Health inspection·May 2, 2022

F 0570 Resident #27 had $2045.64 Level of Harm - Minimal harm or potential for actual harm Resident #31 had $1121.27 Resident #32 had $3113.31 Residents Affected - Some This equaled a total for all residents of $23,396.89. Review of the facility surety bond from [NAME] Insurance Company, effective 01/22/22 revealed the facility had coverage for resident accounts in the amount of $20,000.00. On 04/29/22 at 9:00 A.M. interview with Business Office Manager #42 verified the amount of coverage on the surety bond did not cover the total amount of the resident accounts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 2 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of advance beneficiary notices, facility policy and procedure review and staff interview the facility failed to ensure residents and/or their responsible parties received the appropriate advance beneficiary notices when discharged /cut from Medicare (MCR) Part A services. This affected two residents (#11 and #183) of three residents reviewed for liability/beneficiary protection notification. Residents Affected - Few Findings include: 1. A review of the facility list of residents, who received a liability notice in the past six months, revealed Resident #11 was cut from MCR Part A services on 12/24/21. The resident was identified as having remained in the facility after her skilled service had ended. The facility was not able to provide documented evidence of Resident #11 and/or the resident's representative receiving the CMS Form 10055 (Skilled Nursing Facility Advance Beneficiary Notice) that should have been provided to the resident and/or the resident's representative when she was cut from MCR Part A services. On 04/27/22 10:51 A.M. interview with Business Office Manager #42 confirmed the facility did not provide a CMS Form 10055 (Skilled Nursing Facility Advance Beneficiary Notice) to Resident #11 when the resident was cut from MCR Part A services. 2. A review of the facility list of residents, who received a liability notice in the past six months, revealed Resident #183 was cut from MCR Part A services on 10/12/21 . Resident #183 was identified as not having remained in the facility after her skilled service had ended. The facility was not able to provide documented evidence of Resident #183 and/or the resident's representative receiving the CMS Form 10055 (Skilled Nursing Facility Advance Beneficiary Notice) that should have been provided to the resident and/or the resident's representative when she was cut from MCR Part A services. On 04/27/22 10:51 A.M. interview with Business Office Manager #42 confirmed the facility did not provide a CMS Form 10055 (Skilled Nursing Facility Advance Beneficiary Notice) to Resident #183 when the resident was cut from MCR Part A services. Review of the undated facility policy titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of NON coverage (SNFABN) revealed SNFABN provides information to the beneficiary so that he or she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF prospective payment system (Medicare part A). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 3 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #10, Resident #13, Resident #27 and Resident #32 were free from potential incidents of misappropriation when receipts for monies removed from their personal funds account were not completed/maintained. This affected four residents (#10, #13 #27 and #32) of five residents whose personal funds were reviewed. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, convulsions, major depressive disorder, Alzheimer's dementia, hypertension, anxiety, and cognitive communication deficit. Review of the Resident Fund Management Service authorization and agreement form, dated 05/15/17 revealed Resident #13 had a resident funds account with the facility and his social security check was deposited into the account by an automatic transfer every month. The resident had a $50.00 monthly allowance. The form was signed by the brother for Resident #13 who was the resident's legal representative. Review of the Resident Statement Landscape for Resident #13 revealed on 12/09/21 $1000.00 was withdrawn from the resident's account for personal need items. Review of a copy of check number 1485 revealed a check was written out to the legal representative of Resident #13 on 12/09/21 in the amount of $1000.00 for Christmas gifts. However, there was no receipt/sign out for the money when it was withdrawn from the account and there were no receipts for the items purchased with the money. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/18/22 revealed Resident #13 had severely impaired cognition. On 04/28/22 at 3:26 P.M. interview with Business Office Manager (BOM) #42 revealed she had called all the families and asked them what they wanted to do with the residents' stimulus money. She indicated she had not told the families how to use the money but allowed them to make the decision with what to do with the money. She verified she did not have any receipt(s) for what the $1000.00 for Resident #13 was spent on. 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, diabetes and hemiplegia affecting left side. Review of the Resident Fund Management Service authorization and agreement form, dated 05/06/19 revealed Resident #10 had a resident funds account with the facility and his social security check was deposited into an account by automatic transfer every month. The resident had a $50.00 monthly allowance. The form was signed by the resident's son, who was his legal representative. Review of the Resident Statement Landscape for Resident #10 revealed a withdrawal for $2700.00 on 05/06/21 for personal care items, $700.00 on 11/18/21 for personal care items and on 12/15/21 a withdrawal of $700.00 for personal care items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 4 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0602 Level of Harm - Minimal harm or potential for actual harm Review of the receipt number 826737, dated 05/21/21 revealed the son of Resident #10 withdrew $2700.00 for personal needs and a gift to the son. Review of the check number 1449, dated 05/21/21 revealed a check for $2700.00 was written to the son of Resident #10 and written in the memo line was a gift from dad. Residents Affected - Few There was no documentation for the withdrawal on 11/18/21 for $700.00. Review of receipt number 085570, dated 12/14/21 revealed the son and daughter in law for Resident #10 withdrew $700.00 for Christmas and personal needs. Review of the check number 1488, dated 12/14/21 revealed a check for the amount for $700.00 was written to the son of Resident #10 and written in the memo line was written from dad, Merry Christmas. On 04/28/22 at 3:40 P.M. interview with Resident #10 revealed he did not know about the withdrawals but stated his son had purchased a new wheelchair for him. On 04/28/22 at 3:46 P.M. interview with Family Member #51 revealed his father gave him the $2700.00 because he was having financial problems and needed the money. On 04/28/22 at 3:26 P.M. interview with Business Office Manager (BOM) #42 revealed she had called all the families and asked them what they wanted to do with the residents' stimulus money. She indicated she had not told the families how to use the money but allowed them to make the decision with what to do with the money. She verified she did not have any receipts for what the $2700.00 or the two $700.00 withdraw's for Resident #10 were spent on and, she verified she could not find the receipt for the disbursement of the $700.00 on 11/18/21. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included hypertension, dementia, malignant neoplasm of the cervix, diabetes, and osteoarthritis. Review of an undated Resident Fund Management Service authorization and agreement form revealed Resident #32 had a resident funds account with the facility and the resident's social security check was deposited into an account by automatic transfer every month. The resident had a $50.00 monthly allowance. The form was signed by the resident. Review of the Resident Statement Landscape for Resident #32 revealed a withdrawal for $1000.00 on 12/10/21 for personal care items, $700.00 on 11/18/21 for personal care items and on 12/15/21 for personal care items. Review of the receipt number W001052 dated 12/09/21 revealed the daughter of Resident #32, who was not the resident's power of attorney (POA), withdrew $1000.00 for personal care needs. Review of the check number 1487, dated 12/03/21 revealed a check for $1000.00 was written to the daughter of Resident #32 and written in the memo line was Christmas from mom. Review of the quarterly MDS 3.0 assessment, dated 04/11/22 revealed Resident #32 had moderately impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 5 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0602 Level of Harm - Minimal harm or potential for actual harm On 04/28/22 at 3:26 P.M. interview with Business Office Manager (BOM) #42 revealed she had called all the families and asked them what they wanted to do with the residents' stimulus money. She indicated she had not told the families how to use the money but allowed them to make the decision with what to do with the money. She verified she did not have any receipts for what the $1000.00 withdrawal for Resident #32 was spent on. She verified the daughter of Resident #32 was not the resident's POA. Residents Affected - Few On 04/28/22 at 3:45 P.M. interview with Resident #32 revealed she did not remember giving her daughter $1000.00 at Christmas. She stated her family and facility makes those decisions. 4. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, epilepsy, developmental disorders of motor function and schizoaffective disorder. Review of the Resident Fund Management Service authorization and agreement form, dated 07/17/20 revealed Resident #27 had a resident funds account with the facility. The resident had a $50.00 monthly allowance. The form was signed by the resident's brother who was the resident's legal representative. Review of the Resident Statement Landscape for Resident #27 revealed a withdrawal for $1500.00 on 12/29/21 for personal care items. Review of the receipt number W001057, dated 12/22/21 revealed the brother of Resident #27 withdrew $1500.00 for personal care needs. The note line indicted it was for Christmas gifts for the family. Review of the check number 1490, dated 12/22/21 revealed a check for $1500.00 was written to the brother of Resident #27 and written in the memo line was Christmas gifts. On 04/28/22 at 3:26 P.M. interview with Business Office Manager (BOM) #42 revealed she had called all the families and asked them what they wanted to do with the residents' stimulus money. She indicated she had not told the families how to use the money but allowed them to make the decision with what to do with the money. She verified she did not have any receipts for what the $1500.00 withdrawal for Resident #27 was spent on. Review of the facility policy titled Abuse, Neglect, Misappropriation, Mistreatment Policy and Procedure, dated 03/19 revealed the goal of the facility was that its residents would be protected from verbal, mental, sexual, or physical abuse, corporal punishment mistreatment, neglect, involuntary seclusion and misappropriation of property through the development of operationalized policies and procedures. The resident would not be subjected to abuse, neglect, mistreatment, or misappropriation of property (ANM) by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members or legal guardians. AM reports or investigations involving ANM would be reviewed by and conducted through the facilities CQI committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 6 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, facility policy and procedure review and interview the facility failed to ensure all staff were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 33 residents residing in the facility. Residents Affected - Many Findings include: Review of staff personnel files for staff hired since the last annual recertification survey revealed the following: a. Review of Housekeeping/Laundry Supervisor #15's personnel file revealed a hire date of 06/16/21. There was no evidence Housekeeping/Laundry Supervisor #15's name had been checked against the NAR for potential findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. b. Review of [NAME] #48's personnel file revealed a hire date of 07/21/20. There was no evidence [NAME] #48's name had been checked against the NAR for potential findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. c. Review of Housekeeper #11's personnel file revealed a hire date of 07/20/21. There was no evidence Housekeeper #11's name had been checked against the NAR for potential findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. d. Review of Activity Assistant #49's personnel file revealed a hire date of 06/01/21. There was no evidence Activity Assistant #49's name had been checked against the NAR for potential findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Review of the undated facility policy titled Abuse Prevention Program revealed employee background checks were conducted as part of the screening program and the facility would not knowingly employ any individual convicted of abuse, neglecting or mistreating a resident. The policy did not address monitoring or checking information on the NAR for all staff to determine if the staff member had any findings of possible findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. On 04/08/22 at 1:46 P.M. interview with Human Resources Director (HR) #45 revealed only nursing assistant staff had their names checked against the NAR to determine if the staff member had any findings of possible findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. HR #45 revealed nurses and other licensed personnel were checked only through their licensing boards to ensure the person was in good standing and to see if there was any board action against their license. HR #45 verified the above employees, whose personnel files were reviewed, interacted or could interact with residents and were not checked on the NAR to ensure there were no findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. On 04/28/22 at 2:46 P.M. interview with the facility Medical Director revealed he provided input into facility policies. The medical director revealed staff had never addressed issues with checking potential hires for findings on the NAR and he just assumed the facility staff were doing it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 7 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 - Minimal harm or potential for actual harm 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** 2. Review of Resident #30's medical record revealed diagnoses including ileus, cerebral palsy, and quadriplegia. Residents Affected - Few A nursing note, dated 03/21/2022 at 12:12 A.M. indicated Resident #30's abdomen had been distended. Results of portable abdomen were received and the Nurse Practitioner gave orders to send Resident #30 to the hospital for a computed tomography (CT) scan due to a probably ileus. An ileus is the temporary slowing of digestive tract mobility which can lead to a buildup and blockage in the digestive tract. A nursing note dated 03/21/22 at 7:01 A.M. indicated the hospital reported Resident #30 would be admitted for possible ileus/impaction. Review of a Transfer/Discharge Report, dated 03/21/22 indicated Resident #30 was sent to the hospital on [DATE] related to abdominal x-rays indicating a probable ileus. The report revealed the physician requested a CT scan immediately. The Transfer/Discharge Report did not contain information regarding appeal rights or contact information for the Office of the State Long-Term Care Ombudsman. There was no evidence of the Office of the State Long-Term Care Ombudsman being notified of the transfer or receiving a copy of the Transfer/Discharge Report. On 04/27/22 at 9:28 A.M. interview with the Administrator verified the transfer/discharge notice did not include contact information for the Office of the State Long-Term Care Ombudsman or appeal information. The Administrator indicated there had been staffing changes at the facility and she was unable to locate any evidence the State Long Term Care Ombudsman office was notified of Resident #30's transfer to the hospital. 3. Review of Resident #33's medical record revealed diagnoses including chronic obstructive pulmonary disease, heart failure and obstructive sleep apnea. A nursing note, dated 02/24/22 at 11:23 P.M. indicated Resident #33 had difficulty breathing and was in distress. The physician was notified and gave an order to send Resident #33 to the emergency department for evaluation and treatment. A nursing note dated 02/25/22 at 1:27 A.M. indicated Resident #33 was being admitted to the hospital for respiratory failure and pneumonia. Review of a Transfer/Discharge Report, dated 02/24/22 indicated Resident #33 was sent to the emergency room on [DATE] related to difficulty breathing and oxygen saturations in the 60's to 70's prior to oxygen being increased. The Transfer/Discharge Report did not contain information regarding appeal rights or contact information for the Office of the State Long-Term Care Ombudsman. There was no evidence of the Office of the State Long-Term Care Ombudsman being notified of the transfer or receiving a copy of the Transfer/Discharge Report. On 04/27/22 at 9:28 A.M. interview with the Administrator verified the transfer/discharge notice did not include contact information for the Office of the State Long-Term Care Ombudsman or appeal information. The Administrator indicated there had been staffing changes at the facility and she was unable to locate any evidence the State Long Term Care Ombudsman office was notified of Resident #33's transfer to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 8 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the Ombudsman was notified of transfer/discharges for Resident #24, Resident #30 and Resident #33 as required. This affected three residents (#24, #30 and #33) of 16 sampled residents reviewed for hospitalization. Findings include: Residents Affected - Few 1. Review of the medical record for Resident #24 revealed an admission date of 09/30/21 with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, peripheral vascular disease, and hypertension. Review of Resident #24's nursing note, dated 02/07/22 revealed Resident #24 was admitted to the hospital on this date. Record review revealed no evidence the Ombudsman was notified of the resident's hospital transfer. Review of Resident #24's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #24 had intact cognition. On 04/27/22 at 9:45 A.M. interview with the Administrator verified there was no evidence Resident #24's transfer/discharge notice was sent to the Office of the State Long - Term Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 9 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview the facility failed to ensure a comprehensive plan of care was developed and implemented for Resident #24 related to falls/fall risk. This affected one resident (#24) of sixteen residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/30/21 with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, peripheral vascular disease and hypertension. Review of Resident #24's Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 04/15/22 revealed Resident #24 had intact cognition. The assessment revealed the resident's balance was not steady during transitions and walking and the resident used a wheelchair for mobility. Review of Resident #24's Fall Risk Data Collection Tools, dated 09/30/21 and 03/19/22 revealed Resident #24 was at a moderate risk for falling. Review of Resident #24's nursing notes dated 03/19/22 revealed Resident #24 had an unwitnessed fall from a chair and was transported to the hospital for evaluation. Review of Resident #24's nurse practitioner note, dated 03/20/22 revealed Resident #24 stated he fell out of a chair when trying to get up, he called for help and was assisted by nursing staff. Record review revealed no evidence the facility had developed or implemented a fall risk plan of care for Resident #24. On 04/28/22 at 12:53 P.M. interview with the Director of Nursing revealed Resident #24 was re-educated on using the call light for assistance and verified Resident #24's comprehensive care plan did not include a plan regarding falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 10 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to promptly identify, monitor/assess and implement effective treatment for Resident #4 following the development of an in-house pressure ulcer to the resident's left buttock to prevent the deterioration of the ulcer and promote optimal healing. This affected one resident (#4) of two residents reviewed for pressure ulcers. Residents Affected - Few Actual harm occurred on 03/07/22 when Resident #4, who was at risk for skin breakdown (but admitted with intact skin), cognitively impaired and dependent on staff for all activities of daily living including turning and repositioning, was identified to have an unstageable pressure ulcer (a full-thickness tissue loss with exposed bone, tendon or muscle with slough/eschar present which prevents accurate staging of the ulcer and often include undermining and tunneling) to the left buttocks. On 01/31/22 the resident developed an in-house Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to the left buttock area. There was no evidence of the implementation of interventions (including turning and repositioning) at that time. The ulcer was not assessed from 02/07/22 to 02/28/22. A wound nurse practitioner assessment, dated 03/14/22 was incomplete (lacking measurements) and identified the pressure ulcer had deteriorated. No plan of care was initiated related to the pressure ulcer until 03/23/22. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with dependence on a ventilator, diabetes mellitus, hypertension, adult failure to thrive, pneumonia and traumatic hemorrhage of the cerebrum. Review of the admission assessment, dated 01/21/22 revealed Resident #4 had no open areas/pressure ulcers. The skin assessment revealed the resident had very dry heels. Review of the physician's orders revealed an order, dated 01/21/22 for Resident #4 to have a pressure relieving mattress to his bed. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/28/22 revealed Resident #4 had severely impaired cognition and required total assistance from staff for all activities of daily living (ADL) care. The assessment revealed the resident was incontinent of bowel, had an indwelling urinary catheter, was at risk for developing pressure ulcers and did not have any open areas/pressure areas. Review of the Braden (skin risk) assessment, dated 01/28/22 revealed Resident #4 scored a 10.0 which indicted he was at high risk for developing pressure ulcers. Record review revealed there was no pressure ulcer prevention plan of care initiated. Review of a skin assessment, dated 01/28/22 revealed the skin of Resident #4 was clean, dry, and intact with no new areas observed. Review of the nurse's note, dated 01/31/22 at 10:00 A.M. revealed the nurse was called to the resident's room by the nursing assistant became Resident #4 had an open area to the left buttock which measured 6.0 centimeters (cm) in length by 3.0 cm in width by 0.1 cm in depth. There was no drainage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 11 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0686 Level of Harm - Actual harm Residents Affected - Few The wound nurse practitioner was in the facility and ordered to cleanse the wound with normal saline (NSS), apply alginate and a dry dressing daily. The note indicated the physician and daughter were updated. Review of the physician's order, dated 01/31/22 revealed Resident #4 received an order for the nutritional supplement, ProStat twice daily (protein supplement) and an order to cleanse right buttock with NSS, apply alginate and dry dressing daily and as needed. This order was for the wrong buttock and was not discontinued until 03/16/22. Review of the Weekly Skin/Wound Grid dated 01/31/22 revealed Resident #4 had an in facility, Stage II pressure ulcer to the left buttock that measured 6.0 cm in length by 3.0 cm in width by 0.1 cm in depth. The wound bed had 100 percent (%) pink granulation with a scant amount of serosanguinous drainage. There was no odor, and the surrounding skin was dry and intact. Review of the wound care services (WCS) note, dated 01/31/22 revealed Resident #4 had a Stage II pressure ulcer to the left buttock. The wound was pink, superficial with a small amount of serosanguinous drainage. the note recommend repositioning every two hours, low air loss mattress, gently clean the wound bed, pat dry, apply alginate cut to the wound size, and cover with an adhesive foam dressing daily and as needed. Review of the Braden Scale assessment, dated 02/04/22 revealed Resident #4 scored a 9.0 which indicted he was at very high risk for developing pressure ulcers. There was no pressure ulcer prevention plan of care initiated at that time. Review of the medical record revealed there were no wound assessments/measurements completed on 02/07/22, 02/14/22, 02/21/22 or 02/28/22 for the left buttock wound for Resident #4. Review of the physician's order, dated 02/22/22 revealed an order for a low air loss mattress to the resident's bed at all times for skin breakdown. Review of the resident's medical record, including treatment administration records (from admission through 03/07/22) revealed no evidence staff were repositioning (turning and repositioning) the resident as a pressure ulcer prevention measure prior to the development of the left buttocks pressure ulcer or every two hours as recommended in the wound care service note on 01/31/22. Review of the Weekly Skin/Wound Grid, dated 03/07/22 revealed Resident #4 had an unstageable pressure ulcer to the left buttock which measured 5.0 cm in length by 9.0 cm in width by an undetermined depth. The wound bed had 100% tan adherent slough pink granulation with a scant amount of serosanguinous drainage. There was no odor, and the surrounding skin was dry and intact. Review of the Weekly Skin/Wound Grid, dated 03/14/22 revealed Resident #4 had an unstageable pressure ulcer to the left buttock which measured 11.0 cm in length by 6.0 cm in width by undetermined depth. The wound bed had 75 % tan adherent slough and 25% necrotic tissues which was debrided at bedside by the nurse practitioner (NP). There was a moderate amount of serosanguinous drainage with no odor. Review of the WCS note, dated 03/14/22 revealed Resident #4 had an unstageable pressure ulcer to the left buttock which had deteriorated. The wound was debrided. The note indicated recommend repositioning every two hours, low air loss mattress, gently clean the wound bed, pat dry, apply Dakin's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 12 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0686 solution dampened sterile gauze and lightly pack the wound bed, and cover with an adhesive foam dressing daily and as needed. There were no measurements of the wound contained in the WCS note. Level of Harm - Actual harm Residents Affected - Few Review of the physician's orders revealed an order, dated 03/17/22 to cleanse the left buttock with NSS, apply Sodium hypochlorite, lightly pack the wound bed daily and as needed. The order was written three days after the NP recommended it (on 03/14/22). Review of the plan of care, initiated on 03/23/22 revealed Resident #4 had pressure ulcer development due to immobility. Interventions included to administer medication as ordered, monitor nutritional status, obtain, and monitor laboratory work as ordered, follow facility policy/protocol for skin breakdown, monitor dressing to ensure it was intact and adhering, and administer treatments as ordered. Review of the nurse's note, dated 03/24/22 at 6:17 A.M. revealed Resident #4 was being sent out to the hospital due to no urine output and blood in his urinary drainage bag. Review of the medical record revealed Resident #4 was re-admitted to the facility on [DATE]. Review of the admission assessment dated [DATE] revealed Resident #4 had a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer to the left buttock which measured 2.2 cm in width by 5.0 cm in length by 0.2 in depth, the wound bed was 100% pink granulated tissue with scant amount of serosanguinous drainage. Review of the April 2022 Treatment and Medication Administration record from 04/01/22 to 04/27/22 there was no evidence of a pressure ulcer treatment being completed for the left buttock of Resident #4. Review of the WCS note, dated 04/06/22 revealed Resident #4 had a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer to the left buttock. There were no measurements of the ulcer at that time. The note recommended treatments were to reposition the resident every two hours, a low air loss mattress, incontinence care every two hours, apply barrier cream and to gently clean wound bed, pat dry, apply collagen cut to size to cover wound bed, alginate cut to size to cover wound bed daily and as needed. Review of the Weekly Skin/Wound Grid, dated 04/25/22 revealed Resident #4 had a Stage III pressure ulcer to the left buttock which measured 10.0 com in length by 4.0 com width by 1.0 cm in depth. The wound bed was 100% granulated with moderate amount of serosanguinous drainage. Review of the resident's medical record, including treatment administration records (from 03/07/22 through 04/27/22) revealed no evidence staff were repositioning (turning and repositioning) the resident every two hours as recommended in the wound care service note beginning on 01/31/22 with continued recommendations as noted above. On 04/27/22 at 10:45 A.M. interview with Licensed Practical Nurse (LPN) #12 verified there was no evidence on the April 2022 TAR of the left buttock treatment for Resident #4 being completed. On 04/27/22 at 10:50 A.M. LPN #8 was observed completing the resident's dressing change to the left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 13 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0686 Level of Harm - Actual harm Residents Affected - Few buttock. The resident was observed with a large open area to his left buttock (baseball size) with a moderate amount of bloody drainage and yellow slough tissue to the bottom right edges the size of a dime. The wound bed was reddened. On 04/27/22 at 11:15 A.M. interview with LPN #8 revealed all wound/pressure ulcer assessments were done electronically and in point click care (PCC). The LPN indicated the facility did have a wound nurse who also came in to do assessment of resident wounds. The LPN verified the lack of completed assessments for Resident #4. On 04/27/22 at 3:08 P.M. interview with the Director of Nursing verified the facility had not developed a plan of care related to pressure ulcer prevention or development until 03/23/22. On 04/27/22 at 4:00 P.M. interview with LPN #8 verified there were no assessments/measurements of the left buttock wound for Resident #4 on 02/07/22, 02/14/22, 02/21/22 or 02/28/22. The LPN revealed she was on vacation the week of 02/14/22. The LPN also verified there was no documentation of Resident #4's treatments being completed from 04/01/22 to 04/27/22 because the treatment order was never transcribed to the TAR. The LPN verified the wound NP recommended a Dakin's solution treatment on 03/14/22, however the order was never written until 03/17/22. On 04/28/22 at 11:08 A.M. interview with LPN #8 verified the nurse from Wound Care Services (WCS) recommended an air mattress for the resident on 01/31/22. However there was never an order written until 02/22/22. Review of the undated facility policy titled, Pressure Ulcer Treatment revealed the purpose of the procedure was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 14 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #4's gastrostomy tube was checked for proper placement prior to the administration of medications to prevent complications and to ensure medications were administered as ordered. This affected one resident (#4) of five residents observed for medication administration. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with dependence on a ventilator, diabetes mellitus, hypertension, adult failure to thrive, pneumonia and traumatic hemorrhage of the cerebrum. Review of the physician's orders revealed Resident #4 had an order (dated 01/21/22) for the enteral feeding, Isosource 1.5 at 70 milliliters per hour continuously. On 04/27/22 at 12:00 P.M. LPN #12 was observed to administer medications via enteral tube to Resident #4. The LPN obtained and crushed Acetaminophen 325 milligrams (mg) and Mucinex 600 mg and placed the medications into a cup with 30 mls of water. The LPN flushed the resident's enteral tube with 10 milliliters (mls) of water and then began to administer the medications without first checking for proper gastrostomy tube placement. The enteral tube became clogged and the LPN had to dump the remaining medications into a cup and proceeded to attempt to unclog the tube. On 04/27/22 at 12:10 P.M. interview with LPN #12 verified she failed to check for proper gastrostomy tube placement prior to administering Resident #4's water flush or medications. On 04/28/22 at 3:09 P.M. interview with the Director of Nursing revealed nurses were to check placement per policy by aspirating residual. Review of the undated facility policy titled, Administering Medication through an Enteral Tube revealed the purpose was to provide guidelines for the safe administration of medication through an enteral tube. Check tube placement, observe for a change in the external tube length at the time of the initial insertion x-ray, if feeding had been interrupted for a few hours aspirate a small amount of stomach content. If the resident was on continuous feeding the stomach should contain no more than the total intake from the last hour. If there was more than hold the medication and notify the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 15 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, facility policy and procedure review and interview the facility failed to ensure food items were stored appropriately in refrigerators on the nursing units to prevent contamination and/or spoilage. This affected one resident (#24) and had the potential to affect 28 of 28 residents who received oral intake. The facility identified five residents (#2, #4, #18, #20 and #30) who had orders for nothing by mouth. Findings include: 1. On 04/25/22 at 8:32 P.M., observations of the third floor nutrition refrigerator revealed a brown bag with Resident #24's name on it with notation of beef stew. It was dated 04/10/22. In addition, there was a plastic zip lock baggie with some type of meat and a container of spaghetti that had no name or date. On 04/25/22 at 8:32 P.M. interview with State Tested Nursing Assistant (STNA) #32 revealed the meat looked like ham or corned beef to her and she thought it also belonged to Resident #24 although there was no date or name on the plastic baggie. STNA #32 did not give a definitive response when asked how long food was kept in refrigerators but stated Resident #24 had eaten some of the food dated 04/10/22 on 04/25/22. STNA #32 also verified there was a container of spaghetti with no name or date marked on it. On 04/25/22 at 8:33 P.M. interview with Licensed Practical Nurse (LPN) #22 revealed food was generally kept in the refrigerator 3-5 days and food not marked should not be kept. The bag marked beef stew, the unlabeled baggie of meat, and container of spaghetti were disposed of. 2. On 04/25/22 at 8:43 P.M. observations of the fourth floor nutrition refrigerator revealed one carton of milk with a sell by date of 04/05/22 and a plate of salad with no name or date on it. On 04/25/22 at 8:43 P.M. interview with STNA #13 verified there was a carton of milk with a sell by date of 04/05/22 and a plate of salad with no name or date on it in the fourth floor refrigerator. STNA #13 stated the milk should have been used within two days of the sell by date. Both items were disposed of. On 04/25/22 at 8:47 P.M. interview with Dietary Manager #43 revealed the milk product should have been discarded on the sell by date. Food brought in from the outside should have names and dates marked on them and be disposed of within three days. Nurse aides and dietary staff were responsible for monitoring foods on units. Review of the facility policy titled, Food Brought in from Outside Sources and Personal Food Storage (implementation date not designated), indicated foods and beverages brought in from outside sources that required refrigeration or freezing would be labeled with the resident's name and date and stored in the refrigerator/freezer apart from facility food. Designated facility staff would be assigned to monitor individual room storage and refrigeration units for food or beverage disposal. Staff would provide information on safe food storage and handling as deemed appropriate and referred to Resource: Food Safety for Your Loved One. Review of the procedure, Resource: Food Safety for Your Loved One (no implementation date), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 16 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0812 Level of Harm - Minimal harm or potential for actual harm revealed food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 17 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to complete a Legionella risk assessment and ensure control measures were in place to decrease the risk of Legionella in the facility. This had the potential to affect all 33 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility Legionella Prevention Program revealed no evidence facility conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. There was no evidence of specifying testing protocols, acceptable ranges for control measures, and documenting of the results of testing and corrective actions taken when control limits were not maintained. On 04/27/22 at 4:00 P.M. interview with Maintenance #7 verified the facility did not have a Legionella Risk assessment to determine where pathogens could grow and spread. Maintenance #7 also revealed the facility did not have specified testing protocols and acceptable ranges. Maintenance #7 revealed the facility had been running water weekly in the empty rooms and that was all he had been doing. Maintenance #7 revealed he had never heard of the Legionella Risk assessment. Review of the facility policy revealed the facility promoted proactive steps to establish healthy, infection-free environments for their residents, staff and visitors. The policy was intended to improve services to resident by focusing on proactive strategies and intervention to reduce the likelihood of a Legionella outbreak. Risk management, hazard analysis and critical control points were the most widely used risk management process in the Untied States. It was used to prevent environmental-source disease from harming people. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 18 of 19 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on review of COVID-19 tracking information documents, facility policy and procedure review, review of the Center for Medicare and Medicaid (CMS) Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (QSO-20-29-NH) and interview the facility failed to notify residents and their representatives of positive staff and resident COVID-19 cases in the facility as required. This had the potential to affect all residents residing in the facility beginning on 01/14/22. The facility census was 33. Residents Affected - Some Findings include: Review of a facility provided COVID-19 tracking information document revealed on 01/14/22 Resident #11, who resided on Level Four of the facility tested positive for COVID-19. Continued review revealed the facility only notified residents and representatives (of the positive COVID-19 test) who resided on Level Four and one of the residents/their representative who resided on Level Three. Review of a facility provided COVID-19 tracking information document revealed on 01/30/22 Medical Director #33 tested positive for COVID-19. The facility only notified the family of Resident #191 of the positive COVID-19 test. Review of a facility provided COVID-19 tracking information document revealed on 02/11/22 Dialysis Manager #3 (who provides in house dialysis services) tested positive for COVID-19. The facility only provided notification of the positive COVID-19 test to Resident 19 and her family. Review of a facility provided COVID-19 tracking information document revealed Transportation Worker #18 tested positive for COVID-19 on 02/26/22. The facility only notified Resident #23, Resident #29 and Resident #185 of the positive COVID-19 test. On 04/28/22 at 10:38 A.M. interview with Registered Nurse (RN) #22, who identified herself as the infection control nurse confirmed on 01/14/22 only residents and/or resident representatives who resided on Level Four of the facility were notified the facility had a positive COVID-19 case in the facility, and on 01/30/22, 02/11/22, and 02/26/22 only residents who came in contact with the positive staff member(s) were notified the facility had staff members who tested positive for COVID-19. Review of the Center for Medicare and Medicaid (CMS) Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (QS0-20-29-NH), dated 05/06/2020 revealed The facility must inform residents, their representatives, and families of those residing in facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Review of the facility policy titled Circle of Care Family Notification, dated 01/10/22 revealed the facility would continue to notify the residents, families, or representatives of any suspected or positive COVID activity in the facility by making individual phone calls to the representative or family member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365977 If continuation sheet Page 19 of 19