Health inspection·September 18, 2025

F 0627 Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff, resident, health insurance provider and waiver service provider interviews, review of an Emergency Medical Services (EMS) run report, review of hospital documents, and review of facility policy, the facility failed to ensure a safe resident discharge to home. This resulted in Actual Harm on 07/24/25 at approximately 10:44 A.M. when Resident #62, who was dependent on others for care and required the use of a mechanical lift for transfers, was discharged to home without the needed equipment and services to meet her care needs. Subsequently, Resident #62 remained in a standard wheelchair for approximately six hours without any care provided, including incontinence care, resulting in the development of a pressure ulcer. This affected one (#62) of three residents reviewed for discharge. The facility census was 82. Findings include:Review of the medical record revealed Resident #62 was admitted on [DATE], left for a therapeutic leave on 07/24/25, and returned to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, muscle weakness, schizophrenia, acute respiratory failure with hypoxia, chronic atrial fibrillation, essential hypertension, Type II diabetes mellitus, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 05/29/25, revealed Resident #62 was cognitively intact and dependent on staff assistance for toileting, lower body dressing, applying footwear, and transfers.Review of the physician orders, dated 05/23/25, revealed Resident #62 had an order for oxygen at two liters per minute (lpm) via nasal cannula, wean as tolerated, every shift. Review of the care plan, dated 07/07/25, revealed Resident #62 was at risk/had an activities of daily living (ADL) self-performance deficit due to deconditioning/weakness and was dependent for transfers. Review of a weekly skin assessment, dated 07/20/25, revealed Resident #62 did not have a pressure ulcer. There was no evidence that Resident #62 had any skin conditions on the coccyx or buttock area. Review of the Discharge summary, dated [DATE], revealed Resident #62 had a planned discharge scheduled for 07/23/25. The summary stated the resident needed physical assistance of two people to complete ADL care, and total care for incontinence of bowel and bladder. Resident #62 made progress in therapy by increasing sitting tolerance when sitting up in a Broda chair (specialized wheelchair to promote proper posture and reduce falls and skin breakdown) to engage in daily activities. A follow-up appointment with the resident's primary care physician (PCP) was scheduled for 08/05/25. Resident #62 required home health services (HHS). Physical therapy (PT) and occupational therapy (OT) were recommended, and a referral was made for HHS. Durable medical equipment (DME) was documented as not required. Review of an EMS run report, dated 07/24/25 at 5:26 P.M., revealed Resident #62's case worker requested a check on the resident after she had been discharged from an extended care facility that day. On arrival, Resident #62 was sitting in a wheelchair. The resident was conscious, alert, and oriented. Vitals were obtained and within normal ranges. The resident Page 1 of 3 365737 365737 09/18/2025 Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614

F 0627 Level of Harm - Actual harm Residents Affected - Few stated that she had to go to the hospital because she could not get around her apartment and could not care for herself. EMS services attempted to assist Resident #62 back to bed, but she could not even stand on her own. Resident #62 was transported to the emergency room (ER). Review of the hospital records, dated 07/24/25, revealed the case worker called to report concern for Resident #62's safety after being discharged (from a skilled nursing facility [SNF]) to her home residence earlier today. It was reported that the resident's husband was also ill and unable to care for himself. Resident #62 reported shortness of breath (SOB) and reported improvement after receiving a breathing treatment. The resident reported pain involved bilateral chest pain and pain on her buttocks. An open wound on her coccyx and the anterior, proximal right upper leg were identified and present upon admission [to the ER]. The resident's brief was saturated with urine. Concerns related to home care were identified. Resident #62 discharged from the hospital back to the facility. Review of a weekly skin assessment, dated 07/25/25, revealed Resident #62 had a rash on the chest, groin, and left buttock. The left buttock area measured 0.7 centimeters (cm) by 0.5 cm. Review of the weekly wound assessment, dated 07/29/25, revealed Resident #62 had a stage three left buttock pressure ulcer measuring 0.6 cm by 0.5 cm by 0.2 cm. During an interview on 09/15/25 at 4:25 P.M. with the Director of Nursing (DON) verified Resident #62 was discharged home without oxygen, no working hospital bed, and no Hoyer lift, all of which were needed to provide care for the resident. The DON verified Resident #62's husband was ill and unable to provide needed care for the resident at home. During an interview on 09/16/25 at 8:10 A.M., Resident #62 stated she had discharged home but then went to the hospital because she could not breathe. Resident #62 revealed she did not have anyone at home to provide care for her and she remained in a wheelchair when she arrived home until EMS transported her to the hospital. During an interview on 09/16/25 at 8:20 A.M., Nurse Case Manager (NCM) #301, with the resident's insurance company, stated on 07/24/25, around mid-morning, Resident #62 discharged home from the facility with no oxygen, no working hospital bed, no Hoyer lift, and HHS were not in place. NCM #301 stated Resident #62's spouse contacted the HHS agency and notified them that Resident #62 was home. It was reported Resident #62 did not have her Broda chair and only had a standard wheelchair upon discharge from the facility. NCM #301 encouraged Resident #62 to call EMS due to sounding wheezy and short of breath. NCM #301 revealed she was not notified to assist with a successful discharge home. A follow-up interview on 09/16/25 at 9:50 A.M. with the DON revealed that, according to the census, Resident #62 discharged home on [DATE] at 10:44 A.M. On 07/24/25 at 10:24 P.M., the facility received a call from the hospital inquiring about the resident returning to the facility. The DON stated that former Social Services Designee (SSD) #206 had arranged the discharge for Resident #62; however, had not worked at the facility since the day prior to the discharge. During an interview on 09/16/25 at 10:28 A.M., the DON verified Resident #62 had a planned discharge on [DATE]; however, transportation could not accommodate the resident with her Broda chair. The discharge was rescheduled and occurred on 07/24/25, with Resident #62 only having a standard wheelchair. The DON confirmed that based on the skin assessment completed on 07/22/25, two days prior to discharge, Resident #62 had no skin impairments and the medical record included no evidence of any pressure ulcers prior to discharge. During an interview on 09/16/25 at 10:37 A.M., Licensed Practical Nurse (LPN) #146 verified Resident #62 returned home via a transportation company in a standard wheelchair provided by the family. LPN #146 verified Resident #62 did not have her Broda chair upon discharge. During an interview on 09/17/25 at 2:03 P.M., Wound Nurse Practitioner (WNP) #300 revealed Resident #62's skin was very fragile and could have easily developed a pressure ulcer from sitting in a wheelchair all day. WNP #300 believed the skin assessment on 07/25/25 (the day after the resident's readmission), which identified the left 365737 Page 2 of 3 365737 09/18/2025 Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614

F 0627 Level of Harm - Actual harm Residents Affected - Few buttock as a rash, was likely misidentified and was a pressure ulcer as determined on 07/29/25 and indicated in the hospital records. During an interview on 09/17/25 at 12:00 P.M., Waiver Service Coordinator (WSC) #302 revealed she was responsible for assisting with arranging care for Resident #62 when she was at home. WSC #302 verified the facility did not contact her to assist with arranging needed services to ensure a safe discharge home for Resident #62. WSC #302 revealed that prior to her initial admission to the facility in May 2025, Resident #62 was nearly bed bound and required extensive care. During an interview on 09/18/25 at 10:16 A.M., Certified Nursing Assistant (CNA) #186 revealed Resident #62 had required a Hoyer lift for all transfers since her initial admission in May 2025, and could not transfer on her own. Review of the facility policy titled, Discharge Policy, reviewed August 2024, revealed appropriate discharge planning would be developed based on the resident's medical, physical, social and emotional condition/needs. Available resources would be recommended and made available to provide for the total well-being of the resident and with the approval of the resident's physician. All available local and community resources would be made available and utilized under the coordination of the social services department to ensure that each resident's specific care needs were met upon discharge to maximize the success of each resident. The deficiency was corrected on 08/10/25 when the facility implemented the following corrective actions: On 07/25/25 at 12:30 A.M., Resident #62 was readmitted to the facility. The physician was notified and Resident #62's orders were resumed. On 07/28/25, the DON implemented a discharge checklist, to be initiated upon admission, to verify required services, family/representative/community resource communication, and equipment needs are arranged prior to discharge. On 07/28/25, the DON reviewed the six resident discharges for the previous two weeks, with no negative findings. Beginning on 07/28/25, the Administrator or designee reviewed scheduled discharges daily, Monday through Friday, during the morning clinical meeting to ensure appropriate discharge planning had occurred. Evidence was received to verify discharges were reviewed. On 07/28/25, the DON educated the Unit Managers (LPN #146 and LPN #204) on the discharge checklist. If SS is not in the facility on the day of discharge, discharge tasks will be assigned to the unit manager or DON to ensure a safe discharge. Evidence was received to verify the education was completed on 07/28/25. On 07/28/25, the DON assumed discharge planning responsibilities until the new SS begins in the position (expected 10/01/25) and is fully oriented. Beginning on 07/28/25, the Administrator or designee will monitor compliance of a safe and orderly discharge weekly for four weeks. Audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to ensure the deficient practice has been resolved. Evidence was received verifying audits were completed weekly/after each discharge, with no negative findings. Beginning on 07/28/25, the DON or designee will follow-up contact within 24-hours for any resident discharged from the facility to ensure needs were met. Evidence was received to verify completion and is on-going. Upon the new SSD's start date, anticipated 10/01/25, the DON and Social Service Consultant (SSC) #700 will provide orientation, to include safe discharges and utilization of the discharge checklist to ensure a safe discharge. Review of two (#05 and #06) additional closed medical records, reviewed for safe discharge to home, revealed no additional concerns.This deficiency represents non-compliance investigated under Complaint Numbers 2578313 and 2577168. 365737 Page 3 of 3