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. Page 1 of 3 365977 365977 06/12/2025 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 06/11/25 at 9:01 A.M. Revealed the mother of Resident #7 called the facility and verbalized she was upset to learn Resident #7 had been sent to the hospital and she was not notified of his change in condition of transfer or subsequent return to the facility. Interview on 06/12/25 at 2:26 P.M. with Resident #7 confirmed Resident #7 had been in and out of hospital multiple times. During the interview, Resident #7 confirmed his mother was not always informed by facility staff of the hospital visits and stated she needs to be then reiterated his wishes were for his mother to be updated with his care and anytime he has to go to the hospital. Interview on 06/12/25 at 2:50 P.M. with Licensed Practical Nurse (LPN) #474 confirmed that for falls, incidents with injury, or hospital transfers, the nurses were responsible for calling family or resident representatives to provide notification. Interview on 06/12/25 at 3:00 P.M. with Registered Nurse (RN) #406 confirmed the nurse was to make notifications to family or resident representatives when there was a change in condition. Interview on 06/12/25 with the Director of Nursing (DON) on 06/12/25 from 4:26 P.M. to 4:35 P.M. confirmed there was no documentation of notification of hospital transfers from the transfer the afternoon of 06/01/25 or the transfer on 06/10/25. She further confirmed the progress note dated 06/11/25 at 9:01 A.M. revealed Resident #11's mother verbalized to facility staff she was upset she was not notified of Resident #7's hospital transfer on 06/10/25. Review of the undated Nursing Home Residents' [NAME] of Rights revealed residents had the right to have any significant changes in health status reported to their sponsor and the facility should make every reasonable effort to notify as soon as the change in condition occurs or within 12 hours of the change. Review of the policy titled Change in Resident's Condition or status last reviewed May 2025 revealed that unless otherwise instructed, the resident's family or resident representative was to be informed of accidents or incidents that caused injury, a significant change in physical, mental, or psychosocial status, room changes, decision to discharge, and emergency transfers out of the facility. 2. Review of the medical record for Resident #35 revealed an admission date of 06/10/25 with diagnoses including diabetes insipidus, personal history of traumatic brain injury, neurocognitive disorder with Lewy bodies, muscle weakness, major depressive disorder, systolic congestive heart failure, anxiety disorder, basal cell carcinoma of the skin on unspecified parts of the face, chronic obstructive pulmonary disorder (COPD), and cognitive communication deficit. Review of the quarterly MDS assessment completed on 04/08/25 revealed Resident #35 had intact cognition and medically complex conditions, including but not limited to cancer and non-Alzheimer's dementia. Review of the care plan dated 04/10/25 revealed Resident #35 had a living will and an appointed guardian of person and state. Review of the documents revealed guardianship paperwork certified on 03/15/17 that determined Resident #35 was deemed incompetent and appointed a legal guardian of both person and estate. Review of the census page in the electronic medical record (EMR) revealed Resident #35 was transferred out of the facility to a hospital on [DATE]. 365977 Page 2 of 3 365977 06/12/2025 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 06/08/25 at 2:14 P.M. revealed Resident #35 had picked all the sutures out from the surgical site on the outer aspect of the nose, causing it to be wide open and bleeding, and was sent to the ER for evaluation and possible surgical site repair. There were no progress notes or transfer forms indicating the guardian was notified of this change in status. Interview on 06/12/25 at 12:51 P.M. with the guardian of Resident #35 revealed a concern that the facility routinely neglected to notify him of hospital transfers, and the facility at no time notified him of Resident #35's hospital transfer on 06/08/25. During the interview, Resident #35's guardian stated he only became aware of the hospital transfer because the hospital contacted him to fill out the paperwork necessary for them to treat Resident #35. Interview on 06/12/25 at 2:50 P.M. with LPN #474 confirmed that for falls, incidents with injury, or hospital transfers, the nurses were responsible for calling family or resident representatives to provide notification. Interview on 06/12/25 at 3:00 P.M. with RN #406 confirmed the nurse was to make notifications to family or resident representatives when there was a change in condition, including hospital transfers. Interview on 06/12/25 with the DON on 06/12/25 from 4:26 P.M. to 4:35 P.M. confirmed there was no documentation Resident #35's guardian had been notified of Resident #35 pulling out the stitches from the surgical site or subsequent hospital transfer. Review of the undated Nursing Home Residents' [NAME] of Rights revealed residents had the right to have any significant changes in health status reported to their sponsor and the facility should make every reasonable effort to notify as soon as the change in condition occurs or within 12 hours of the change. Review of the policy titled Change in Resident's Condition or status last reviewed May 2025 revealed that unless otherwise instructed, the resident's family or resident representative was to be informed of accidents or incidents that caused injury, a significant change in physical, mental, or psychosocial status, room changes, decision to discharge, and emergency transfers out of the facility. This deficiency represents noncompliance investigated under Complaint Number OH00166072. 365977 Page 3 of 3