Health inspection·May 24, 2023

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to provide residents and/or resident representatives of bed hold notice and/or bed hold policy upon discharge to the hospital. This affected four residents (#3, #11, #14, and #26) of four residents reviewed for hospitalizations. The facility census was 17. Findings include: 1. Review of the medical record for Resident #3 revealed admission date of 03/17/23 and a discharge date of 05/22/23 with diagnoses including pleural effusion (accumulation of excess fluid around the lungs), cystitis (inflammation of the urinary bladder), cerebral infarction (stroke), hemiplegia (paralysis) affecting left nondominant side and right dominant side, dysphagia (difficulty swallowing), diabetes mellitus, chronic kidney disease stage three, and systolic congestive heart failure, and depressive disorder. Review of the progress notes for Resident #3 revealed on 04/08/23 Resident #3 had increased edema to thighs and abdomen, and family had expressed concerns regarding the increase edema. The nurse practitioner was notified and gave an order to send Resident #3 to the emergency department. On 04/09/23, Resident #3 was admitted to the hospital with a diagnosis of pleural effusion. On 04/14/23, Resident #3 was readmitted to the facility from the hospital. A progress note dated 04/19/23 revealed Resident #3 felt an increase in shortness of breath and wanted to be sent to the emergency department. On 04/20/23, Resident #3 was admitted to the hospital with pleural effusion. Further review of the medical record for Resident #3 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #3 and/or Resident #3's representative when the resident was sent to the hospital on [DATE] and 04/19/23. 2. Review of the medical record for Resident #11 revealed an admission date of 02/23/23 and a discharge date of 05/05/23 with diagnoses including gross hematuria (blood in urine), long term use of anticoagulants (blood thinners), permanent atrial fibrillation (abnormal heart rhythm), and cirrhosis (impaired function caused by formation of scar tissue) of liver. Review of the progress notes for Resident #11 revealed on 04/11/23 Resident #11 was complaining of abdominal pain, the Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) was noted to have blood-tinged urine in the bag, the Foley catheter was unable to be flushed, and the Foley catheter was removed. The doctor was notified and ordered Resident #11 sent to the emergency room. On 04/12/23, Resident #11 was admitted to the hospital for acute (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 5 Event ID: 366442 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 366442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center for Rehabilitation at Hampton Woods The 1517 East Western Reserve Road Poland, OH 44514 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)