Inspection·May 11, 2023

E0800 for rejection of care was assessed as behavior not exhibited and the response was locked on 04/17/23 prior to the ARD of 04/21/23. Section E0900 for wandering was assessed as behavior not exhibited and the response was locked on 04/17/23 prior to the ARD of 04/21/23. Interview on 05/04/23 at 12:18 P.M. with Social Services Designee (SSD) #608 and Licensed Social Worker (LSW) #509 verified Resident #88's 5-day admission MDS assessment dated [DATE] did not capture all the behaviors documented during the look back period from the ARD because it was completed prior to the ARD. LSW #509 indicated it was acceptable to complete the assessment anytime within the assessment period. 2. Record review revealed Resident #159 was admitted to the facility on [DATE] with diagnoses including psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, post-traumatic stress disorder, major depressive disorder, anxiety, and insomnia. Review of the behavior documentation report for March 2023 and April 2023 revealed Resident #159 demonstrated pacing/wandering and disruptive sounds on 03/30/23, and refusal of care on 04/01/23. Review of the behavior tracking log for March 2023 and April 2023 revealed Resident #159 (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: 365286 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 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few demonstrated pacing/wandering on 03/29/23 and 03/30/23, and was resistive to care on 03/29/23, 03/30/23, 03/31/23, 04/01/23, 04/03/23, and 04/04/23. Review of the admission MDS 3.0 assessment, dated 04/04/23, revealed Resident #159 was assessed in section E0200(C) for other behavioral symptoms not directed towards others (e.g., verbal/vocal symptoms like screaming or disruptive sounds) as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Section E0800 for rejection of care was assessed as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Section E0900 for wandering was assessed as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Interview on 05/04/23 at 12:18 P.M. with SSD #608 and LSW #509 verified Resident #159's admission MDS assessment dated [DATE] did not capture all the behaviors documented during the look back period from the ARD because it was completed prior to the ARD. LSW #509 indicated it was acceptable to complete the assessment anytime within the assessment period. 3. Record review revealed Resident #161 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, Parkinson's disease, and acute myeloblastic leukemia. Review of the 5-day MDS 3.0 assessment, dated 04/22/23, revealed Resident #161 was assessed in section E0200(A) for physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) as behavior exhibited one to three days and the response was locked on 04/24/23. Review of the psychosocial assessment dated [DATE] for Resident #161 revealed E0200(A) for physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) was answered as behavior exhibited one to three days. Review of the behavior documentation report and progress notes for April 2023 revealed Resident #161 did not demonstrate any physical behavior directed toward others. Interview on 05/03/23 at 10:01 A.M. with SSD #608 and MDS Registered Nurse (RN) #583 confirmed Resident #161's 5-day MDS assessment dated [DATE] was incorrect. Resident #161 did not exhibit any physical behavioral symptoms. SSD #608 indicated selecting the wrong response when completing the assessment. MDS RN #608 stated Resident #161's MDS assessment would be corrected. Review of Resident #161's 5-day MDS assessment dated [DATE] revealed section E0200(A) for physical behavioral symptoms directed toward others was modified to behavior not exhibited and was locked on 05/03/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 2 of 2