Inspection·October 13, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, staff interview and policy review, the facility failed to notify the Ombudsman in writing of discharges to the hospital. This affected two (#6 and #14) of three residents reviewed for hospitalization. The facility census was 58. Findings include: 1. Record review of Resident #14's medical record revealed an admission date of 05/31/22, with pertinent diagnoses of: asthma, atherosclerotic heart disease, heart failure, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, gastro-esophagael reflux, arthritis, glaucoma, obstructive hypertrophic cardiomyopathy, adjustment disorder with anxiety, respiratory failure, cardiomegaly, shortness of breath, constipation, inappropriate diet and eating habits, dysphagia oropharyngeal phase, cognitive communication deficit, and chronic obstructive pulmonary disease. Review of a progress note dated 06/27/22 at 9:00 A.M., revealed Resident #14 with a low grade fever since this morning. Tremors have worsened over this shift. Primary Care Physician recommended to send to the Emergency Room. Review of Resident #14's medical record revealed she was at the hospital from [DATE] to 07/13/22 and there was no evidence the ombudsman was notified of the transfer. Interview on 10/13/22 at 10:46 A.M., with Director of Social Services #51 confirmed the facility had not been sending notifications to the Long-Term Care Ombudsman regarding transfers and discharges. This included Resident #14's 06/27/22 discharge. 2. Review of the medical record for Resident #6 revealed the resident was admitted to the facility on [DATE], discharged on 09/05/22, and re-admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, major depressive disorder, schizoaffective disorder bipolar type, hyperlipidemia, unspecified convulsions, hypertension, peripheral vascular disease, type two diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, encephalopathy, aphasia, and other lack of coordination. Review of the annual Minimum Data Set (MDS) assessment, dated 07/03/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, eating, dressing, toileting, and personal hygiene. (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 6 Event ID: 365241 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 365241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE London Health & Rehab Center 218 Elm St London, OH 43140 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)