Inspection·January 30, 2020

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to issue a written notice of bed hold policy to residents and resident representatives when transferred from the facility. This affected one (#20) of one resident reviewed for hospitalization. The facility identified six residents who were transferred to the hospital from the facility in the last three months. The census was 33. Findings include: Review of Resident #20's medical record revealed an admission date of 12/06/19. Diagnoses included acute bronchitis, retention of urine, iron deficiency anemia, muscle weakness, chronic kidney disease, and congestive heart failure. Review of an admission Minimum Data Set (MDS) assessment, dated 12/09/19, revealed Resident #20 had intact cognition. Review of a facility Bed Holds and Leaves of Absence for revealed Resident #20 indicated she wanted her bed held for any visits to hospitals, visits with friends or family, or any leaves of absence. Resident #20 signed the document on 12/06/19. Review of nursing progress notes on 12/26/19 revealed Resident #20 was transferred from the facility to a local hospital to seek medical treatment. Resident #20 returned to the facility from the hospital on [DATE] Review of nursing progress notes on 01/20/20 revealed Resident #20 was transferred from the facility to a local hospital to seek medical treatment. Resident #20 returned to the facility from the hospital on [DATE]. There was no documentation in the nursing progress notes, or any place in the medical record, where Resident #20 and a resident representative were provided a written notice of bed hold policy at the time of transfer to the hospital on [DATE] and 01/20/20. Interview on 01/30/20 at 11:39 A.M. with admission Coordinator #250 stated residents and resident responsible parties are provided the facility's bed hold policy upon admission, and a determination of whether a bed hold was to be implemented was indicated on that admission document. admission Coordinator #250 stated when residents are transferred to the hospital from the facility the facility usually contacts residents or resident responsible parties via telephone about bed hold options, but verified the facility did not issue the written notice of bed hold policy upon transfer from the (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: 365996 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 365996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Swan Creek 1650 Swan Creek Lane Toledo, OH 43614 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)