Community Skilled Health Care

F-F686). Interview via telephone on 07/08/24 at 10:53 A.M. with Wound Care Physician (WCP) #700 revealed he had seen Resident #44 due to moisture associated dermatitis (MASD) that turned into a pressure ulcer. WCP #700 revealed MASD should never progress to a pressure ulcer. The physician stated

the facility staff do not turn and reposition as they should, nor do they provide timely incontinence care for Resident #44 which was why Resident #44 developed a pressure ulcer from MASD.

Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they were able to provide only four shower sheets for Resident #44.

Interview on 07/09/24 at 2:30 P.M. with Resident #44 revealed she was able to answer yes and no questions and would elaborate a little bit. When asked if she received showers she said no and she could not remember the last time she had one. She stated staff had to help her with everything including washing her up and giving her showers.

2. Review of the medical record for Resident #4 revealed an admitted [DATE REDACTED]. Diagnoses included major depressive disorder, generalized anxiety, chronic pain, hypertension, unspecified intellectual disabilities, and hypothyroidism.

Review of Resident #4's plan of care initiated on 03/05/24, revealed the resident preferred not to take a shower and stated he only wanted bed baths. Interventions included staff to continue to encourage and assist Resident #4 to take showers or bed baths, anticipate and meet the resident's needs.

Review of Resident #4's shower schedule revealed he was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays when he resided in room [ROOM NUMBER], and on Tuesdays and Fridays when he resided in room [ROOM NUMBER].

Review of the requested shower sheets from 05/01/24 to 07/01/24 for Resident #4 revealed Director of Nursing (DON) #804 and LPN/WN #800 were only able to provide evidence of one bed bath completed on 05/14/24.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/2024, revealed Resident #4 to have intact cognition. He was assessed to be independent for most of their activities of daily living (ADL). He was assessed to need partial assistance by staff for personal hygiene and showers.

Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he stated he does not like to take showers, he prefers bed baths, staff do not really like to help him and if he doesn't try to wash himself the staff did not provide his bed baths.

Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed one sheet for Resident #4 for the time period requested from 05/01/24 to 07/01/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0725 3. Review of the medical record for Resident #10 revealed an admitted [DATE REDACTED]. Diagnoses included dementia with mild agitation, hypertensive chronic kidney disease, pressure ulcer of left buttock stage III, Level of Harm - Minimal harm or agoraphobia, and a personal history of prostate cancer. potential for actual harm

Review of Resident #10's quarterly MDS assessment, dated 06/04/24 revealed the resident had impaired Residents Affected - Many cognition, he required partial to moderate assistance from staff for toileting, and required substantial to maximal assistance with showers, personal hygiene, and dressing.

Review of Resident #10's plan of care initiated 06/11/24, revealed the resident has a deficit in all ADLs including showers, personal hygiene, and dressing performance with the potential for fluctuations related to dementia and pain. The care plan also stated the staff will encourage the resident to turn and reposition

during care rounds.

Review of Resident #10's shower schedule revealed he was scheduled to have showers on the 7:00 A.M. to 3:00 P.M. shift on Mondays and Fridays.

Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #10, revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested.

Interview on 07/09/24 at 11:30 A.M. with Resident #10 revealed he was alert and could answer some questions and when asked about getting showers he stated he had not had a shower in a long time. The resident also said the staff do not encourage him to turn and reposition.

4. Review of the medical record for Resident #32 revealed an admitted [DATE REDACTED]. Diagnoses included autistic disorder, anxiety disorder, hypertension, and scoliosis.

Review of Resident #32's plan of care initiated on 09/12/23 revealed the resident had a deficit in ADL self-performance with potential for fluctuations and/or decline related to cognitive impairment.

Review of Resident #32's annual MDS assessment, dated 05/24/24, revealed Resident #32 had severely impaired cognition, and was dependent on staff for all ADLs including toileting, showers, personal hygiene and dressing.

Review of Resident #32's shower schedule revealed she was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays.

Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #32, revealed DON #804 and LPN/WN #800 were only able to provide one shower sheet dated 05/23/24, for the time frame requested.

5. Review of the medical record for Resident #72 revealed an admitted [DATE REDACTED]. Diagnoses include Parkinson's disease, Stiff-Man syndrome, hypertension, torticollis, contracture to right and left hand, anxiety disorder, pressure ulcer of sacral region stage III, and muscle spasms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0725 Review of Resident #72's plan of care initiated on 09/12/23, revealed Resident #72 had a deficit in ADL self-performance with potential for fluctuations and/or decline related to diagnosis of Parkinson, and Stiff Man Level of Harm - Minimal harm or Syndrome. Interventions included encouraging the resident to fully participate as possible with each potential for actual harm interaction and praise all efforts at self-care. In addition, the resident was to be provided incontinence care.

Residents Affected - Many Review of the physician order dated 01/19/22 revealed Resident #72 was to be checked and changed on rounds and as needed for incontinence care.

Review of Resident #72's quarterly MDS assessment dated [DATE REDACTED] revealed the resident had severely impaired cognition and was dependent on staff for all ADLs including toileting, showers, personal hygiene, dressing and bed mobility. He was incontinent of bladder and bowel.

Review of Resident #72's shower schedule revealed he was scheduled to have showers on the 11:00 P.M. to 7:00 A.M. shift on Tuesdays and Thursdays.

Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #72 revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested.

Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they could not produce shower sheets for Resident #72.

Interview on 07/09/24 at 12:45 P.M. with Resident #72 revealed he was alert and able to answer questions.

He stated he does not get showers and staff do not check on him regularly for repositioning or incontinence care.

6. Review of the medical record for Resident #79 revealed an admitted [DATE REDACTED]. Diagnoses include multiple sclerosis, chronic respiratory failure with hypoxia, anxiety disorder, kidney stones, depression, and peripheral vascular disease.

Review of Resident #79's quarterly MDS assessment dated [DATE REDACTED] revealed she had intact cognition and required partial to moderate assistance with showers, and was dependent on staff for personal hygiene, bed mobility, and toileting.

Review of Resident #79's plan of care initiated on 11/10/23 revealed she had a deficit in ADL self-performance related to decreased mobility due to a diagnosis of multiple sclerosis. Interventions included encouraging the resident to fully participate as possible with each interaction and praise all efforts at self-care.

Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #79 revealed DON #804 and LPN/WN #800 were able to provide five shower sheets dated 05/12/24, 05/15/24, 05/16/24, and 06/26/24 for

the time frame requested.

Review of Resident #79's shower schedule revealed she was scheduled to have showers on the 7:00 A.M. to 3:00 P.M. shift on Sundays and Wednesdays.

Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they were only able to provide four sheets for Resident #79.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0725 Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she does not get showers per her schedule or preference. She stated most of the time she had to ask for a shower or she would not get Level of Harm - Minimal harm or one. potential for actual harm

Review of the facility policy titled Shower/Bath Policy, last revised December 2013, revealed the purpose of Residents Affected - Many the policy was to provide residents with a bath/shower according to their preference.

A request was made to review any additional policy and procedures related to turning and repositioning and frequency of incontinence care; however, no additional information was provided.

This deficiency represents non-compliance investigated under Complaint Numbers OH00155024, OH00154346 and OH00154092.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44461 potential for actual harm Based on observation, record review and interview, the facility administration did not ensure proper Residents Affected - Many management of all resources for the highest practicable wellbeing of all residents which included failure to eradicate bed bugs, failure to ensure sufficient nursing staff to meet the resident's acuity needs, and failure to ensure resident rooms were maintained in a manner to protect the resident right to a safe, clean, comfortable environment. This had the potential to affect all 78 residents living in the facility. The facility census was 78.

Findings include:

Review of the undated job description for the Administrator revealed it was the essential function of the Administrator to enforce implementation of policies and procedures, supervise all department supervisors and administrative staff, assume responsibility with department supervisors to ensure adequate staffing, and establish systems to ensure compliance with all state, federal and local regulations.

Review of the undated job description for the Director of Nursing revealed responsibilities included managing

the nursing department to maintain quality standards, directs the nursing staff in its entirety, making clinical rounds to determine quality of care, maintain staffing at an acceptable level and assuming responsibility for nursing services compliance with state, federal and local regulations.

Interview was conducted with the Administrator on 07/09/24 at approximately 12:00 P.M. who revealed he was the Interim Administrator who had only been on the job at the facility for a few days, so he was still getting acclimated to the needs of the facility. This Administrator stated he started in the position on 06/28/24 because the prior administrator left on 06/27/24.

Interview was conducted with the DON on 07/09/24 at approximately 1:30 P.M. and revealed she was the Minimum Data Set (MDS) nurse for the facility who took over the role of the DON on 06/21/24 since the prior DON stopped working at the facility on 06/21/24. She said the current Administrator was interim and came out of retirement to oversee the facility with his first day worked of 06/28/24. The DON revealed she had identified staffing concerns related to meeting the acuity needs of the residents and had done some education with the staff but still needed to do more training since she had only been in the DON position a few weeks prior to the start of this survey.

During the onsite investigation, the following concerns were identified related to a lack of comprehensive and effective administrative oversight:

1. Review of the Facility Assessment (dated 05/16/24) revealed the average daily census at the facility was 85. On page three and four of the assessment, the staffing plan was outlined and indicated to meet the acuity needs of the residents, the licensed nurses and STNA would provide a range of 3.28 to 4.78 hours of direct resident care per resident per day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0835 Interview on 07/01/24 at 3:22 P.M. with State tested Nursing Assistant (STNA) #808 revealed staff were unable to complete showers due to the facility getting rid of the shower aides. She stated residents might get Level of Harm - Minimal harm or bed baths, but they do not get showers. STNA #808 stated the facility was short staffed most of the time and potential for actual harm staff were not able to turn/reposition residents timely nor provide timely incontinence care.

Residents Affected - Many Interview on 07/02/24 at 10:00 A.M. with Licensed Practical Nurse (LPN)/Wound Nurse (WN) #800 revealed

she was the wound nurse for the facility, and she had concerns about the residents not getting showered, not getting timely incontinence care and not being turned and repositioned as they should be to prevent skin breakdown (related to a lack of staff).

Interview on 07/02/24 at 2:45 P.M. with STNA #809 revealed residents do not get showers like they should per the schedule or per their preference. STNA #809 stated showers were not done due to the facility getting rid of the shower aides and the floor staff were stretched pretty thin.

On 07/09/24 at 3: 33 P.M. to 3:56 P.M. an evaluation of the facility staffing was completed with Human Resources (HR) #805 and Staffing Coordinator (SC) #806 who provided the schedules and payroll punch details for 06/07/24 to 06/13/24 and 06/21/24 to 06/27/24. For the date range of 06/07/24 to 06/13/24 licensed nurses and STNAs provided a range of 3.20 to 3.65 hours of direct care per resident per day and for

the date range of 06/21/24 to 06/27/24 the licensed nurses and STNAs provided a range of 2.95 to 3.56 hours of direct resident care per resident per day which did not meet the minimum range of hours of 3.28 to 4. 78 identified in the Facility Assessment staffing plan for licensed nurses and STNAs to meet resident acuity needs. These findings were verified with HR #805 and SC #806 at the time of the completion of the staffing tool.

On 07/09/24 at 4:00 P.M. interview with HR #805 and SC #806 revealed in order to meet resident acuity needs including but not limited to providing showers/bathing, incontinence care and regular turning/repositioning there needed to be eight State tested Nursing Assistants (STNA) on the day shift, seven STNA on afternoon shift and seven STNA on midnight shift. At the time of the interview, both confirmed on 06/08/24 there were only five STNA on day shift, on 06/09/24 there were only six STNA on day shift, on 06/10/24 there were only six STNA on afternoon shift, on 06/21/24 there were only six STNA on day shift and six STNA on afternoon shift and on 06/27/24 there were only six STNA on day shift as per the staffing tool referenced prior. Both also confirmed the facility no longer had a shower aide position so the STNA's on each unit were responsible for giving showers to the residents.

2. Reivew of the exterminator invoice dated 05/23/24 revealed the facility had a chemical treatment completed for bed bugs along with their routine pest control measures. On 06/05/24 they had a chemical treatment for bed bugs completed to room [ROOM NUMBER], and then again on 06/27/24 they had a chemical treatment for bed bugs in the facility along with their monthly pest control measures.

Observation made on 07/01/24 at 2:44 P.M. of the physical environment revealed in resident room [ROOM NUMBER] and room [ROOM NUMBER], both rooms unoccupied at the time of the observation, there were multiple bed bugs present.

Interview on 07/01/24 at 2:58 P.M. with Resident #21 revealed she confirmed there are bed bugs in the rooms across the hall from her in rooms 118 and room [ROOM NUMBER]. She stated the exterminators have been out multiple times with no luck of getting rid of them. She stated she had seen them in the hallway as well.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0835 Interview on 07/01/24 at 3:22 P.M. with STNA #808 revealed she confirmed there were bed bugs in the facility in the room of Resident #4, and also in room [ROOM NUMBER] and 101. She stated the facility was Level of Harm - Minimal harm or only using chemicals to try to get rid of them however you have to heat treat everything in order to eradicate potential for actual harm them.

Residents Affected - Many Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he confirmed he was being treated for bed bug bites, he had them in his room when he occupied room [ROOM NUMBER]. He stated they moved him to room [ROOM NUMBER] and he had bed bugs in there as well, and now he is in his current room [ROOM NUMBER].

Interview on 07/02/24 at 2:45 P.M. with State tested Nursing Assistant (STNA) #809 revealed she confirmed there were bed bugs in the facility and they have been there since May 2024. She stated residents complain about them to her.

Interview on 07/02/24 at 3:21 P.M. with Exterminator #600 revealed all belongings need laundered with high heat, minimize contact, monitor visitation, normally yes they treat the adjacent rooms but this facility only wanted the chemical treatment to the one room where hundreds of bed bugs were found, she stated this would not kill all the bed bugs and they need to do a heat treatment on the infested room and the room next to it due to being the only way to get rid of bed bugs. She confirmed they were scheduled to come out on Friday 07/05/24 to do a heat treatment to room [ROOM NUMBER] and room [ROOM NUMBER].

Interview on 07/09/24 at 11:45 A.M. with the Director of Nursing (DON) #804 confirmed there was one resident (Resident #4) who was treated for bed bug bites. His room was moved from #120 to #105 due to the bed bugs.

Interview on 07/09/24 at 11:52 A.M. with the Environmental Director (ED) #807 confirmed Grace exterminating was here on 07/05/24 and heat-treated Resident rooms #120 and #118 for bed bugs, cut holes

in walls and applied a powder chemical as well for treatment of bed bugs. The facility was tearing out all the drywall in room [ROOM NUMBER] and cabinets and replacing all of them. He stated once they are done with room [ROOM NUMBER], they will move on to #118.

3. Observation made on 07/01/24 at 12:15 P.M. and at 2:40 P.M. revealed there were holes in the walls of rooms for Resident #1 and #79. The holes were in the wall behind the headboards.

Interview on 07/01/24 at 1:02 P.M. with the Environmental Director (ED) #807 revealed he confirmed there were holes in the walls of rooms for Resident #1 and #79. He stated they have the equipment to fix the holes but have not done it yet.

Interview on 07/01/24 at 2:45 P.M. with the Maintenance Director (Main Dir.) #813 revealed he confirmed there were holes in the walls of rooms for Resident #1 and #79. He stated they knew about them but have not fixed them yet. He stated it was from the beds being pushed up against the wall and the headboard put

the holes in the walls.

Observation made on 07/01/24 at 2:48 P.M. revealed the Main Dir. #813 and team working on Resident #79's room installing new floors, due to laminate coming up, there were no subfloors exposed, they were beginning to patch the holes in the wall where the headboard caused damage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0835 Interview on 07/01/24 at 2:53 P.M. with Resident #1 revealed she stated she came to the facility in April but was unsure of the date. She confirmed there were holes in her walls behind her headboard that were pretty Level of Harm - Minimal harm or big, and they bothered her. She stated she told the staff about them, but no one ever fixed them. potential for actual harm

Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she had holes in the walls in Residents Affected - Many her room. She stated she has told the Administration team about them, but they have not been fixed.

Review of the maintenance log from 04/01/24 to 07/01/24 revealed there was no mention of the holes in the walls in rooms for Resident #1 and Resident #79.

This deficiency identified noncompliance during the investigation of Master Complaint Number OH00155219 and Complaint Numbers OH00155024, Oh00154346 and OH00154092.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44461 potential for actual harm Based on observation, staff and resident interviews, record review and review of exterminator invoices the Residents Affected - Few facility failed to maintain an effective pest control program for bed bugs. This affected one resident (Resident #4) of eleven residents reviewed for physical environment and had the potential to affect the additional 77 residents residing in the facility. The facility census was 78.

Findings include:

Review of the medical record for Resident #4 revealed an admitted [DATE REDACTED]. Diagnoses included rash and other nonspecific skin eruption, major depressive disorder, generalized anxiety, hypertension, atrial fibrillation, and hypothyroidism.

Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had intact cognition. He was independent with eating, oral hygiene, toileting hygiene, dressing, and bed mobility. Resident #4 required partial assistance for showers and personal hygiene.

Review of Resident #4's physician orders dated 06/03/24 revealed the resident was prescribed hydrocortisone cream 1%, applied to arms, lower back, and abdomen topically two times a day for itching from rash caused by bed bugs.

Reivew of the exterminator invoice dated 05/23/24 revealed the facility had a chemical treatment completed for bed bugs along with their routine pest control measures. On 06/05/24 they had a chemical treatment for bed bugs completed to room [ROOM NUMBER], and then again on 06/27/24 they had a chemical treatment for bed bugs in the facility along with their monthly pest control measures.

Observation made on 07/01/24 at 2:44 P.M. of the physical environment revealed in resident room [ROOM NUMBER] and room [ROOM NUMBER], both rooms unoccupied at the time of the observation, there were multiple bed bugs present.

Interview on 07/01/24 at 2:58 P.M. with Resident #21 revealed she confirmed there are bed bugs in the rooms across the hall from her in rooms 118 and room [ROOM NUMBER]. She stated the exterminators have been out multiple times with no luck of getting rid of them. She stated she had seen them in the hallway as well.

Interview on 07/01/24 at 3:22 P.M. with STNA #808 revealed she confirmed there were bed bugs in the facility in the room of Resident #4, and also in room [ROOM NUMBER] and 101. She stated the facility was only using chemicals to try to get rid of them however you have to heat treat everything in order to eradicate them.

Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he confirmed he was being treated for bed bug bites, he had them in his room when he occupied room [ROOM NUMBER]. He stated they moved him to room [ROOM NUMBER] and he had bed bugs in there as well, and now he is in his current room [ROOM NUMBER].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 28 365412 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 365412 B. Wing 07/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

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)

F 0925 Interview on 07/02/24 at 2:45 P.M. with State tested Nursing Assistant (STNA) #809 revealed she confirmed there were bed bugs in the facility and they have been there since May 2024. She stated residents complain Level of Harm - Minimal harm or about them to her. potential for actual harm

Interview on 07/02/24 at 3:21 P.M. with Exterminator #600 revealed all belongings need laundered with high Residents Affected - Few heat, minimize contact, monitor visitation, normally yes they treat the adjacent rooms but this facility only wanted the chemical treatment to the one room where hundreds of bed bugs were found, she stated this would not kill all the bed bugs and they need to do a heat treatment on the infested room and the room next to it due to being the only way to get rid of bed bugs. She confirmed they were scheduled to come out on Friday 07/05/24 to do a heat treatment to room [ROOM NUMBER] and room [ROOM NUMBER].

Interview on 07/09/24 at 11:45 A.M. with the Director of Nursing (DON) #804 confirmed there was one resident (Resident #4) who was treated for bed bug bites. His room was moved from #120 to #105 due to the bed bugs.

Interview on 07/09/24 at 11:52 A.M. with the Environmental Director (ED) #807 confirmed Grace exterminating was here on 07/05/24 and heat-treated Resident rooms #120 and #118 for bed bugs, cut holes

in walls and applied a powder chemical as well for treatment of bed bugs. The facility was tearing out all the drywall in room [ROOM NUMBER] and cabinets and replacing all of them. He stated once they are done with room [ROOM NUMBER], they will move on to #118.

This deficiency represents noncompliance investigated under Complaint Number OH00155219, OH00154346 and OH00154092.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 28 365412