Health inspection·April 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to notify Resident #12's physician that he had an active infection and was currently being isolated before sending him to an appointment at the physician's office. This affected one resident (#12) of three residents reviewed for infection control. The facility census was 23. Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/19/24. Diagnoses included congestive heart failure, type two diabetes mellitus, and diarrhea unspecified. Review of the hospital information sent to the facility on admission, printed on 03/19/24 revealed Resident #12 had a positive stool for clostridioides difficile (c-diff) on 03/14/24. Resident #12 was started on oral vancomycin 250 milligrams (mg) (antibiotic) four times daily on 03/19/24. Review of the physician's order dated 03/20/24 and discontinued on 04/02/24 revealed Resident #12 was to remain in contact isolation for c-diff. Review of the physician's order dated 03/20/24 and ended on 04/02/24 revealed an order to administer vancomycin 250 mg by mouth to Resident #12 four times a day for c-diff. Review of the care plan for Resident #12 dated 03/20/24 revealed he had an infection. Interventions included to administer medications as ordered and to provide perineal care after each incontinent episode. Review of the transfer for Resident #12 dated 03/21/24 revealed he was leaving for an appointment at a physician's office. No diagnoses were listed on the form, just emergency contact information. At the bottom of the form where the physician writes a response, the physician left a note questioning the facility for sending a patient to his office with an active c-diff diagnosis. The form was signed by the physician. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 required some help of another person for self-care and was independent for ambulation with or without a device. Resident #12 was occasionally incontinent of urine and bowel. He had also received an antibiotic in the past seven days. Interview on 04/12/24 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #12 was (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 2 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 04/12/2024 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)