Health inspection·May 5, 2022

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many 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 record review and interview the facility failed to ensure the Ombudsman was notified of resident transfers and discharges to the hospital. This affected three (Residents #45, #46, and #10) of four residents reviewed for transfer and discharge to the hospital. The facility census was 54. Findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure. Resident #45 was hospitalized from [DATE] through 03/22/22. Review of physicians orders dated April 2022 revealed orders for nursing staff to obtain a full set of vitals including pulse, respirations, blood pressure, temperature, and blood oxygen level twice a day and as needed, oxygen at three liters per min (LPM) via nasal cannula (NC) continuously, and the head of her bed was to be elevated to alleviate shortness of breath. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. Review of the care plan dated 03/23/22 revealed she was at cardiopulmonary risk related to a diagnosis of acute and chronic respiratory failure. Nursing staff were to encourage the resident to cough and deep breath frequently, monitor respiratory rate, blood oxygen saturation, and lungs sounds every shift. The resident was to wear her oxygen at 3 LPM continuously. Review of nurses notes dated 03/13/22 at 8:59 P.M. revealed Resident #45 was in respiratory distress with a blood oxygen level of 79 percent (%) on 3 LPM, a non-rebreather oxygen mask was applied, and her oxygen was increased to 4 LPM, her blood oxygen level increased to 89%. Resident #45's daughter was at the bedside and kept informed of the resident's condition. Resident #45's physician was updated and gave an order to send the resident to the emergency room where she was admitted for respiratory failure. Review of nurses notes dated 03/14/22 revealed Social Worker (SW) #143 mailed out the resident's bed hold letter to the representative but did not notify or document notification to the Ombudsman. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses which included Coronavirus 19 infection, generalized muscle weakness, atrial fibrillation and chronic obstructive pulmonary disease. Page 1 of 3 366339 366339 05/05/2022 Ohio Living Lake Vista 303 North Mecca Street Cortland, OH 44410

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Review of the admission MDS dated [DATE] revealed Resident #46 was cognitively intact and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing. The MDS assessment dated [DATE] revealed Resident #46 was discharged , return not anticipated. Review of nurses notes revealed Resident #46 was sent to the hospital on [DATE] per physician orders due to a change in mental status and being short of breath. Resident #46 was admitted to the hospital with diagnoses of hypotension and peripheral edema and did not return to the facility after hospitalization. 3. Resident #10 was admitted to the facility on [DATE] with diagnoses including subarachnoid hemorrhage secondary to a fall at home, left sixth rib fracture, right distal radius fracture, hypertension and hypothyroidism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 was severely cognitively impaired and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing. Review of nurses notes revealed Resident #10 was sent to the hospital on [DATE] per physician orders for evaluation and treatment after a fall and was admitted with a left femur fracture. Nurses notes dated 03/07/22 revealed SW #143 mailed out the resident's bed hold letter to the representative but was absent documentation of any notification to the Ombudsman. Nurses notes dated 03/08/22 revealed Resident #10 returned to the facility. Interview on 05/04/22 at 2:00 P.M. with the Administrator confirmed the facility did not notify the Ombudsman of transfers or discharges of residents. The Administrator stated he was aware that the facility had to notify the Ombudsman of resident transfers/discharges to the hospital but could not say why it was not being done. He stated one years' worth of discharge notifications had been sent to the Ombudsman as of today 05/04/22. Interview on 05/04/22 at 2:01 P.M. with the Director of Nursing (DON) also confirmed they did not notify the Ombudsman of resident transfers or discharges. Interview on 05/05/22 at 9:43 A.M. with the Ombudsman confirmed the office had not received notifications of resident transfers or discharges from the facility. The Ombudsman confirmed she received emails last night (05/04/22) and this morning (05/05/22) of all the transfers and discharges for March, April and May 2022. Review of facility policy titled Discharge, Transfer of Resident dated 05/03 revealed the facility was to in situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility must send a notice of discharge to the resident and resident representative and must also send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice to the Office of the State Long Term Care (LTC) Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the ombudsman only needed to occur as soon as practicable as described below. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman 366339 Page 2 of 3 366339 05/05/2022 Ohio Living Lake Vista 303 North Mecca Street Cortland, OH 44410

F 0623 at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative. Level of Harm - Potential for minimal harm Residents Affected - Many 366339 Page 3 of 3