Health inspection·February 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure all parties were notified Resident #75's change of condition. This affected one resident (#75) of three residents reviewed for notification. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. Review of the fall incident report dated 12/19/23 at 2:00 P.M. Resident #75 was found on the floor between the wall and bed. No injury was noted at the time of the fall. Resident #75 was sent to hospital for evaluation. There was no documented evidence of family notification of the fall and transfer to the hospital. Interview on 02/12/24 at 11:01 A.M. with the Director of Nursing (DON) verified the agency nurse told her she was going to notify the family of the fall. She stated she went to a meeting after Resident #75 left the facility. The DON stated she was interrupted during the meeting and was told the family of Resident #75 was on the phone. The family was upset that they were not notified that Resident #75 was sent to hospital after a fall, so the hospital had to call them. The DON verified the facility staff did not notify Resident #75's family of the fall and transfer to the hospital on [DATE]. Review of the facility policy Change in a Resident's Condition or Status, dated 02/2021, revealed the facility will promptly notify the resident, his/her physician and the residents' representative of changes in the residents medical/mental condition and/or status. This deficiency represents non-compliance investigated under Master Complaint Number OH00150201. 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: 365667 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 365667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256 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)