Inspection·June 28, 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 interview, the facility failed to ensure Resident #102's physician was notified timely of a family request to send the resident to the emergency department (ED) and the facility failed to ensure emergency transport (ET) services were called timely to provide Resident #102 transportation to the ED per family request. This finding affected one (Resident #102) of three residents reviewed for changes in condition. Findings include: Review of Resident #102's medical record revealed an admission date of 05/20/23 and a discharge date of 06/01/23 with diagnoses including fracture of the left femur, muscle weakness and peripheral vascular disease. Review of Resident #102's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #102's progress note authored by Licensed Practical Nurse (LPN) #802 dated 05/27/23 at 5:16 P.M. revealed the nurse spoke with the daughter who requested a print out of the medications. The daughter requested the blood pressure to be obtained which was 116/76 with a pulse of 76. The daughter indicated she would like for Resident #102 to be checked for a urinary tract infection (UTI) and she was informed the urinalysis (UA) results could take a day or two to get the results. The daughter was informed if she felt the need to call ET services, she had the right but the nurse could not call ET services to pick up the resident because she was sleeping and her vitals were stable. The daughter called ET services and the resident was sent out to the ED. Review of Resident #102's progress note dated 05/28/23 at 2:55 A.M. indicated the resident returned from ED in stable condition with a diagnosis of acute cystitis without hematuria and dehydration. A new order for Omnicef (antibiotic) 300 mg (milligrams) one tablet twice daily for ten days was obtained. Interview on 06/22/23 at 11:05 A.M. with LPN #802 indicated Resident #102's daughter had requested the resident go to the ED and the nurse told the daughter the resident was stable and if she wanted the resident sent out to the ED she had to call ET services herself. LPN #802 did not update Resident #102's physician of the family request to send the resident to the ED. Review of the Change in Condition policy dated 05/2020 indicated it was the policy of the facility to inform the resident, consult with the physician and the representative when there was an accident (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: 366113 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 366113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center Inc 1355 Churchill Hubbard Rd Youngstown, OH 44505 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)