Inspection·October 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident and resident representative interviews and policy review, the facility failed to notify the resident's representative when their was a change of condition. This affected one (#1) of three reviewed for change of condition. The census was 71. Findings included: Medical record review for Resident #1 revealed an admission date of 08/18/23. Medical diagnoses included history of fractures and atrial fibrillation. Review of admission Minimum Data Set, dated [DATE] revealed she was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. She was independent for eating. She was occasionally incontinent for bowel and bladder. Review of physician progress note dated 09/26/23 revealed Resident #1 was being seen for red, painful, and warm thumb noted by the therapy department. Review of the progress note dated 09/26/23 revealed there wasn't any evidence Resident #1's Representative was notified of this skin condition. Interview with Resident #1 on 10/25/23 at 10:00 A.M. revealed she couldn't remember if she had a blister on her thumb. Interview with Resident #1's Representative on 10/25/23 at 1:19 P.M. revealed she was not contacted about Resident #'1's thumb on 09/26/23 and was quite surprised by the call. Interview with Assistant Director of Nursing (ADON) #9 on 10/26/23 at 2:15 P.M. revealed Resident #1 wasn't quite herself after she had COVID-19 on 09/09/23 and had periods of confusion and her cognitively status fluctuated. ADON #9 stated there were times they would call the resident's representative if the resident didn't seem alert and oriented. ADON #9 confirmed there wasn't any evidence in the chart the representative as contacted concerning her blister on her thumb. Review of the policy entitled Change in Condition dated 06/01/15 revealed the facility staff will report identified significant changes in resident's status. Documentation of the condition will be noted in the nurses charting or interdisciplinary charting as indicated. The resident's physicians/clinicians and responsible party will be notified of significant changes in resident's conditions. If a resident specified on admission they do want family members notified of a significant change the facility will respect that. If the resident is incapable of making decision, the responsible party will make any decisions that have to be made, but the resident should be up dated on his/her condition. (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 2 Event ID: 366040 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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)