Health inspection·June 12, 2025

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 review of the medical record, interview, review of the facility policy and review of the Nursing Home Residents' [NAME] of Rights, the facility failed to ensure residents representatives were notified of significant changes. This affected two (Resident #7 and #35) of three residents who were reviewed for changes in condition. The facility census was 36. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/16/25 and a re-entry date of 05/30/25. Diagnoses included sepsis (admission diagnosis), streptococcal sepsis, osteomyelitis, paraplegia, end stage renal disease, diabetes insipidus, chronic pain, neuromuscular dysfunction of the bladder, colostomy status, muscle contracture, unspecified site, depression, hyperkalemia, hypo-osmolality, hyponatremia, and other disorders of plasma-protein metabolism. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/06/25 revealed Resident #7 had intact cognition and had medically complex conditions including, but not limited to cardiac/circulatory problems, multiple metabolic issues, end stage renal disease, paraplegia, and depression. Review of the resident census page revealed Resident #7 was transferred out of the facility to the hospital on [DATE], 06/05/25, and from 06/10/25 to 06/11/25. Review of the progress note dated 06/01/25 at 1:25 P.M. revealed Resident #7 exhibited an altered mental status, blood pressure of 90/56, and an oxygen saturation of 90 percent (%). The note further revealed the emergency medical technicians (EMTs) were called to transport Resident #7 to the hospital emergency room (ER) via stretcher and the Nurse Practitioner was notified of the change in condition and resulting hospital transfer. The progress note did not contain documentation that Resident #7's mother was notified of the transfer. Review of the progress note dated 06/10/25 at 11:43 P.M. revealed Resident had an emesis containing fecal matter, elevated blood pressure of 152/77, heart rate of 94, and oxygen saturation of 90%. The note further revealed the Nurse Practitioner was notified of Resident #7's change in condition at 10:39 P.M., a nurse-to-nurse report was provided to the ER nurse at the selected hospital, and the EMTs left the facility with Resident #7 for ER transport at 11:41 P.M. There were no notes reflecting notification of the health status change or hospital transfer was provided to Resident #7's mother. (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: 365977 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 06/12/2025 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)