Health inspection·May 5, 2022

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366339 If continuation sheet Page 2 of 3 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 366339 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Lake Vista 303 North Mecca Street Cortland, OH 44410 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)

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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366339 If continuation sheet Page 3 of 3