Health inspection·April 18, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, review of a self-reported incident and interview, the facility failed to ensure medical records were accurate and complete for Residents #2 and #11. This affected two residents (#2 and #11) of three records reviewed for accuracy. The facility census was 70. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 07/10/20 with diagnoses including Alzheimer's disease, dementia, intermittent explosive disorder, and anxiety disorder. Further review of the medical record identified no documentation of any complaints of hip or knee pain and possible rotation of the leg for Resident #2. Review of the facility's investigation of Self-Reported Incident (SRI) #245125 revealed Resident #2's skin check identified complaints of pain to the left hip and knee and a slight internal rotation of the left leg. On 04/18/24 at 1:41 P.M., interview with Corporate Quality Assurance Nurse #107 verified Resident #2's skin check, obtained during the investigation of SRI #245125, revealed complaints of pain to his left hip and knee and a slight rotation of his leg. Corporate Quality Assurance Nurse #107 confirmed Resident #2's medical record had no documentation of this identified concern or the Nurse Practitioner's assessment of this potential injury. She also stated the facility had an overall problem with documentation. 2. Review of the medical record for Resident #11 revealed an admission date of 08/18/22 with diagnoses including anxiety, major depressive disorder, difficulty in walking, and muscle weakness. Review of the nurse aide task documentation for bed to chair transfers, dated 03/20/24 to 04/18/24, identified no refusals were documented and there were 34 instances of not-applicable or not attempted. On 04/18/24 at 11:38 A.M., interview with Restorative Therapy State Tested Nurse Aide (STNA) #104 stated Resident #11 liked to stay in bed. On 04/18/24 at 11:40 A.M., interview with STNA #103 stated Resident #11 refused to get out of bed all the time and refusals should have been documented as refusals on the nurse aide tasks instead of not-applicable or not attempted. STNA #103 verified there were no refusals documented in the nurse aide tasks. (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 04/18/2024 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)