Inspection·August 22, 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 policy review, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected one (#21) of one resident reviewed for hospitalizations. The facility census was 22. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, congestive heart failure, stage three chronic kidney disease, atrial fibrillation, urinary tract infection, alkalosis, overactive bladder, hypothyroidism, history of venous thrombosis and embolism, gastroesophageal reflux disease, chronic pain, headache, muscle weakness, difficulty walking, cataract, major depressive disorder, morbid obesity, fracture of left toes, nonspecific abnormal finding of lung field, low back pain, anemia and constipation. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital by ambulance on 07/15/19 at 12:14 P.M. Resiident #21 returned to the facility on [DATE] at 4:32 P.M. Additional review of Resident #21's medical record revealed the resident was also transferred to the hospital by ambulance on 07/23/19 at 2:37 P.M. Resident #21 had not returned to the facility as of 08/20/19. The medical record had no evidence of the written notifications being provided to the resident and/or resident representative at the 07/15/19 or 07/23/19 discharge. Interview on 08/20/19 at 2:27 P.M. with Social Services Manager (SSM) #100 confirmed Resident #21's medical record had no documented written notifications being provided to the resident and/or resident representative. Review of a facility policy titled Transfer and Discharge, dated 11/2017, revealed notice will be provided to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. 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: 366468 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 366468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Payne 650 North Main Street Payne, OH 45880 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)