Inspection·August 29, 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident and or representative were provided with written documentation upon transfer and/or discharge to the hospital. This affected two (#46, #48) of two residents reviewed for hospitalizations. The facility census was 47. Findings include : 1. Review of the medical record for Resident #46 revealed an admission date of 06/25/19. Diagnoses included pneumonia, multiple sclerosis, chronic respiratory failure and severe sepsis with septic shock. Review of the nurses notes dated 07/21/19 and 07/30/19 revealed Resident #46 was sent to the emergency room. Review of the medical record revealed no documentation of a notice of the transfer was given to the resident and or representative. Interview with the Administrator on 08/28/19 at 2:25 P.M. verified they did not provide a reason for transfer notice to Resident # 46 for either of his discharges to the hospital on [DATE] or 07/30/19. The Administrator stated the facility does have a form for discharge and transfers which has not been utilized. 2. Review of the medical record for Resident #48 revealed an initial admission date of 05/22/19, with an re-entry date of 06/10/2019, and a discharge date of 06/25/2019. Diagnoses included acute mastioditis, mass, and lump , severe protein malnutrition and acute kidney failure Review of the nurses notes for Resident #48 dated 06/22/2019 at 9:53 A.M. revealed resident was sent to the emergency room. A nurses note dated 06/25/2019 8:30 P.M. revealed the nurse received an order to send the resident out to emergency room. Review of the medical record revealed no documentation of a notice of the transfer was given to the resident and or representative. Interview with the Administrator on 8/29/19 08:15 A.M. verified there is no notice of transfer completed when Resident #48 went to the hospital on [DATE] and 06/25/19 as the facility doesn't do the notices. Review of the facility's policy titled Transfer and Discharge Requirements, dated 08/16/18, (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 6 Event ID: 366144 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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)