Inspection·April 19, 2021

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** 2. Review of the medical record for Resident #31 revealed an admission date of 02/24/21 and a discharge date of 03/05/21. Diagnoses included cancer of the esophagus, malnutrition and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) for Resident #31 dated 02/24/21 revealed the resident had impaired cognition. Resident requires extensive assist of one for bed mobility, transfers, and toileting. Review of the Nurses Notes dated on 03/05/21 revealed Resident #31 had a change in condition and required a transfer to the hospital. The record did not contain evidence that the facility provided the required paper work prior to discharge. The record also did not contain evidence of the required discharge paper work being sent to the responsible party. Interview with the Administrator on 04/14/21 at 3:05 P.M. revealed no paper work was given to the resident or his family when he was discharged /transferred to the hospital. Review of facility policy titled Guidelines for Transfer and Discharge, dated 05/23/18, revealed the facility failed to implemented the policy as written. Number one, letter a, stated the facility will notify the resident in writing for reason for transfer. Based on medical record review, resident and staff interview and review of facility policy, the facility failed to ensure residents were notified in writing when transfers to the hospital occurred. This affected two (#18 and #31) residents of two reviewed for transfers. The facility census was 30. Findings included: 1. Medical record review for Resident #18 revealed an admission date of 03/28/19 with a discharge on [DATE] and readmission on [DATE]. Diagnoses on admission include heart failure, atrial fibrillation, left knee pain, cerebral vascular accident (CVA), type two diabetes mellitus, heart disease, hypertension, sciatica, major depressive disorder, hyperlipidemia, chronic kidney disease, dementia without behaviors, chronic obstructive pulmonary disease (COPD), systemic inflammatory response syndrome and oxygen dependence. Review of most recent quarterly Minimum Data Set (MDS) assessment for Resident #18 dated 02/12/21 revealed the resident had intact cognition. Resident requires extensive assist from two staff members for bed mobility, transfers, and toileting. Eating is independent. Resident is dependent with bathing from one staff member. Resident #18 in frequently incontinent of bladder and bowel. Resident (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: 365505 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 365505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Green Rehabilitation and Healthcare Center 1315 Kitchen Aid Way Greenville, OH 45331 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)