Health inspection·June 20, 2019

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 review of medical record, staff interview, and review of facility policy, the facility failed to to provide a transfer/discharge letter with appeal rights when residents were transferred/discharged from the facility. This affected one residents (#44) of three residents who were transferred/discharged from the facility. The facility also failed to notify the Ombudsman of a transfer/discharge from the facility. This affected one resident (#44) of three residents who were transferred/discharged from the facility. The facility census was 65. Findings include Review of Resident #44's medical record revealed the resident was initially admitted to the facility on [DATE], discharged with return anticipated on 03/25/19, readmitted on [DATE], discharged with return anticipated on 05/10/19 and readmitted on [DATE]. Diagnoses included acquired absence of left hip joint, right above the knee amputation, peripheral vascular disease, embolism and thrombosis of iliac artery, and type one diabetes. Review of comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Resident #44 was independent to requiring limited assistance for activities of daily living. Review of Progress Notes on 03/24/19 revealed Resident #44 the resident was transferred to the hospital on [DATE] and returned on 04/06/19. Upon transfer/discharge from the facility the resident was only provided a bed hold notice. The facility did not provide a transfer/discharge letter with appeal rights to Resident #44 nor notify the Ombudsman of the transfer/discharge from the facility. Review of Progress Notes revealed Resident #44 was sent out to the hospital on [DATE] and was readmitted to the facility on [DATE]. The facility provided a bed hold notice and notified the Ombudsman of the resident's transfer/discharge from the facility. The facility did not provide a transfer/discharge letter with appeal rights to Resident #44. Interview on 06/18/19 at 05:34 P.M. with the Director of Nursing (DON) and Social Service Director (SSD) #72 verified the facility did not provide a transfer/discharge notice with appeal rights to the resident and/or representative when the resident was transferred to the hospital on [DATE] and 05/10/19. The DON and SSD also verified the Ombudsman was not notified when Resident #44 was transferred/discharged from the facility on 03/10/19. Review of facility policy titled Resident Transfers and Discharge Notification date 04/2018 revealed for a facility initiated transfer or discharge the facility must notify the resident and 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 2 Event ID: 366013 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 366013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Court Care Center 250 Delaware St Lexington, OH 44904 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)