Inspection·March 20, 2024

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 medical record review, staff and resident interview, and policy review, the facility failed to notify resident representatives of a change in condition requiring a transfer to the hospital. This affected two (#27 and #66) of four residents reviewed for change in condition. The facility census was 65. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/09/23 with diagnoses including chronic atrial fibrillation, congestive heart failure, type two diabetes, hypertension, amputation between the left knee and ankle, and acquired absence of the right foot. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was assessed as cognitively intact and was dependent on staff for activities of daily living (ADLs). Review of a nurses note dated 02/03/24 at 11:16 A.M. revealed Resident #27 was sent to the hospital for evaluation and treatment. Further review of the note and the medical record revealed no evidence Resident #27's family or representative were notified of the transfer to the hospital. Interview on 03/20/24 at 11:04 A.M. with Resident #27 verified his family was not notified when he went to the hospital the last time, and he would have liked them to have been notified. Resident #27 stated he was admitted and spent a couple days in the hospital for pneumonia. 2. Review of the medical record for Resident #66 revealed an admission date of 12/14/23 and discharge date of 01/01/24. Diagnoses included acute on chronic respiratory failure with hypoxia, dependence on respirator, tracheostomy, type two diabetes, right-sided heart failure, atrial fibrillation, cellulitis of bilateral lower limbs, alcoholic hepatitis, alcoholic cirrhosis of liver, depression, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #66 was assessed as cognitively intact and was dependent on staff for ADLs. Review of the Situation, Background, Assessment, and Recommendation (SBAR) communication form and progress note dated 01/01/24 revealed Resident #66 had an increased heart rate, decreased oxygen saturation rate, and decreased blood pressure. Resident #66 also had new onset of left flank pain. An order was received to send Resident #66 to the hospital. Further review of the SBAR form, progress note, and the medical record revealed no evidence Resident #66's family was notified of the transfer to the hospital. (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 3 Event ID: 365523 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 365523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616 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)