Health inspection·December 5, 2019

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 medical record review, staff interview and review of facility policy the facility failed to ensure residents and responsible parties were provided with a written notice of transfer upon transfer/discharge from the facility. This affected one (Resident #38) of one resident reviewed for hospitalizations. The facility identified four residents transferred to the hospital in the last 60 days. The facility census was 57. Findings include: Review of the medical record for Resident #38 revealed the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Diagnoses include schizoaffective disorder, bipolar type, moderate intellectual disabilities, convulsions, vitamin D deficiency, bacteriuria, chronic respiratory failure, heart failure, hypertension, hyperlipidemia, vitamin B deficiency, osteoarthritis, legally blind, depression, insomnia, restless and agitation, auditory hallucinations, paranoid personality disorder, post-traumatic stress disorder, anxiety and conversion disorder with seizures or convulsions. Review of a comprehensive significant change Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had severe cognitive deficits , delusions and fluctuating periods of inattention and disorganized thinking. Review of physician orders dated 09/03/19 and 10/24/19 revealed the resident was sent to the hospital on two separate occasions. Further review of the medical record revealed no documentation was present to indicate the resident and/or responsible party were provided with a written notice of transfer for either transfer. Review of a Transfer Notice dated 09/03/19 revealed the resident was sent to the hospital. There was no documentation of who the form was provided to. Review of a Transfer Notice dated 10/25/19 revealed the resident was sent to the hospital. There was no documentation of who the form was provided to. Interview with Business Office Manager #300 on 12/03/19 at 10:20 A.M. verified the facility did not provide residents and families with a written notice of transfer when the residents were transferred to the hospital. Review of facility policy Skilled Nursing Facility Transfer and discharge Required Notices Policy (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 4 Event ID: 365570 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 365570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Care Center 328 West Vine Street Edgerton, OH 43517 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)