Health inspection·October 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility self-reported incident (SRI) review, interviews, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state agency. This affected two residents (Resident #32 and Resident #65) out of three residents reviewed for abuse. The facility census was 63. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 11/02/21. Diagnoses included chronic diastolic (congestive) heart failure, major depressive disorder, anxiety disorder, and exudative age-related macular degeneration of the right eye. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was moderately impaired cognitively with no behaviors or signs or symptoms of delirium and required supervision or touch assistance from staff for sit to stand, transfers, and walking ten feet. Interview on 10/11/24 at 5:56 A.M. with Resident #32 revealed there had been an incident where another resident (Resident #33), who was mentally unstable, hit her with a phone on an unspecified day. Review of the Ohio Department Health's Gateway System of SRI tracking #252676 revealed on 10/05/24 (Saturday) at 3:30 P.M. Resident #32 reported Resident #33 was upset and hit her hand. The facility created an SRI report for physical abuse on 10/06/24 (Sunday)at 9:59 A.M. Review of the witness statement dated 10/06/24 and authored by Licensed Practical Nurse (LPN) #607 revealed on 10/05/24, as she was completing a treatment to Resident #33's leg, when the resident said, that girl next door hit me with my phone. She was swinging it around and it hit my hand. Review of the witness statement dated 10/06/24 authored by State Tested Nursing Assistant (STNA) #651 revealed on 10/05/24, STNA #651 heard Resident #33 shouting. When she went down the hall, STNA #651 observed Resident #33 coming out of Resident #32's room. Resident #32 stated Resident #33 hit her on her hand with Resident #32's phone. Interview on 10/11/24 at 10:11 A.M. with the Administrator confirmed the incident had occurred on Saturday (10/05/24) around 3:30 P.M. and he was not notified of the incident until Sunday morning (10/06/24) around 9:00 A.M. He also confirmed the SRI related to the physical abuse allegation on 10/05/24 was not submitted to the state agency within two hours of discovery as required because he was not notified of the incident until the next morning. (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 10/11/2024 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)