Inspection·March 21, 2024

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, admission packet review, review of facility documents and review of facility policy, the facility failed to ensure a written discharge notice was provided to residents and their representatives for a facility-initiated discharge. This affected one (#1) of three residents reviewed for discharge. The facility census was 80. Findings Include: Review of Resident #1's medical record revealed an admission date of 07/18/23 and a discharge date of 02/24/24. Diagnoses included pleural effusion (fluid around his lungs), Alzheimer's disease, dementia, cough, edema, shortness of breath and altered mental status. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating Resident #1 was severely cognitively impaired. Resident #1 required partial assistance from staff with toilet use, bathing, and dressing. Resident #1 displayed no behaviors at the time of the review. Review of Resident #1's care plan canceled 02/29/24 revealed supports and interventions for dependence on staff for meeting emotional, intellectual, physical and social needs, self-care deficit, impaired cognitive function, risk for pain, and psychosocial wellbeing problem related to ineffective coping and dementia. Review of Resident #1's admission referral packet dated 07/14/23 revealed Resident #1's wife had reported Resident #1 had been confused, aggressive and cussing which was new for Resident #1. There was no indication Resident #1 was a registered sex offender. Review of Resident #1's progress notes revealed on 07/18/23 Resident #1 admitted to the facility. Social Services contacted Resident #1's wife and was informed Resident #1's wife and children had a difficult relationship with Resident #1 and provided some background information on their family life. Resident #1's wife indicated Resident #1 may need long term placement due to worsening disease process. Resident #1's wife reported she had power of attorney. There was no indication documented Resident #1 was a sex offender. On 07/20/23 a care conference was held. There was no information provided to the facility regarding Resident #1 being a sex offender. Further review of Resident #1's medical record found no evidence he was checked prior to admission (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 2 Event ID: 365898 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)