Health inspection·November 6, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed following the addition of a new mental health diagnosis. This affected two (#3 and #7) of the four residents reviewed for PASARR during the annual survey. The facility census was 21. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 06/11/20, with diagnoses including: hypertension, dementia, insomnia, chronic respiratory failure, unspecified psychosis, basal cell carcinoma, macular degeneration, peripheral vascular disease, hallucinations, peripheral vascular disease, chronic embolism and thrombosis, insomnia, schizophrenia, atherosclerosis, and delusional disorders. A diagnosis of unspecified psychosis was added on 07/21/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had severely impaired cognition . Review of completed PASSAR documents revealed the facility did not complete a new PASSAR designation following the addition of the unspecified psychosis diagnosis on 07/21/22. Interview on 11/06/24 at 10:22 A.M., with Licensed Practical Nurse (LPN) #400 verified a new PASSAR had not been completed with the addition of the new diagnosis. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE], with diagnoses including: muscle weakness, heart failure, and mood disorder. The resident had a new diagnosis of schizoaffective disorder added on 10/13/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/24, revealed the resident was assessed to be rarely/never understood. Further record review for Resident #7 revealed no significant change PASSAR was completed following a new diagnosis of schizoaffective disorder. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed a significant change PASSAR was not completed following the new diagnosis of schizoaffective disorder for Resident #7. 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: 366360 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 366360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Concord, The 119 West High Street Frankfort, OH 45628 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)