Health inspection·July 14, 2023

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #83's discharge was orderly and included accurate medications provided to the resident upon discharge home. This finding affected one (Resident #83) of four residents reviewed for discharges. Residents Affected - Few Findings include: Review of Resident #83's medical record revealed an admission date of 03/28/23 and a discharge date of 04/12/23 with diagnoses including major depressive disorder, muscle weakness and cognitive communication deficit. Review of Resident #83's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment. Review of Resident #83's nursing progress note dated 04/12/23 at 11:00 A.M. revealed she was discharged home with the brother and the medications were sent with the resident. The medications were reviewed along with the discharge orders. Review of Resident #85's medical record revealed an admission date of 03/25/23 and a discharge date of 04/20/23 with diagnoses including schizoaffective disorder, bipolar disorder and low back pain. Review of Resident #85's admission MDS 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. Review of Resident #85's physician orders revealed an order dated 03/25/23 for Gabapentin (for nerve pain) give 200 mg (milligrams) by mouth three times a day for low back pain; an order dated 03/26/23 for Sertraline (Zoloft) 50 mg (antidepressant) give one time a day for bipolar/schizophrenia; and an order dated 04/01/23 for Metformin 500 mg give one tablet two times a day for diabetes. Telephone interview on 07/14/23 at 9:56 A.M. of Resident #83's brother with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #805 present revealed the resident was discharged home with three of her medication cards and three of Resident #85's medication cards. Resident #83's brother confirmed the resident did not consume any of the medications that belonged to Resident #85. Interview on 07/14/23 at 10:35 A.M. with ADON #805 confirmed Resident #83 was discharged home with three medication cards that belonged to Resident #85 including Gabapentin, Zoloft and Metformin and the brother brought the medications back to the facility. ADON #805 was unclear of how many tablets of Resident #85's Gabapentin, Zoloft and Metformin medications were on the medication cards when Page 1 of 2 366127 366127 07/14/2023 Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266

F 0660 they were returned to the facility. Level of Harm - Minimal harm or potential for actual harm Review of the Discharge Planning Policy revised 09/24/20 indicated the discharge needs of each resident would be identified and result in the development of a discharge plan for each resident. This included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00143633. 366127 Page 2 of 2