfaction Concern/ Suggestion form dated 02/06/20, revealed the
resident was missing one USB cable, a screen protector, and a 25 dollar gift card. The concern was
reviewed by the Administrator and referred to Registered Nurse (RN) #413. The investigation and findings
portion of the the form was blank.
Review of the form that was rewritten on 03/03/19 revealed under investigations and findings revealed on
02/07/20 RN #413 spoke to Resident #43 and her family, and the resident had asked her daughter-in-law to
take boxes home and the inside of the box was the screen protector and USB cable. Under the resolution
portion of the form, RN #413 indicated the family stated the boxes were empty, and Resident #43 was
upset the boxes were thrown out. Resident #43's family indicated they had not gone to the store to use the
gift cart yet, and the family was afraid the resident may have thrown the gift card away on accident, as the
resident had a room full of stuff. The form indicated a replacement was offered and declined. The resolution
portion of the form was not signed by the Administrator.
Interview on 03/04/20 at 7:46 A.M. with Administrator revealed there was a concern form for Resident #43,
but they could not locate the original copy of the concern form, so RN #413 rewrote the concern form to
indicate what happened with the concern Resident #43 had.
Interview on 03/04/20 with RN #413 revealed on 02/06/20 it was reported to one of the nurses that
Resident #43 was missing the phone items and a gift card. RN #413 confirmed the above details in the
concern form and revealed the resident was mad her daughter took the box out of her room, but the family
indicated there was nothing in the box. RN #413 revealed the family indicated Resident #43 could have
misplaced the items, and they continued to look in other resident rooms and medication rooms for the gift
card in case anyone secured the gift card. RN #413 revealed Resident #43's family indicated the resident
may have thrown the gift card away, as she has many items throughout her room. Although the concern
form did not indicate any discussion with Resident #43, RN #413 indicated on 02/07/20 she spoke with
Resident #43 and her family to notify her they could not find the items, and both parties declined
replacement of the items.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 3 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 03/04/20 at 8:06 A.M. with Administrator revealed when a resident had a concern she
delegated who should address the concern, and the Administrator signed off on the resolution. The
Administrator confirmed there was no evidence she signed off on Resident #43's concern as they lost the
original concern form.
Review of the facility policy and procedure titled, Guest Satisfaction Concern/Suggestion Form revealed the
facility will thoroughly investigate all concerns and apply correctively measures to resolve issue in a timely
manner. The procedure includes the guest, family, or staff member is to complete the guest satisfaction
concern/suggestion form. The Administrator will review the nature of the concern, and sign and date that
he/she has reviewed it. The Administrator will then either complete the investigation or refer to concern to
the appropriate employee for follow-up during the next business day. The Social Service Director will
receive the yellow copy of the form to record the concern on the guest satisfaction concern/suggestion
tracking log. The appointed employee will investigate and review his/her findings with the Administrator.
Follow-up with the family member and/or guest will be done in writing by the employee within seven days,
pending approval of the action plan by the Administrator. Upon resolution or the concern, to the satisfaction
of the guest and/or family member who initiated the process, the Administrator will sign the form to signify
completion/resolution. It will then go to Social Services to complete the necessary information for the guest
satisfaction/concern tracking log, designed as part of the quality assurance program. A copy of the
completed form with resolution will be given to the guest or responsible party.
Event ID:
Facility ID:
366078
If continuation sheet
Page 4 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident
#104 was admitted on [DATE] and discharged on 12/31/19.
Residents Affected - Few
Review of Resident #104's Social Services Note dated 12/31/19 revealed the resident was discharged
home.
Review of Resident #104's Discharge Return Not Anticipated MDS 3.0 assessment dated [DATE] revealed
the assessment identified he was discharged to an acute hospital.
Interview on 03/03/20 at 4:37 P.M. with the Director of Nursing revealed Resident #104 was not hospitalized
and was discharged home and confirmed the MDS was coded inaccurately.
Based on record review and interview, the facility failed to ensure comprehensive assessments were
accurate for Resident #13's wounds and Resident #104's discharge location. This affected two residents
(Resident #13 and Resident #104) of 25 residents reviewed for comprehensive assessments. Facility
census was 111.
Findings include:
1. Review of Resident #13's medical record revealed an admission date of 09/20/19 and diagnoses
including Parkinson's disease, peripheral vascular disease, hypertension, osteomyelitis and right heel
unstageable pressure ulcer (obscured full-thickness and tissue loss in which the extent of tissue damage
within the ulcer cannot be confirmed because it is obscured by slough or eschar).
Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #13
had three stage two pressure ulcers (partial-thickness skin loss), two unstageable pressure ulcers and two
deep tissue injuries (DTI), a pressure-related injury to subcutaneous tissues under intact skin.
Review of a quarterly MDS 3.0 assessment dated [DATE] indicated Resident #13 had one stage two
pressure ulcer and five unstageable pressure ulcers.
Review of a discharge/return anticipated MDS 3.0 assessment dated [DATE] indicated Resident #13 had
two unstageable pressure ulcers.
Review of a significant change MDS 3.0 assessment dated [DATE] indicated Resident #13 had two
unstageable pressure ulcers.
Review of a quarterly MDS 3.0 assessment dated [DATE] indicated Resident #13 had one unstageable
pressure ulcer and one vascular ulcer.
Review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had one unstageable
pressure ulcer and two vascular ulcers (chronic or long term breaches in the skin caused by problems with
the vascular system).
Review of facility skin and wound evaluations dated 11/25/19, 12/02/19, 12/09/19, 12/16/19, 12/30/19,
01/06/20, 01/14/20, 01/20/20, 01/28/20, 02/03/20, 02/11/20, 02/17/20, 02/24/20 and 03/02/20
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 5 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0641
revealed Resident #13 had an unstageable pressure area to right heel.
Level of Harm - Minimal harm
or potential for actual harm
Review of an outside wound consultant note dated 02/20/20 revealed Resident #13 had unstageable
pressure ulcers to right heel and right calf and a surgical incision at his left above knee amputation site. The
right heel measured five centimeters by three centimeters with no depth and was 100 percent (%) eschar
(dead or necrotic tissue). The right calf measured 10 centimeters by four centimeters with no depth and was
40 % slough (dead tissue coming to the surface) and 60 % eschar.
Residents Affected - Few
Review of a care plan for impairment to skin integrity, revised 02/24/20, revealed Resident #13 had
unstageable vascular areas to right heel and right calf and a below-knee amputation incision. Vascular
areas were noted to right lower extremity. Listed interventions included the wound nurse practitioner
following in-house.
Interviews on 03/03/20 at 11:16 A.M. and 12:56 P.M. with Registered Nurse (RN) #401, who served as the
facility's wound nurse, revealed Resident #13's wounds were not pressure areas but were vascular. RN
#401 explained the areas started out as pressure areas but then became vascular. RN #401 looked through
Resident #13's nurses notes with the surveyor and could not determine when the wound changed
classification from pressure to vascular in nature. RN #401 also shared the facility utilized a cellular phone
to measure wounds; when an wound was put into the phone, any subsequent entries would be
pre-populated with the wound type, which in this case was pressure.
A follow-up interview on 03/03/20 at 3:20 P.M. with RN #401 provided the surveyor with a nurse practitioner
note dated 11/24/19 which revealed Resident #13 had severe and significant peripheral vascular disease
(PVD).
An interview on 03/03/20 at 4:21 P.M. with RN #401 and RN #400, who also completed MDS assessments,
revealed she used nursing notes and facility skin and wound assessments to complete MDS assessments.
RN #400 stated if RN #401's notes classified a wound as a pressure area, she coded that area as
pressure. RN #401 confirmed Resident #13's wounds were vascular after 11/24/19 and were not pressure
areas which made Resident #13's MDS assessments on 12/10/19 and 02/19/20 incorrect.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 6 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure Resident #33 and Resident #68 was
offered activities to meet their activity needs and interests. This affected two (Resident #33 and Resident
#68) of four residents reviewed for activities.
Residents Affected - Few
Findings include:
1. Resident #33 was admitted on [DATE] with diagnoses Alzheimer's disease and muscle weakness.
Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition
was severely impaired.
Observation on 03/02/20 at 9:06 A.M., 03/02/20 at 2:31 P.M., 03/03/20 at 10:19 A.M., and on 03/03/10 at
2:51 P.M. revealed the resident was sitting in the common area far from being able to view the television.
Resident #33 was not engaged in television or socializing with staff or residents. Resident #33's back was
towards any staff walking by, and residents in her area were not conversing.
Review of Resident #33's quarterly Activity Re-evaluation, dated 01/06/20, revealed the resident initiated
independent activities daily, including prayer, television and with encouragement may attend group activities
including religion, entertainment and bingo.
Resident #33's active comprehensive care plan revealed she had the potential for decreased leisure
lifestyle with rehabilitation stay due to focus on therapy and goal of returning home. Resident #33 preferred
independence in pursuit of leisure. Staff were to encourage self-initiated activities of interest including
prayer, music, and television. Resident #33 would be encouraged to socialize and would be invited and
escorted to activities including religion, entertainment, and bingo.
Review of Resident #33's Documentation Survey Report for January 2020 activities, revealed the resident
participated in 14 self prayer activities, one community event, one music/radio activity, and two room visits.
There was no evidence the resident was offered additional music, entertainment, or bingo activities.
Review of Resident #33's Documentation Survey Report for February 2020 activities, revealed the resident
had eight self prayer activities, one social activity on 02/07/20, one room visit on 02/20/20, and 02/27/20
(two within seven days). There was no evidence the resident was offered bingo or other entertainment
activities.
Interview on 03/04/20 at 9:33 A.M. with Activities Director (AD) #414 revealed Resident #33 sits in the
social area to socialize with peers, and her family comes in often. AD #414 revealed the resident comes to
entertainment, enjoys variety of music, and she is seen two times a month on a one on one , and there are
volunteers that may see her weekly on Thursdays. AD #414 confirmed there was no evidence of volunteer
visits weekly on Thursdays. AD #414 revealed Resident #33's care plan for leisure activities needed
updated as she does not play bingo. AD #414 revealed she was unsure how it was determined that the
residents is initiating self prayer as staff are not involved with the residents self prayer activity. AD #414
confirmed the lack of evidence of Resident #33 had additional music activities in January 2020.
2. Resident #68 was admitted on [DATE] with diagnoses including sequelae following unspecified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 7 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
cerebrovascular disease, hemiplegia and hemiparesis affecting right dominant side, difficulty walking,
schizophrenia, anxiety disorder, dementia with behavioral disturbance, right elbow, wrist, and hand
contracture. Resident #68's quarterly MDS 3.0 assessment dated [DATE] revealed the resident's cognition
was intact.
Resident #68's quarterly Activities Re-evaluation dated 02/24/20 revealed the resident self initiates
independent activities and may attend group activities, such as bingo.
Resident #68's active comprehensive care plan for leisure activity revealed she preferred independent
activities but may show interest in bingo
Review of the facility January 2020 and February 2020 Activities Schedule revealed bingo was offered two
to three times a week.
Review of Resident #68's Documentation Survey Report for activities, for January 2020 and February 2020
revealed no evidence the resident was offered bingo as an activity.
Interview on 03/04/20 at 9:24 A.M. with AD #414 confirmed there was no evidence Resident #68 was
offered bingo as an activity.
Interview on 03/05/20 at 7:07 A.M. with Resident #68 revealed she would need help to play bingo, but if she
had the help she would like to play.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 8 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
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, medical record review, staff interview and policy review, the facility failed to ensure pressure
injuries were accurately assessed, measured and documented for Residents #13, #33, #92, and #94. This
affected four residents (Residents #13, #33, #92, and #94) of five residents reviewed for pressure injuries.
Residents Affected - Some
Findings include:
1. Review of the medical record revealed Resident #92 was admitted to the facility 10/02/15 with the
diagnoses of end stage renal disease, acquired absence of right leg above the knee, diabetes, restless leg
syndrome, hypertension, abnormal weight loss, injury, major depression, gout, constipation,
hypothyroidism, ischemic cardiomyopathy, atherosclerotic heart disease, vascular dementia, dysphagia,
hyperlipidemia, sleep apnea, anemia, gastro-esophageal reflux disease, peripheral vascular disease, and
hear failure. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE]
revealed Resident #92 had moderately impaired cognition and had one unstageable pressure ulcer
(obscured full-thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be
confirmed because it is obscured by slough or eschar).
Review of the Skin assessment dated [DATE] revealed Resident #92 had an unstageable sacral pressure
ulcer measuring 1.6 centimeters (cm) in length by 1.7 cm in width.
Observation of the dressing change on 03/03/20 at 1:40 P.M. Registered Nurse (RN) #401 performed a
dressing change to the sacrum of Resident #92. RN #401 measured the sacrum wound of Resident #92,
which measured 3.5 centimeters (cm) in length by 2.0 cm in width.
Interview on 03/03/20 at 1:40 P.M. RN #401 indicated she had taken the measurements on 03/02/20 with
her telephone. She indicated it was the facility policy to measure all wound with the program on her
telephone. She verified the measures were different from the telephone and manually measuring the
wound. The wound was twice the size manually than with the telephone, and she did not understand why it
was measuring differently.
Review of the facility policy Skin Management, dated 10/19, revealed the facility policy the facility should
identify implement interventions to prevent development of clinically unavoidable pressure injuries.
Photographs may be taken of the pressure injury and vascular wounds.
2. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with the
diagnoses of orthopedic aftercare, pressure ulcer sacral region stage IV (full-thickness skin loss with
extensive destruction, tissue necrosis, or damage to muscle, bone or tendons), major depressive disorder,
spinal stenosis, constipation, and long-term use of anticoagulants. Review of the quarterly MDS 3.0
assessment dated [DATE] revealed Resident #94 had moderately impaired cognition, two unstageable
pressure ulcers present upon admission and two deep tissue injuries (pressure-related injury to
subcutaneous tissues under intact skin) present upon admission.
Review of the skin assessment dated [DATE] revealed the sacral wound for Resident #94 measured 4.5 cm
in length by 5.1 cm in width by 4 cm deep, the left heel measured 1.6 cm in length by 4.0 in width, the left
foot, first digit measured 0.3 cm in length by 0.6 cm in width, and the right heel measured 0.9 cm in length
by 2.0 cm in length.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 9 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation of a dressing change and measurements on 03/03/20 at 2:00 P.M. RN #401 manually
measured the pressure wounds of Resident #94, which revealed:
The sacral wound measured 6.0 cm in length by 4.0 cm in width by 4.0 cm deep, the left heel measured 2.0
cm in length by 5.2 cm in width, the left foot, first digit measured 2.0 cm in length by 0.2 cm in width, the
right heel measured 3.0 cm in length by 2.0 cm in width.
Interview on 03/03/20 at 2:30 P.M. RN #401 verified the measurement from 03/02/20 and during the
dressing change were not the same and were measuring worse than previously documented.
Review of the facility policy Skin Management, dated 10/19, revealed the facility policy the facility should
identify implement interventions to prevent development of clinically unavoidable pressure injuries.
Photographs may be taken of the pressure injury and vascular wounds.
3. Resident #33 was admitted on [DATE] with diagnoses including Alzheimer's disease and muscle
weakness. Resident #33's quarterly MDS 3.0 assessment dated [DATE] revealed her cognition was
severely impaired, she required two person extensive assistance with bed mobility, transfers, and one
person extensive assistance with dressing.
Resident #33's Skin and Wound Evaluation dated 07/19/20 revealed she had an unstageable pressure
ulcer to her right heel, measuring 1.1 cm long by 0.8 cm long.
Resident #33's physician orders dated 08/23/20 through 09/12/20 revealed orders to cleanse the right heel
with normal saline, apply nickel thick Santyl ointment (debridement ointment), cover with dry dressing, and
change daily and as needed.
Review of Resident #33's August Treatment Administration Record (TAR) and medical record revealed no
evidence the treatment was completed 08/24/19 through 08/28/29, 08/30/19, and 08/31/19.
Review of Resident #33's September TAR and medical record revealed no evidence the treatment was
completed 09/01/19 through 09/05/19, 09/07/19, 09/08/19, 09/10/19, and 09/11/19.
Review of Resident #33's physician orders revealed from 09/21/19 through 12/05/19 it was ordered to
cleanse the resident's right heel with normal saline, apply Theraworks, Santyl nickel thick, cover with foam
dressing until exhausted then use super absorbent dressing, and changed daily and as needed.
Review of Resident #33's October 2019 TAR revealed no evidence the treatment was completed 10/02/19,
10/09/19, 10/11/19, 10/16/19, 10/19/29, 10/23/19, and 10/30/19.
Review of Resident #33's November 2019 TAR revealed no evidence the treatment was completed
11/02/19 and 11/03/19.
Review of Resident #33's Skin and Wound Evaluation, dated 03/02/20 revealed Resident #33 still had the
unstageable pressure ulcer to her right heel.
Interview on 03/04/20 at 5:05 P.M. with Director of Nursing confirmed there was no evidence Resident #33's
treatments were completed on the above dates.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 10 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4. Review of Resident #13's medical record revealed an admission date of 09/20/19 and diagnoses
including Parkinson's disease, peripheral vascular disease, hypertension, osteomyelitis and right heel
unstageable pressure ulcer.
Review of an admission MDS 3.0 assessment dated [DATE] indicated Resident #13 had three stage two
pressure ulcers (partial-thickness skin loss), two unstageable pressure ulcers and two deep tissue injuries
(DTI).
Review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had one stage two pressure
ulcer and five unstageable pressure ulcers.
Review of a discharge/return anticipated MDS 3.0 assessment dated [DATE] indicated Resident #13 had
two unstageable pressure ulcers.
Review of a significant change MDS 3.0 assessment dated [DATE] indicated Resident #13 had two
unstageable pressure ulcers.
Review of a quarterly MDS 3.0 assessment dated [DATE] indicated Resident #13 had one unstageable
pressure ulcer and one vascular ulcer.
Review of a quarterly MDS 3.0 assessment dated [DATE] indicated Resident #13 had one unstageable
pressure ulcer and two vascular ulcers (chronic or long term breaches in the skin caused by problems with
the vascular system).
Review of facility skin and wound evaluations dated 11/25/19, 12/02/19, 12/09/19, 12/16/19, 12/30/19,
01/06/20, 01/14/20, 01/20/20, 01/28/20, 02/03/20, 02/11/20, 02/17/20, 02/24/20 and 03/02/20 revealed
Resident #13 had an unstageable pressure area to right heel.
Review of an outside wound consultant note dated 02/20/20 revealed Resident #13 had unstageable
pressure ulcers to right heel and right calf and a surgical incision at his left above knee amputation site. The
right heel measured 5.0 cm by 3.0 cm with no depth and was 100 percent (%) eschar (dead or necrotic
tissue). The right calf measured 10 cm by 4.0 cm with no depth and was 40% slough (dead tissue coming
to the surface) and 60% eschar.
Review of a care plan for impairment to skin integrity revised 02/24/20 revealed Resident #13 had
unstageable vascular areas to right heel and right calf and a below-knee amputation incision. Vascular
areas were noted to right lower extremity. Listed interventions included the wound nurse practitioner
following in-house.
Interviews on 03/03/20 at 11:16 A.M. and 12:56 P.M. with RN #401, who served as the facility's wound
nurse, revealed Resident #13's wounds were not pressure areas but were vascular. RN #401 explained the
areas started out as pressure areas but then became vascular. RN #401 looked through Resident #13's
nurses notes with the surveyor and could not determine when the wound changed classification from
pressure to vascular in nature. RN #401 also shared the facility utilized a cellular phone to measure
wounds; when an wound was put into the phone, any subsequent entries would be pre-populated with the
wound type which in this case was pressure.
A follow-up interview on 03/03/20 at 3:20 P.M. with RN #401 provided the surveyor with a nurse practitioner
note dated 11/24/19 which revealed Resident #13 had severe and significant peripheral
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 11 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0686
vascular disease (PVD).
Level of Harm - Minimal harm
or potential for actual harm
An interview on 03/03/20 at 4:21 P.M. with RN #401 and RN #400, who also completed MDS assessments,
revealed she used nursing notes and facility skin and wound assessments to complete MDS assessments.
RN #400 stated if RN #401's notes classified a wound as a pressure area, she coded that area as
pressure. RN #401 confirmed Resident #13's wounds were vascular after 11/24/19 and were not pressure
areas which made Resident #13's MDS assessments on 12/10/19 and 02/19/20 incorrect.
Residents Affected - Some
Review of the facility policy Skin Management, revised October 2019, revealed residents with wounds
and/or pressure injury and those at risk for skin compromise were identified, evaluated and provided
appropriate treatment to promote prevention and healing. In electronic health record (EHR) facilities the
nurse would document on the skin and wound evaluation for pressure injuries and vascular ulcers on a
weekly basis until resolved.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 12 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure Resident #33's fall precaution
interventions were in place at all times. This affected one (Resident #33) of three residents reviewed for
falls.
Findings include:
Resident #33 was admitted on with diagnoses including Alzheimer's disease and muscle weakness.
Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition
was severely impaired, she required two person extensive assistance with bed mobility, transfers, and one
person extensive assistance with dressing.
Resident #33's comprehensive care plan related to being at risk for falls, revised 06/24/19, revealed the
resident should wear non-skid foot wear when out of bed, and to encourage the resident to wear
appropriate footwear as needed.
Observation on 03/02/20 at 9:06 A.M. revealed Resident #33 was sitting in her wheelchair in a common
area with socks that were not non-skid.
Interview on 03/02/20 at 11:09 A.M. with Registered Nurse (RN) #413 confirmed Resident #33 should be
wearing non-skid socks and she was not wearing them at the time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 13 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record and staff interview the facility failed to implement non-pharmacological intervention prior to
administering as needed anti-anxiety medication, Alprazolam, for Resident #49. This affected one resident
(Resident #49) of five residents reviewed for unnecessary medications.
Findings include:
Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with the
diagnoses of Parkinson's disease, dysphagia, pneumonia, dementia, delusional disorder, low back pain,
major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, atherosclerotic heart
disease, congestive heart failure, atrial fibrillation, hypertension, and psychotic disorder with delusions.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had
moderately impaired cognition and received an anti-anxiety medication for seven days.
Review of the March 2020 physician's orders revealed Resident #49 had an order dated 01/23/20 for 0.25
milligrams of Alprazolam one tablet as needed for anxiety twice daily for 88 days.
Review of the January 2020 medication administration record (MAR) revealed Resident #49 received
Alprazolam 17 times without non-pharmacological interventions attempted prior to administration.
Review of the February 2020 MAR revealed Resident #49 received Alprazolam 15 times without
non-pharmacological interventions attempted prior to administration.
Review of the March 2020 MAR revealed Resident #49 received Alprazolam one time without
non-pharmacological interventions attempted prior to administration.
Interview on 03/05/20 at 2:06 P.M. the Director of Nursing verified there was no documentation of
non-pharmacological interventions attempted prior to the administration of Alprazolam.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 14 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based observation, staff interview and policy review, the facility failed to ensure pureed food was the proper
consistency. This affected one resident (Resident #92) but had the potential to affect all 13 residents
(Resident #5, #9, #14, #15, #27, #31, #33, #34, #47, #77, #78, #92 and #154) who received pureed diets.
Finding include:
Observation on 03/02/20 at 11:51 A.M. staff gave Resident #92 a meal tray. The pureed food was on a
regular plate, the food had a very thin consistency and was running all over the plate mixing into each
other. An interview at this time State Tested Nursing Assistant (STNA) #409 verified the pureed food was
too runny and looked terrible on the plate.
An interview on 03/02/20 at 11:57 A.M. Dietary Manger #410 verified the pureed food for Resident #92 was
too runny, and she went to get him a new plate of purred food.
Review of the facility policy Mechanically Altered Diet, dated 04/10, revealed mechanically altered diets
would be prepared and served as prescribed by the physician. Guests would be provided with the least
restrictive diet to optimize nutritional status and to promote overall satisfaction with meals. All guests with a
physician's order for a pureed diet would receive pureed, homogenous, and cohesive foods. Foods would
be pudding-like. No coarse textures, raw fruits, or vegetables, nuts are allowed. Any food that requires bolus
formation, controlled manipulation, or mastication.
Review of the facility policy National Dysphagia Diet, Level 1: Pureed Diet, dated 04/10, revealed the NDD1
diet consists of pureed, homogenous, and cohesive foods in pudding like consistency. Any foods that
require bolus formation, controlled manipulation, or mastication are excluded. This diet was designed for
people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect
their airway. Close or complete supervision and alternated feeding methods may be required on an
individual basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 15 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and staff interview the facility failed to ensure food service carts were maintained in a
sanitary manner. This affected all 69 residents (Resident #1, #3, #4, #5, #6, #7, #8, #10, #16, #18, #19,
#20, #21, #22, #24, #28, #29, #31, #32 #40, #41, #42, #44, #45, #47, #49, #51, #52, #54, #55, #56, #57,
#60, #61, #62, #63, #64, #65, #66, #67, #69, #70, #71, #76, #77, #80, #82, #87, #88, #89, #91, #92, #93,
#94, #95, #98, #100, #102, #154, #155, #156, #157, #158, #159, #160, #161, #162, #164, and #308) who
were served from the metal meal storage carts on the 100, 200 and 300 hallways.
Findings include:
Observation on 03/02/20 at 12:20 P.M. revealed the metal food storage cart on the 100 hallway with the
residents meals was soiled with food and dried liquid. The cart had a red substance spilled on the outside
of the cart, a white substance spilled on the inside of the cart on the door, and a brown sticky substance on
the outside of the cart by the handle. An interview at this time State Tested Nursing Assistant (STNA) #408
verified the carts were soiled
Observation on 03/02/20 at 12:25 P.M. revealed the metal food storage cart on the 300 hallway with the
residents meals was soiled with food and dried liquid. The cart had a white dried liquid substance spilled on
the inside on the cart, a white dried liquid spilled on the outside of the cart, the rail along outside bottom of
the cart had a moderate amount of food debris laying along it.
Observation on 03/02/20 at 12:27 P.M. revealed the metal food storage cart on the 200 hallway with the
resident's meals was soiled with food and dried liquid. The cart had white and brown substance spilled on
the inside and outside, the rail along outside bottom of the cart had a moderate amount of food debris
laying along it, and the handle had a brown sticky substance on it.
An interview on 03/02/20 at 12:30 P.M. STNA #600 verified the meal carts were dirty and indicated they
were always dirty. She stated sometimes they were so dirty the doors stick shut.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 16 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, interviews and policy review, the facility failed to maintain standard infection
control practices when Resident #1's food tray was delivered to the room without proper implementation of
contact isolation precautions and during Resident #33's dressing change. This affected one resident
(Resident #1) and had the potential to affect three additional residents (Resident #41, #51, and #93)
residing on the hall who received lunch trays, and affected one resident (Resident #33) of two residents
observed during dressing changes.
Residents Affected - Few
Findings include:
1. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including anemia
and cerebral palsy.
On 03/02/20 at 11:57 A.M., observation revealed a contact isolation sign posted on Resident #1's room
door and personal protective equipment (PPE) located outside of the room's doorway. Observation of the
lunch tray service revealed State-Tested Nursing Assistant (STNA) #420 removed Resident #1's tray from
the service cart, entered the resident's room, and delivered the tray without wearing gloves or other PPE.
STNA #420 then exited the room and removed Resident #41's tray from the service cart and carried it to
the common area dining table.
During interview on 03/02/20 at 12:00 P.M., STNA #420 confirmed that C-Diff contact isolation precautions
were being implemented for Resident #1 and stated she did touch the resident's bedside table while
delivering the the lunch tray. STNA #420 further confirmed she should have been wearing gloves and the
designated PPE. During interview at 03/02/20 at 12:02 P.M., Registered Nurse (RN) #421 confirmed STNA
#420 should have worn proper PPE while delivering Resident #1's tray.
Review of the facility's policy Infection Prevention Program Overview, revision date September 2019, stated
when the infection control program identifies that a resident needs isolation to prevent the spread of
infection, the facility must isolate the resident.
2. Resident #33 was admitted on [DATE] with diagnoses including Alzheimer's disease and muscle
weakness. Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her
cognition was severely impaired, she required two person extensive assistance with bed mobility, transfers,
and one person extensive assistance with dressing.
Resident #33's physician orders dated 02/28/20 revealed orders to cleans the resident's right heel with
normal saline (wound cleanser), apply collagen to wound bed, cover with heel protector and change
Monday, Wednesday, and Friday.
Resident #33's Skin and Wound Evaluation dated 03/02/20 revealed she had an unstageable pressure
ulcer to her right heel (obscured full-thickness and tissue loss in which the extent of tissue damage within
the ulcer cannot be confirmed because it is obscured by slough or eschar).
Observation on 03/02/20 10:50 A.M. of RN #401 completing Resident #33's right heel pressure ulcer
dressing revealed she placed all of the dressing change supplies on a clean field on the resident's bed side
table. The dressings were in unopened packages. After RN #401 discarded the resident's old heel protector,
she washed her hands and applied new clean gloves. RN #401 than opened up the foam
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 17 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
dressing packaging with her clean gloves, grabbed a permanent marker that was lying on a blanket on the
residents bed, and dated the dressing with her clean gloves on. RN #401 then placed her thumb in the
middle of the foam dressing before applying the collagen ointment to the foam dressing. RN #401 than
applied the collagen to the foam heel protector and placed the dressing on the right heel wound.
Interview on 03/02/20 at 11:10 A.M. with RN #401 revealed she did not sanitize the marker before the
dressing change and opened the dressings with clean gloves on.
Review of the facility procedure for Clean Dressing Change, printed 03/02/20, revealed the staff are to
gather and set up supplies in the resident area, including establishing a clean field, open supplies onto
clean field, and to pour solution into clean container, prepare ointments, and medications. Upon completion
of informing the resident of what they are doing and provide privacy, they are to wash hands and apply
clean gloves and remove and discard old dressing. Staff are then to remove gloves, wash hands and apply
new closed, and then cleanse and dress the wound as ordered. The procedure did not provide steps on
how to use a marker to date the dressing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 18 of 19
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
366078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Massillon, The
2000 Sherman Circle 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)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, record review and policy review, the facility failed to ensure two residents (Resident #19
and #99) of five residents reviewed for pneumococcal and influenza vaccines received the education
addressing the benefits and risks of the pneumococcal and influenza vaccines or the date when re-offered
the vaccines. The facility census was 111.
Residents Affected - Few
Findings include:
Review of Resident #19's Acknowledgement of Receipt of Vaccine Information Sheet (VIS), revealed the
resident declined the pneumonia polysaccharide vaccine and the influenza vaccine; however, the medical
record failed to include a date confirming when Resident #19 received the education addressing the
benefits and risks or the date when the resident was re-offered the vaccines.
Review of Resident #99's Acknowledgement of Receipt of Vaccine Information Sheet (VIS), revealed the
resident declined the pneumonia polysaccharide vaccine and the influenza vaccine; however, the medical
record failed to include a date confirming when Resident #99 received the education addressing the
benefits and risks or the date when the resident was re-offered the vaccine.
During an interview on 03/05/20 at 2:32 P.M., the Director of Nursing confirmed that Resident #19 and
Resident #99's Vaccine Information Sheets did not provide evidence of the date when the residents
received education or were re-offered the pneumococcal and influenza vaccinations.
Review of the facility's policy titled, Influenza and Pneumococcal Vaccine Policy, revised September 2019,
stated informed consent in the form of a discussion regarding risks and benefits of vaccination will occur
prior to vaccination. Vaccination refusal should be documented by the facility. If the resident chooses to
decline the vaccination, it will be re-evaluated annually.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366078
If continuation sheet
Page 19 of 19
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Back to topCitations
11 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.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F679 - Activities
Provide activities to meet all resident's needs.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the March 5, 2020 survey of LAURELS OF MASSILLON, THE?
This was a inspection survey of LAURELS OF MASSILLON, THE on March 5, 2020. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAURELS OF MASSILLON, THE on March 5, 2020?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.