Inspection·February 29, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to administer medications that followed appropriate nursing standards of care and left medications unsecured at Resident #60's bedside. This affected one resident (#60) and had the potential to affect 90 residents (#1, #3, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #22, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #41, #42, #43, #45, #47, #48, #49, #51, #53, #54, #55, #57, #59, #60, #61, #62, #63, #64, #66, #69, #70, #71, #76, #78, #79, #82, #83, #84, #85, #86, #89, #91, #93, #97, #109, #110, #113, #114, #115, #116, #117, #118, #120, #122, #123, #125, #127, #129, #130, #132, #137, #139, #140, #142, #145, #147, #301, #351, #401, #402) who were independently mobile and resided on the secured unit. The facility census was 150. Findings Include: Review of Resident #60's medical record revealed an admission date of 10/26/23 with medical diagnoses including vascular dementia with moderate behavioral disturbance, schizophrenia, symptoms and signs involving cognitive functions and awareness, bipolar disorder, heart failure, hyperlipidemia, and atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was mildly cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine of 15. Resident #60 showed behaviors of rejection of care and wandering. Review of the care plan dated 10/26/23 revealed Resident #60 experienced alteration in mood and behavior related to bipolar disorder, schizophrenia, unspecified vascular dementia with behavioral disturbance, and major depressive disorder. Resident #60 had a history of refusing care, pacing, confusion, poor safety awareness, hording, rummaging, and refusing care. Observation on 02/26/24 at 10:59 A.M. revealed a medication cup filled over halfway with oral medication tablets and capsules were on Resident #60's bedside table. Resident #60 was observed lying in bed next to bedside table with eyes closed. Interview on 02/26/24 with Licensed Practical Nurse (LPN) #565 confirmed oral medications were not observed to be administered when LPN #565 left a medication cup filled with Resident #60's medication at the bedside. LPN #565 stated that was not normal practice to leave medications at the resident's bedside, and that she was in a hurry that morning. Review of medication administration audit report dated 02/26/24 revealed on 02/26/24 at 9:23 A.M. (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 02/29/2024 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)