Health inspection·July 31, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, staf interview and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level 1 was updated and resubmitted following a new diagnosis of a serious mental illness for one (Resident #13) of three residents reviewed for PASRR. The facility census was 94.Findings included:Review of Resident #13's Preadmission Screen/Resident Review (PAS/RR) Identification Screen, dated 01/06/20, revealed that Resident #13 had a diagnosis of dementia/Alzheimer's disease, and had diagnoses that included mood disorder and major depressive disorder. A review of the clinical record for Resident #13 revealed no evidence of any additional PASRR forms. Interview on 07/30/25 at 12:28 P.M., with the Social Services Director (SSD) stated when a new psychiatric diagnosis was added to a resident record, a new Level I PASRR would be completed. The SSD stated a new PASRR Level I should have been completed for Resident #13 when their schizoaffective disorder diagnosis was added. Interview on 07/31/25 at 11:07 A.M., with the Administrator and the Director of Nursing (DON), the Administrator stated it was her expectation that the PASRR was accurate and resubmitted when there was a significant change in the resident's condition or a new psychiatric diagnosis was added. The Administrator stated it was her expectation that a PASRR Level I would have been resubmitted for Resident #13 at the time the new psychiatric diagnosis was added. The DON stated she would defer to the Administrator for PASRR-related questions.Review of the policy titled,PASRR and Level of Care Policies for Ohio, dated 06/11/18, revealed, it is the policy of [Facility Name] to follow the State and Federal regulations related to completing the appropriate PASRR and Level of Care as needed on admission, following a 30 day stay, appropriate change in level of condition and as needed for payor change to Medicaid. The results of the PASRR or Level of Care will be maintained in the electronic medical record. 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: 365639 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 365639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Vermilion 4210 Telegraph Lane Vermilion, OH 44089 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)