Health inspection·February 9, 2024

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** Based on closed record review and interview, the facility failed to provide written notice of discharge to two residents when they transferred to the hospital. This affected two residents (#13, #87) of three residents reviewed for hospitalization with the potential to affect all 73 residents as facility does not have a process in place for discharge or transfer notices. The facility census was 73. Findings included: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, anemia, anxiety disorder, and muscle weakness. Review of a nursing note dated 12/19/23 at 10:05 A.M. by Licensed Practical Nurse (LPN) #114 revealed Resident #13 was seen by the facility nurse practitioner due to refusal to eat and edema to upper and lower extremities. The provider gave an order for Resident #13 to be sent to the hospital for evaluation. Resident #13's responsible party was notified by phone of the transfer. Review of Resident #13's record revealed no written notice of transfer or discharge. 2. Record review revealed Resident #87 admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, dementia, borderline personality disorder, type II diabetes, and personal history of traumatic brain injury. Review of a nursing note dated 01/17/24 at 2:01 P.M. by LPN #127 revealed Resident #87 was exhibiting agitation, pacing back and forth, raising her voice, and made the statement she wanted to kill herself and needs mental health. Resident #87 was placed on one to one supervision and the Director of Nursing was notified. Review of a nursing note dated 01/17/24 at 2:30 P.M. by Registered Nurse (RN) #148 revealed the physician was updated on Resident #87's behaviors and gave an order for Resident #87 to be sent to the hospital for a psychiatric evaluation. While awaiting transport, Resident #87 stated she wanted to harm herself by running out of the door, going into the street and getting hit by a car. Resident #87 made several attempts to leave and five staff members stood near the door to block the exit due to Resident #87 trying to push the door for 15 seconds until it opened. Resident #87 stated multiple times to the staff she needed psychiatric help. Resident's responsible party was made aware of the situation and in agreement to send Resident #87 to the hospital for evaluation. Review of Resident #87's record revealed no written notice of transfer or discharge on file. (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: 365673 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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)