Health inspection·May 26, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to maintain a clean and sanitary environment for Resident #14 and Resident #49. This affected two residents (#14 and #49) and had the potential to affect all 23 additional residents (#1, #2, #3, #5, #7, #10, #12, #15, #25, #28, #32, #34, #39, #40, #41, #47, #52, #53, #56, #57, and #59) residing on the C lodge unit of the facility. The facility census was 60. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 08/11/20. Diagnoses included polycythemia vera, acquired absence of the right leg above the knee, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. Resident #14 required extensive two-person physical assistance for bed mobility, dressing, and personal hygiene; and total dependence of one-person for eating and toilet use. Resident #14 was always incontinent of urine and bowel. Review of the care plan dated 02/28/23 revealed Resident #14 had a self-care deficit related to limited mobility and range of motion. Interventions included assisting with toileting and total dependence with personal hygiene. 2. Review of the medical record for Resident #49 revealed an admission date of 02/12/22. Diagnoses included chronic obstructive pulmonary disease, pulmonary embolism, and traumatic brain injury. Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had intact cognition. Resident #49 required limited one-person physical assistance for bed mobility, transfers, and toilet use; independent with one-person assistance for dressing; and supervision with set-up help only for eating and personal hygiene. Resident #49 was occasionally incontinent of urine and always continent of bowel. Review of the care plan dated 05/03/23 revealed Resident #49 had a self-care deficit due to a diagnosis of localized edema, and abnormalities of gait, and mobility. Interventions included assisting with activities of daily living as needed and encouraging the resident to do as much for herself as possible. Interview on 05/26/23 at 10:10 A.M. with Resident #49 revealed the facility had a wonderful (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: 366460 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 366460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Acres LLC Dba Windsor House at Canfield 6445 State Route 446 Canfield, OH 44406 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)