Health inspection·January 4, 2020

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 #18 was eligible to reside in a long term care facility. This affected one (Resident #18) of one resident reviewed for pre-admission screen and resident review (PASRR). The facility census was 36. Residents Affected - Few Findings include: Review of the PASRR determination dated 03/26/19, while Resident #18 was at another long term care facility, revealed the resident had been denied living at a nursing facility. The determination revealed the resident must return to the community. Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses including paranoid schizophrenia, delusional disorders, diabetes mellitus, major depressive disorder and anxiety. Review of the plan care for discharge date d 06/24/19 revealed Resident #18 was to return to the community with services once housing was obtained. The Medicare 30-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had cognitive impairment. Interview on 01/03/20 at 2:58 P.M. with Social Services #227 revealed Resident #18 was admitted from another facility where the PASRR determination revealed the resident was denied living at a nursing facility. Social Services #227 stated she was on vacation when the resident was admitted without an appropriate PASRR determination. Interview on 01/03/20 at 3:40 P.M. the Administrator verified residents should have a PASRR determining they were appropriate for nursing home placement. 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 3 Event ID: 366014 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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)