Inspection·June 1, 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 interview, record review, review of the dialysis contact, and review of the facility policy on change in condition the facility failed to ensure Resident #65's emergency contact/ family was notified regarding his change in condition requiring cardiopulmonary resuscitation (CPR) and transport to the hospital. This affected one resident (#65) out of three residents reviewed for change in condition. The facility census was 64. Findings include: Review of the closed medical record for Resident #65 revealed an admission date of [DATE]. The resident expired at the hospital on [DATE]. His diagnoses included acute respiratory failure with hypoxia, dependence on renal dialysis, ventilator dependent, diabetes, atrial flutter, tachycardia, biventricular heart failure, and tracheostomy. Review of the care plan dated [DATE] revealed Resident #65 had advanced directives to be a full code. Interventions included full code, adhere to his desired code status, and inform the resident and/or responsible party should the resident change his decision regarding his code status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had impaired cognition and was rarely and/or never understood. He required oxygen, suctioning, and dialysis. He also had a tracheostomy and ventilator. He required two person staff assist with bed mobility and was unable to transfer and/or ambulate. Review of the nursing note dated [DATE] at 8:10 A.M. and completed by the Director of Nursing revealed Resident #65 was unresponsive and without vitals while at dialysis. The note revealed CPR was initiated and the emergency rescue squad (EMS) was called. CPR continued with (Automated External Defibrillator) AED in place until the ambulance arrived and he was transported to the hospital. The note revealed dialysis was to make the family aware of the resident's transfer. Interview on [DATE] at 8:20 A.M. with Resident #65's sister revealed she was upset that the facility and/or dialysis had not contacted her that her brother had a change in condition while at dialysis requiring CPR and transfer to the hospital. She revealed she was not notified until later in the day by the coroner that Resident #65 had passed away. Interview on [DATE] at 8:14 A.M. with Licensed Practical Nurse (LPN) #600 revealed she was Resident #65's nurse on [DATE]. She revealed he had gone to dialysis which was next door, and she was contacted over a walkie-talkie that he had stopped breathing and had no vitals requiring CPR. She revealed (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: 365411 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 365411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Andover Village Retirement Community 486 S Main St Andover, OH 44003 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)