Health inspection·December 9, 2024

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #131) of three residents reviewed for elopement. The facility census was 130. Findings include: Review of the medical record for Resident #131 revealed an admission date of 07/26/24 with diagnoses including traumatic brain injury, depression and hypertension. Resident #131 was discharged to the hospital on [DATE]. Review of the physician's orders for Resident #131 revealed orders dated 07/26/24 to check the wanderguard placement on his right lower extremity, send him to the emergency room if he became violent, psychiatric referral and Lorazepam 0.5 milligrams to be given one time at bedtime as needed for agitation. Review of the care plan dated 07/26/24 for Resident #131 revealed he was at risk for exit seeking and wandering related to cognitive dysfunction, impulsivity and traumatic brain injury. Interventions included to apply a wanderguard per the physician's order, observe wandering behaviors, attempt diversional interventions, provide structured activities and redirect resident as needed. Review of the nursing progress notes dated from 07/26/24 through 07/27/24 for Resident #131 revealed he arrived at the facility on 07/26/24 at 12:10 P.M. He became agitated and began making verbal insults at his wife requiring de-escalating interventions by the nurse. On 07/26/24 at 1:50 P.M., he was assessed by the nurse practitioner and an order for a wanderguard was given due to his confusion and wandering. On 07/26/24 at 7:31 P.M. Resident #131 was noted to have one-on-one supervision and was in his room. He was noted to be agitated with the staff and visitors. His wife was updated on his behaviors and the need for him to transition to another facility due to his needs for a locked unit. On 07/26/24 at 8:19 P.M. the nurse updated the nurse practitioner on Resident #131's agitation and exit seeking. A return call was received at 8:45 P.M. and new orders for as needed anxiety medication was provided as well as an order to send him to the emergency for evaluation and treatment if he became violent. On 07/26/24 at 9:33 P.M. he was provided with the as needed anxiety medication. It was noted he was sexually inappropriate with staff and slamming his door. He would not allow the one-on-one male caregiver in his room. On 07/27/24 at 1:05 A.M. Resident #131's nursing progress note stated he returned to the facility with a nurse aid and nurse. A full head to toe assessment was (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 6 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 12/09/2024 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)