Bellbrook Health And Rehab

nursing services, dietary services, activities, and rehabilitation services were all blank, and the form was not signed.

Interview on 10/29/25 at 9:20 A.M. with the Director of Nursing (DON) #52 from the ALF community where the resident was listed as being discharged to, revealed Resident #100 never resided in the ALF. DON #52 stated Resident #100 had always lived in an independent living apartment and was discharged back to his independent living apartment from the facility.

Interview on 10/29/25 at 9:53 A.M. with Nurse Practitioner (NP) #501 revealed Resident #100 expressed concerns about not being ready to go home related to his insulin. NP #501 stated she thought Resident #100 was discharged to an ALF and was surprised to learn Resident #100 was discharged to an independent living apartment. NP #501 stated she was certain Resident #100 went home with home health referral because a home health care nurse called her to ask for a prescription for insulin because the resident was discharged without any insulin and without having a primary care physician in place.Interview on 10/29/25 at 10:25 A.M. with Home Health Care Registered Nurse (RN) #504 stated Resident #100 was discharged from the facility to an independent living apartment with no primary care physician to follow him. RN #504 stated she visited Resident #100 on 05/17/25 and the resident did not have any insulin in his apartment. RN #504 stated she reached out to NP #501 because Resident #100 did not have a primary care physician to contact. RN #504 requested an insulin order from NP #501 and to be sent to Resident #504's independent living apartment. RN #504 stated she had to assist Resident #504 with finding a primary care physician.

Interview with the Administrator on 10/29/25 at 1:54 P.M. verified Resident #100 was discharged from the facility without a discharge summary or a discharge plan.

The Administrator stated Resident #100 was discharged from the facility without a primary care physician in place or a scheduled follow up appointment with a primary care physician.

Review of the facility policy titled Discharge Summary and Plan dated October 2022, revealed when a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge.

The discharge summary of the resident's stay at the facility and final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and permitted by the resident. A copy of the resident's post-discharge plan and discharge summary will be filed in the Residents medical record.2)

Review of the May 2025 through October 2025 information sent to the Ombudsman's Office for discharges, revealed each monthly cover sheet was sent to an unknown fax number.

Each cover sheet contained a list of discharges from the facility; however, there was no documented evidence that the information was sent and /or received by the Ombudsman's Office.

Interview with Ombudsman #506 on 10/29/25 at 9:08 A.M,, revealed the Ombudsman's Office did not receive any notification of discharges from the facility in the past six months.

Ombudsman #506 verified they were not aware Resident #100 was discharged .

Ombudsman #506 stated the fax number listed on the facility's cover sheet was not a fax number for the Ombudsman's Office.Interview with the Administrator on 10/29/25 at 1:54 P.M., stated a list of the discharges were to be faxed to the local Ombudsman's Office monthly.

The Administrator reported the facility was not aware of the incorrect number where the faxes were being sent.

The Administrator verified the facility had no documented evidence that the Ombudsman's Office was being notified of the facility discharges.

This deficiency represents non-compliance investigated under Complaint Number 1367217.

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