Health inspection·February 27, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure advance directives for Resident #43 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#43) of one resident reviewed for advance directives. The facility census was 62. Findings included: Review of medical record for Resident #43 with an admission date of 01/15/20 and diagnoses included hemiplegia and hemiparesis following infarction affecting right dominant side, Parkinson's disease, atrial fibrillation, and hypertension heart and chronic kidney disease with heart failure. Review of nursing notes dated 01/15/20 at 12:52 P.M. completed per Licensed Practical Nurse (LPN) #600 revealed Resident #43 was admitted to the facility on [DATE] and Resident #43's power of attorney signed for Resident #43 to be a Do Not Resuscitate Comfort Care (DNRCC). Resident #43 Primary Care Physician (PCP) #601 was notified, and the family was awaiting on the physician's arrival. Review of form labeled, DNR Comfort Care located in Resident #43's chart revealed Resident #43's authorized representative signed but did not date requesting Resident #43 to be a DNRCC. Resident #43's Primary Care Physician (PCP) #601 signed the DNRCC form and dated the form 01/16/20. The form indicated the following DNR protocol was effective immediately. Review of admission Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #43 had impaired cognition. Review of care plan for Resident #43 dated 01/29/20 revealed Resident #43 was a full code. Intervention included review code status quarterly and as needed. Review of physician orders for February 2020 revealed Resident #43 did not have a code status listed on his physician orders. Interview on 02/26/20 at 10:52 A.M. with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #602 revealed when a code status was not listed on the physician orders the resident was a full code. RN/ ADON #602 verified PCP #601 signed Resident #43's DNR comfort care form to have Resident #43 a DNR Comfort Care (DNRCC) on 01/16/20. She verified the facility did not change Resident #43's code status in his physician orders or in his care plan. Review of facility policy labeled, Advance Directives dated 11/21/16 revealed the purpose of the (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: 365642 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St 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)