Health inspection·December 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to notify Resident #94's responsible party after a fall. This affected one resident (Resident #94) of three residents reviewed for notifications. The census was 121. Findings include: Record review of Resident #94 revealed an admission date of 04/05/22 with diagnoses including myelodyspastic syndrome, Alzheimer's Disease and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #94 was cognitively intact. Review of the progress note dated 11/28/23 and timed at 3:34 A.M. revealed Resident #94 had a fall with no injury. A note at 10:05 A.M. revealed her hand was swollen and bruised. An x-ray was ordered. A note at 12:36 P.M. revealed there was no fracture. There was no indication the responsible party was notified. Review of the Change in Condition report titled SBAR, dated 11/28/23 revealed it was not completely filled out including notification of responsible party. Review of the post-fall evaluation dated 11/28/23 revealed it does not indicate if a responsible party or physician was notified. Interview on 12/27/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #303 revealed she did Resident #94's post-fall assessment and progress note. She stated she was not sure if the family was notified but stated she asked the Certified Nurse Practitioner (CNP) for an x-ray though it was not documented. Phone Interview on 12/27/23 at 12:29 P.M. with Registered Nurse (RN) #300 revealed she was the nurse on duty when Resident #94 had fallen. She stated she was told because the resident fell on the mat it was not considered a fall. She did start a fall investigation however it was not completed. She stated she did not notify the physician, CNP or the responsible party. Interview on 12/27/23 at 3:45 P.M. with Director of Nursing revealed any change of plane was considered a fall. DON verified there was no evidence Resident #94's family was notified of the fall. Review of the policy titled Fall Management, dated 09/22/23 revealed the licensed nurse will notify (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 2 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 12/27/2023 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)