Inspection·July 3, 2023

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to develop an effective discharge planning process to facilitate a proposed facility-initiated discharge. This affected one (#15) of two residents reviewed for discharge notices. The facility census was 40. Residents Affected - Few Findings include: Review of Resident #15's medical record an admission date of 03/03/08. Diagnoses included schizophrenia, diabetes, lung cancer, and chronic obstructive pulmonary disease (COPD). The medical record identified Resident #15 had a legal guardian in the community. Review of Resident #15's medical record revealed a letter dated 04/26/23 that was addressed to Resident #15. Further review of the letter revealed the facility reviewed Resident #15's current ability to perform activities of daily living (ADLs) including a Brief Interview for Mental Status (BIMS), and were are pleased to inform Resident #15 that he scored 15 out of a total of 15 points indicating Resident #15 had intact cognition. The review indicated a long-term skilled nursing care setting was no longer the most appropriate setting to meet Resident #15's care needs or appropriate for his quality of life. Therefore, the staff would like to schedule a meeting to review new/potential living arrangements for a transition within the next 30 calendar days. Review of Resident #15's current plan of care identified no evidence of discharge planning. Further review of the medical record revealed Resident #15 has twice a day blood glucose checks with insulin administration, multiple oral medications, and pain patch use. The medical record identified no evidence of education and/or attempts to instruct Resident #15 to self administer his medications. Interview with Resident #15 on 07/03/23 at 8:48 A.M. revealed he was moving to an independent apartment, was on a waiting list, and had no specific date to move in. Resident #15 confirmed he and his guardian agreed to try the move after getting the letter from the facility. Resident #15 confirmed the facility had not started any education to teach him how to do his own medications; and the resident confirmed he did not know if he would need to prepare his own meals at the new apartment. Resident #15 confirmed he lived in his current nursing home for many, many years. Interview with the facility Administrator on 07/03/23 at 8:29 A.M. revealed the facility interdisciplinary team determined Resident #15 was able to be discharged to a lesser care facility. The interview with the Administrator confirmed there was no written evidence of a discharge plan in place as of 07/03/23, and confirmed the facility sent a letter to Resident #15 on 04/26/23. The Administrator confirmed there was no written evidence of what Resident #15 would need, including pertinent education, to live safely in the apartment nor a plan to ensure Resident #15 was capable of living on his own in an independent apartment. (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: 365118 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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)