Health inspection·September 19, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, the facility failed to ensure a resident received an adequate supply of medications upon discharge to home. This affected one (#97) of three residents reviewed for discharge. The facility census was 95. Findings include: Review of Resident #97's medical record revealed Resident #97 admitted to the facility on [DATE]. Diagnoses included epilepsy. Resident #97 discharged from the facility on 06/28/25. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively intact. Resident #97's discharge was a planned discharge to home. Review of Resident #97's discharge care plan dated 06/18/25 revealed Resident #97 was admitted to the facility for a short-term stay utilizing rehabilitation therapy. Resident #97 had a goal to discharge home and needed assistance with planning post discharge care. Interventions included acknowledge family and resident concerns, identify and coordinate discharge planning needs, obtain needed durable medical equipment, identify and discuss barriers to discharge, social services to coordinate discharge planning with the resident, family and the interdisciplinary team, and social services to provide education on services and resources in the community. The progress note dated 06/25/25 at 12:14 P.M. revealed LSW #144 notified Resident #97 and her spouse that a Notice of Medicare Non-Coverage (NOMNC) with a last covered day of 06/27/25 had been issued by insurance. LSW #144 informed Resident #97 and her spouse that they had the right to appeal. Resident #97 and her spouse stated they were not sure if they wanted to appeal and stated they would think it over. LSW #144 explained that LSW #144 could make a referral to home health if they decided not to appeal or if the appeal was denied. Review of LSW #144's email to the home health provider dated 06/25/26 at 12:28 P.M. revealed Resident #97 was discharging home on [DATE] and LSW #144 would like to make a referral for physical therapy, occupational therapy, speech therapy, nursing and a home health aide. Review of Resident #97's care conference dated 06/27/25 revealed Resident #97 and the resident representative attended the care conference. Resident #97's discharge plan was reviewed. The progress note dated 06/28/25 at 10:15 A.M. revealed Resident #97's spouse came into the building that morning and was asking about Resident #97's discharge. The information was not relayed to Registered Nurse (RN) #501 about Resident #97's discharge on that date. Resident #97's spouse became very irate and said RN #501 could discharge her or he would just take her out of the facility anyway. RN #501 made a telephone call to the unit supervisor. Resident #97's spouse was adamant about leaving. The discharge was completed and the recapitulation of the stay, medication list, medications, and paperwork for discharge were sent home with the resident. The telephone order dated 06/28/25 revealed Resident #97 could discharge home on [DATE] with stated it was okay to send Resident #97's remaining medications and it was okay to send a two-week supply of medications. Resident #97 was to follow up with her primary care physician in one week. The telephone order was signed by NP #502 on 07/24/25. Review of Resident #97's discharge summary and recapitulation of stay assessment dated [DATE] Page 1 of 3 365984 365984 09/19/2025 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed medication reconciliation was completed to prepare predischarge medications, a current medication list was provided to the resident and resident representative and medications and supplies were sent home with the resident. The assessment was signed by Resident #97. The progress note dated 06/30/25 revealed Resident #97 discharged home on [DATE]. Review of Resident #97's Medication Administration Record (MAR) from 06/01/25 to 06/28/25 revealed Resident #97 was prescribed Thiamine Mononitrate 100 milligrams (mg) give one tablet by mouth in the evening for a supplement; Prevacid 30 mg give one tablet by mouth one time a day for gastroesophageal reflux disease (GERD), Melatonin (a sleep aide) five mg give two tablets by mouth at bedtime, levetiracetam 750 mg give one tablet by mouth two times a day for seizures, Fluoxetine 20 mg give one tablet by mouth one time a day for an anti-depressant, Cholestyramine oral packet four grams (gm) give one packet by mouth two times a day for hyperlipidemia, atorvastatin calcium 40 mg give one tablet by mouth at bedtime for hyperlipidemia, and Aspirin 81 mg give one tablet by mouth one time a day for a preventative. The medical record from 06/18/25 to 06/28/25 revealed no documentation that any of Resident #97's prescriptions were sent to the pharmacy upon discharge from the facility on 06/28/25.Interview with RN #501 on 09/19/25 at 10:25 A.M. revealed RN #501 was not aware that Resident #97 was discharging on 06/28/25 until Resident #97's husband came to the facility and demanded that Resident #97 be discharged . RN #501 stated she contacted the supervisor, and the supervisor stated Resident #97 and her husband informed the facility that they were debating on appealing the insurance NOMNC and they still had not decided about the appeal at the end of the day on 06/27/25. RN #501 reported Resident #97's husband must have decided that he did not want to appeal the NOMNC and that he wanted Resident #97 discharged from the facility on 06/28/25. RN #501 reported that an order was obtained to discharge Resident #97 by the physician on call and Resident #97 was sent home with all her medications except for narcotics. RN #501 was not sure how many days' worth of medications were sent with Resident #97. RN #501 reported the facility typically sent electronic prescriptions of medications to the pharmacy upon discharge. RN #501 stated she did not receive any information that Resident #97 was not able to obtain her medications or that she ran out of her medications after discharge. Interview with the Director of Nursing (DON) on 09/19/25 at 10:30 A.M. revealed Resident #97 and her husband were saying that they wanted to appeal the NOMNC on 06/27/25 but then Resident #97's husband came to the facility and wanted her discharged on 06/28/25 because he did not want to pay if the appeal was denied. The DON stated Resident #97's husband reached out to the Administrator after the discharge for some paperwork, but she was not aware of Resident #97 not having her medication upon discharge. The DON stated Resident #97's Levetiracetam 750 mgs was a medication that Resident #97 had been taking prior to her hospital admission. The DON reported Resident #97 had Levetiracetam 750 mg at home prior to the hospital admission and the prescription at the pharmacy from the neurologist. Interview with the Administrator on 09/19/25 at 11:09 A.M. revealed Resident #97 discharged from the facility on a Saturday and Resident #97's husband called her on the following Tuesday and stated Resident #97 was at the hospital. The Administrator stated Resident #97's husband wanted the facility to send a copy of Resident #97's medications to the hospital. The Administrator had the medication list sent to the hospital. The Administrator stated Resident #97's husband reported no concerns with Resident #97 receiving her medications upon discharge from the facility. Interview with the DON on 09/19/25 at 2:22 P.M. verified NP #502's telephone order on 06/28/25 stated Resident #97 was to be discharged with her remaining medications and to send Resident #97 with a two-week supply of prescriptions. The DON verified the facility did not have any documentation of any electronic prescriptions being sent and Resident #97 only discharged with the remaining amount of medications to be given on 06/28/25. Review of the facility's team 365984 Page 2 of 3 365984 09/19/2025 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0627 Level of Harm - Minimal harm or potential for actual harm discharge planning process policy dated January 2018 revealed all staff should communicate the same message with the resident and the facility regarding the goal for a safe and successful discharge. The amount of medications to be sent with the resident upon discharge from the facility was not listed in the policy. This deficiency represents non-compliance investigated under Complaint Number 2621217. Residents Affected - Few 365984 Page 3 of 3