Inspection·November 7, 2019

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many 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 the medical record for Resident #23 revealed an admission date of 11/27/18. Diagnoses included sepsis, hemiplegia and hemiparesis (weakness on one side of the body) following a cerebral infarction, end stage kidney disease, type two diabetes with diabetic neuropathy, and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and cognitively intact. The annual MDS assessment dated [DATE] revealed the resident was still alert and cognitively intact. Review of the nursing progress notes revealed Resident #23 was hospitalized from [DATE] to 10/01/19 for a right great toe amputation due to gangrene. Resident #23 was also hospitalized on [DATE], and 10/22/19 with gangrene/infection to the right toe wound site. Resident #22's medical record contained no evidence the written transfer/discharge notice was provided at any time. Interview on 11/06/19 at 11:18 A.M. with the Administrator verified the written transfer notice was not given to the Resident #23 for any of the resident's transfers to the hospital, either at the time, after transfer, or readmission to the facility. Based on record review and staff interview, the facility failed to notify the resident and/or their representative in writing of a transfer/discharge to the hospital. This affected two (Resident #23 and #27) of three residents reviewed for hospitalization and had the potential to affect all 100 residents residing in the facility. Findings include: 1. Review of Resident #27's medical record revealed an initial admission date of 02/15/17. Diagnoses included cerebral infarction (stroke), dysarthria (speech disorder) following cerebral infarction, hemiplegia,(paralysis on one side of the body), aphasia (inability to formulate or comprehend language), schizoaffective disorder, pain, major depressive disorder, and repeated falls. Progress notes indicated Resident #27 was transferred to the hospital on [DATE] with slurred speech and trouble talking. He was readmitted on [DATE]. No documentation was located indicating the resident representative was provided, in writing, a transfer/discharge notice indicating the reasons for the transfer/discharge, the effective date of the transfer/discharge, location to which the resident was transferred/discharged , a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and the name, address (mailing and email) and telephone number of the Office of (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: 365340 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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)