Health inspection·February 6, 2020

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents and/or resident representatives received written notification for the reason for the discharge to the hospital in an easily understood language at the time of the discharge or within twenty-four hours as appropriate. This finding affected six (Residents #1, #25, #39, #82, #83 and #89) of six resident records reviewed for hospitalization. The facility census was 85. Findings include: 1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, type two diabetes and muscle weakness. Review of Resident #25's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #25's progress note dated 12/02/19 at 11:59 P.M. indicated the resident was admitted to the hospital with a diagnosis of intractable vomiting. Interview on 02/05/20 on 9:18 A.M. with the Administrator confirmed the facility did not provide Resident #25 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, overactive bladder, mixed hyperlipidemia and other Alzheimer's disease. Review of Resident #1's MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #1's progress note dated 01/13/20 at 5:37 P.M. indicated the nurse was called to the dining room due to the resident shaking and not feeling well. The resident had a small emesis and complained of cough and congestion. The resident sent to the emergency room and the guardian was notified. Interview on 02/05/20 at 9:18 A.M. with the Administrator confirmed the facility did not provide Resident #1 or the resident's representative written notification of the reason of the discharge to the hospital at the time of the discharge or within twenty-four hours as appropriate in an easily understood language. 3. Review of Resident #82's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic heart disease, hemiplegia, schizophrenia, bipolar disorder and Alzheimer's Dementia. Review of Resident #25's MDS 3.0 assessment dated [DATE] indicated the resident's memory was impaired. Review of Resident #82's progress note dated 12/19/19 at 11:12 P.M. indicated the resident was admitted to the hospital with an diagnosis of acute mental status change. Interview on 02/05/20 on 9:18 A.M. with the Administrator confirmed the facility did not provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365545 If continuation sheet Page 2 of 6 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 365545 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarfield at Ashley Circle 5291 Ashley Circle Youngstown, OH 44515 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Resident #82 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 4. Review of Resident #89's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cancer of the colon, cancer of the liver and type two diabetes. Review of Resident #89's progress note dated 11/11/19 at 9:03 A .M. indicated resident was sent to the hospital due to labored breathing and generalized weakness and was admitted . Interview on 02/05/20 at 9:18 A.M. with the Administrator confirmed the facility did not provide Resident #1 or the resident's representative written notification of the reason of the discharge to the hospital at the time of the discharge or within twenty-four hours as appropriate in an easily understood language. 5. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #83's MDS 3.0 assessment dated [DATE] indicated the resident's memory was intact. Review of Resident #83's progress note dated 01/25/20 at 8:45 P.M. indicated the resident was admitted to the hospital with respiratory distress . Interview on 02/05/20 on 9:18 A.M. with the Administrator confirmed the facility did not provide Resident #83 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 6. Review of Resident #39's medical record revealed an admission date of 08/13/18 with diagnoses including multiple sclerosis, partial small bowel obstruction and paraplegia. Review of Resident #39's MDS 3.0 assessment dated [DATE] indicated resident was cognitively intact. Review of Resident #39's progress notes dated 11/30/19 at 4:53 P.M. revealed the resident was admitted to the hospital with a diagnosis of small bowel obstruction. Interview on 02/05/20 at 9:18 A.M. with the Administrator confirmed the facility did not provide Resident #39 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty four hours in a easily understood language. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365545 If continuation sheet Page 3 of 6 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 365545 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarfield at Ashley Circle 5291 Ashley Circle Youngstown, OH 44515 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure Resident #50's pacemaker check was completed accurately and sent to the physician's office and did not ensure nurse aides did not disconnect tube feeding for Resident #53. This affected one resident (Resident #50) of one resident reviewed for pacemaker checks and one resident (Resident #53) of four residents (Resident #6, Resident #28, Resident #39 and Resident #53) reviewed for tube feedings. The facility census was 85. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 04/10/18 with diagnoses including congestive heart failure, hypertensive heart disease with heart failure, left ventricular failure and a cardiac defibrillator placement 04/21/14. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive impairment. Review of the physician's orders for Resident #50 dated 12/12/19 revealed a pacemaker check every three months. Make sure the resident is in her room near the machine and it is turned on, then press the heart button and follow the prompts; to start 12/18/19. Observation on 02/03/20 at 1:22 P.M. revealed a white box with the words Boston Scientific Latitude sitting on Resident #50's bedside stand with a heart shaped button in the middle of it with a blinking green light. Interview on 02/03/20 at 1:22 P.M. with Resident #50 indicated I have been waiting for parts for my heart monitor for a couple weeks. Interview on 02/05/20 at 8:05 A.M. with the Director of Nursing (DON) revealed the information from Resident #50's pacemaker did not get sent to the physician's office on 12/18/19 as ordered by the physician. The facility did not find out the information was not sent to the physician's office until Insurance Representative (IR) #807 called the physician's office on 01/23/20 and was told the information did not get transmitted. Interview on 02/05/20 at 8:15 A.M. with Licensed Practical Nurse (LPN) #806 revealed on 12/18/19 she took Resident #50 to her room and had her sit in front of the machine and pushed the button on the heart monitor. An orange light started flashing from the monitor and did not change to a different color. The lights stopped flashing and nothing else happened. LPN #806 did not know if the information had been sent but thought the physician's office would call if they did not receive it. Interview on 02/05/20 at 8:37 A.M. with IR #807 revealed he contacted Resident #50's daughter via telephone on 01/23/20 and was told the physician's office had contacted her because the pacemaker information had not been received from the facility on 12/18/19. Resident #50's daughter did not call the facility about the missing information. IR #807 then called the physician's office and was told they did not receive the pacemaker information from Resident #50. IR #807 contacted the manufacturer of the pacemaker home monitor and was informed that a cellular adapter was needed to send the data. The cellular adapter was ordered and mailed to the facility on [DATE] and had not been received yet. Interview on 02/05/20 at 9:01 A.M. with the DON revealed the facility did not have an in-service on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365545 If continuation sheet Page 4 of 6 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 365545 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarfield at Ashley Circle 5291 Ashley Circle Youngstown, OH 44515 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 0726 the operation of Resident #50's home heart monitor. Level of Harm - Minimal harm or potential for actual harm Interview on 02/05/19 at 12:50 P.M. with the DON revealed Resident #50 had an appointment with her cardiologist on 05/08/19 and was given the heart home monitor at that time. At an appointment on 09/18/19, Resident #50 was told that the heart home monitor would be used for the next data check. Residents Affected - Few Interview on 02/07/20 at 2:08 P.M. with Manufacturer Representative (MR) #810 revealed the cellular adapter was received and signed for by the facility on 01/27/20 at 10:48 A.M. Review of information provided by the facility titled Latitude Communicator, dated 03/2015, revealed connection method using cellular data network required an adapter kit which was available separately. Further review revealed the Communicator can perform a patient initiated Interrogation by pressing the heart button located in the middle of the Communicator. The Interrogation was complete and had been sent to Latitude when all the waves were lit green. 2. Review of the medical record for Resident #53 revealed an admission date of 12/17/18 with diagnoses including intracranial injury without loss of consciousness, acute respiratory failure with hypoxia, paraplegia and the resident had a percutaneous endoscopic gastrostomy (peg) tube. Review of the MDS 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) was unable to be conducted because resident was rarely/never understood. Review of Resident #53's physician's orders revealed enteral feeding every day and night shift, Isosource HN (tube feeding) running continuously at 62 milliliters (ml) per hour. Observation on 02/03/20 at 1:50 P.M. revealed Resident #53 lying in bed with his side rails up and tube feeding running continuously at 62 ml per hour via peg tube. Interview on 02/03/20 at 1:58 P.M. with Resident #53's mother revealed two days ago when the State Tested Nursing Assistants (STNAs) were putting Resident #53 back to bed from his chair, the back of his gown and pants were saturated with tube feeding. She stated this had happened eight times recently when the STNAs disconnected the tube feeding from the peg tube when they moved Resident #53 from bed to chair and chair to bed. The STNAs stop the tube feeding, disconnect the tube feeding from the peg tube, place a plastic cap on the end of it and hang the tubing on the tube feeding pump. When they are finished moving Resident #53, they take the tubing with the plastic end on it, connect it to the peg tube without removing the plastic cap and turn the pump back on. The tube feeding begins to run, but cannot flow into the peg tube because of the plastic cap. Instead the tube feeding backs up and flows onto the resident and saturates his clothing. Resident #53's mother stated that she told the staff this was happening and they got mad at me and will not talk to me. Interview on 02/06/20 at 11:15 A.M. with STNA #804 revealed STNA #804 will re-connect Resident #53's tube feeding if she cannot find a nurse, and turn it back on. When I turn the tube feeding on I make sure the tube feeding bag is full and the rate is 62 ml per hour. STNA #804 further stated she makes sure the lighted circle is on and working that shows the pump is infusing the tube feeding. Review of facility policy titled Job title: State Tested Nursing Assistant, undated, revealed no instruction for administration of tube feeding to the residents. Review of facility policy titled IIB12: Enteral Tube Medication Administration, revised 01/2018, revealed no documentation that STNA's are able to administer tube feedings to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365545 If continuation sheet Page 5 of 6 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 365545 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarfield at Ashley Circle 5291 Ashley Circle Youngstown, OH 44515 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #33's medical record accurately coded the medications administered to the resident. This finding affected one (Resident #33) of one resident reviewed for dialysis. Findings include: Review of Resident #33's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including dependence on renal dialysis and end stage renal disease. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Review of Resident #33's physician orders revealed an order dated 12/06/18 for aspirin enteric coated give 81 mg (milligrams) by mouth one time a day related to atherosclerotic heart disease, an order dated 04/14/17 for fish oil capsule 1000 mg give one time a day related to cardiomyopathies, an order dated 12/26/18 for Neurontin capsules give 200 mg by mouth in the morning for neuropathy, an order dated 04/19/17 for renal capsule one mg give by mouth one time a day for vitamin supplement, an order dated 04/14/17 for vitamin D give 4000 units by mouth one time a day for a vitamin supplement, and an order dated 10/01/19 for Eliquis five mg give one tablet by mouth two times a day for atrial fibrillation. Review of Resident #33's medication administration records (MAR) from 01/01/20 to 02/05/20 revealed the aspirin, fish oil, Neurontin, renal capsule, vitamin D and Eliquis were documented on the MAR dated 01/10/20, 01/13/20, 01/15/20, 01/22/20, 02/03/20 and 02/05/20 as away from home with medications (Code #1). Interview on 02/04/20 at 1:50 P.M. with Corporate Registered Nurse (RN) #803 confirmed the nursing staff inaccurately signed medications were given to the resident to be administered when she was away from the facility. Corporate Registered RN #803 stated the facility investigation verified the staff actually administered the resident's medications but coded it inaccurately in the resident's record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365545 If continuation sheet Page 6 of 6