Health inspection·November 4, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #115's guardian was informed and gave consent for Resident #115 to be discharged from the facility. This affected one resident ( Resident # 115) of the three residents reviewed for discharge. The facility census was 114. Residents Affected - Few Findings include: Review of the medical record revealed Resident #115 was admitted to the facility on [DATE] and discharged from the facility on 08/12/24. Guardian #392 was listed as the responsible party guardian and emergency contact #1. Resident #115's mother was the emergency contact #2. Medical diagnoses included pulmonary edema, Asperger's syndrome, diabetes, bipolar, hypertension, glaucoma, dependence on renal dialysis, depression, and anemia. Review of the Minimum Data Set ( MDS) 3.0 Discharge Return Not Anticipated assessment dated [DATE] revealed discharge was unplanned to home. Resident #115 had moderate impairment for decision making. Resident #115 displayed physical behaviors. Resident #115 needed set up for eating. Maximum assistance was needed for oral hygiene. Moderate assistance was needed for toilet hygiene, bathing and dressing. Resident #115 needed moderate assistance to roll left and right in bed, sit on the side of the bed, lie back in bed , stand and transfer from bed. Moderate assistance was needed to walk ten feet. Resident #115 received hemodialysis. Review of the Health Status Note dated 08/12/24 at 2:41 P.M. written by Licensed Practical Nurse (LPN) #344 , revealed Resident #115's mother stated she wanted to take Resident #115 home. The physician was notified. This note stated Residents guardian [NAME] was also notified of residents discharge from the facility. Review of the document titled Probate Court of Ashtabula County Letters of Guardianship, dated 08/07/23, revealed Catholic Charities of Ashtabula County shall be appointed Guardian of Resident #115, an incompetent and the duties of the Guardian shall be discharged by the appointed agent Guardian #392. As Guardian, powers were person only for an indefinite time period. The document was signed by the Probate Judge. Review of medical record Discharge summary dated [DATE] revealed Resident #115 was discharged from the facility to home and Resident #115's mother signed the Discharge Summary along with LPN #344. Interview with Healthcare Compliance Investigator( HCI) #391 on 11/04/24 at 8:34 A.M. revealed the facility allowed Resident #115 and his mother to sign themselves out because of behaviors Resident #115 was displaying. The legal guardian was not notified until after Resident #115 was discharged (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: 365741 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 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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)