Inspection·December 27, 2023

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, policy review, and interviews, the facility failed to notify a resident's family prior to a transfer to another facility. This affected one resident (#22) of four residents reviewed for resident rights. The facility census was 40. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, hypertension, schizoaffective disorder, hypothyroidism, dementia, dysphagia, anxiety disorder, and osteoarthritis. Review of a minimum data set (MDS) assessment completed on 12/04/23 revealed Resident #22 had moderately impaired cognition and was transferred to another facility on 12/04/23. Review of a discharge assessment completed on 12/04/23 revealed the discharge instructions were given to Resident #22. Review of nursing note from 11/30/23 at 8:09 P.M. entered by the Administrator revealed Resident #22's son was spoken with regarding a transfer to a new facility for behavior management, and son was agreeable to transfer as long as it was within three hours of his home. Review of a social services note from 12/04/23 at 3:00 P.M. revealed a voicemail was left to inform Resident #22's family the resident would be transferring to another facility. Review of a social services note from 12/05/23 at 9:00 A.M. revealed Resident #22's family was left another message requesting a return call. Review of a Transfer and Discharge log from December 2023 revealed Resident #22 was transferred to a facility in Xenia on 12/04/23. Review of the Transfer and Discharge Notice revealed Social Worker (SW) #102 reviewed the notice with Resident #22's representative. Interview on 12/27/23 at 12:19 P.M. with Resident #22's representative revealed he had been called days prior to the transfer to discuss potential other facilities but was given the impression he would be more involved in the process and have a chance to visit and approve the facility Resident #22 was sent to. The representative stated he was not aware Resident #22 had been transferred for a couple days and he had no idea where she had been transferred to. The representative denied having any missed calls or voicemails from the facility regarding Resident #22's transfer and stated he had left multiple voicemails for the administrator with no return call. The representative denied ever reviewing a Discharge or Transfer Notice with the facility. The representative stated when Resident #22 (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: 365461 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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)