Vineyards At Concord, The

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

what she needed she stated He hit me. I proceeded to ask male resident if he had hit her, he stated, She kicked me. I then assessed both residents with the charge nurse. No injuries were noticed to male resident.

There was a small cut on female residents lip, I wiped clean the cut with a clean cloth. I kept both residents separated from each other for the resident of my shift. Review of the nursing progress note dated 09/03/2025 at 1:24 P.M. created by the Directed of Nursing revealed, Dark Purple and red bruising noted to

the top of the right hand, across knuckles. Resident States, I must have hit something, Review of the History and Physician progress note dated 09/04/2025 no time noted revealed, Right hand with significant edema and bruising. Continued review revealed, Patient sustained metatarsal fractures of the second, third, fourth, and fifth metatarsals in a recent fall. Review of the nursing progress note date 09/06/2025 at 11:09 A.M. author unknown revealed, Resident complained of left elbow and left hip pain. Provider notified with new orders for by mouth pain medication, topical pain medication relief. Provider also notified of right hand x-ray results.Review of the nursing progress note dated 09/11/2025 at 10:00 A.M. author unknown revealed, Resident is presently at the hospital. Resident #106 is now noted to have a severe complicated fracture in her hip and they are not sure if this is old or new. Interview on 11/10/2026 at 2:20 P.M. with the Administrator revealed he completed a investigation for the incident between Resident #106 and Resident #70 and at that time found there to be no reason for any additional investigation. The Administrator claimed

he did not submit this incident as a Self-Reported Incident due to there being no concern for abuse. The Administrator also confirmed he did not submit a report or investigation for Resident #106's injured right hand or fractured pelvis. Review of the facility policy titled, Investigations of Abuse. dated 12/2022 revealed, Procedure 6. In the case of allegations or suspicions of abuse or misappropriation state officials shall be notified immediately and not later than 2 hours of facility's of the allegations being made to facility in the form of initiating a Self-Reported Incident. (SRI). Full investigation shall be made available to Ohio Department of Health (ODH) within 5 business days or less by the Administrator or delegate in the form of

a finalized SRI. In addition the Sheriff shall be notified within 2 hours of suspected crime. 7. All alleged violations and substantiations of abuse shall be reported to all appropriate state agencies and licensing or registration bureaus. This deficiency represents non compliance investigated under Complaint Number

1. 2661527. Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

progress note date 09/06/2025 at 11:09 A.M. author unknown revealed, Resident complained of left elbow and left hip pain. Provider notified with new orders for by mouth pain medication, topical pain medication relief. Provider also notified of right hand x-ray results.Review of the nursing progress note dated 09/11/2025 at 10:00 A.M. author unknown revealed, Resident is presently at the hospital. Resident #106 is now noted to have a severe complicated fracture in her hip and they are not sure if this is old or new.

Interview on 11/10/2026 at 2:20 P.M. with the Administrator revealed he completed a investigation for the incident between Resident #106 and Resident #70 and at that time found there to be no reason for any additional investigation. The Administrator claimed he did not submit this incident as a Self-Reported Incident due to there being no concern for abuse. The Administrator also confirmed he did not submit a report or investigation for Resident #106's injured right hand or fractured pelvis. Review of the facility policy titled, Investigations of Abuse. dated 12/2022 revealed, Procedure 1) Upon allegation of abuse resident safety shall immediately be assured and shall be maintained thru out investigation process. 3) If resident makes allegation of staff to resident abuse, staff shall be relieved of duty until investigation is complete.

Administrator or delegate shall be immediately notified and shall also immediately initiate investigation of allegation. 4) Formal investigation shall be based on written statements from witnesses and other parties with information regarding the allegation or abuse or incident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

plan in place related to falls. Interview on 11/10/2025 at 2:00 P.M. with the DON confirmed Resident #78 did not have a care plan in place for falls and confirmed a fall investigation or report had not been completed for the falls that occurred on 09/16/2025 and 12/22/2025. Review of the facility policy titled Falls Policy, no date noted revealed It is the policy of this facility to utilize preventative measures in order to avoid accidental falls. 2. Residents identified as being at risk for falls shall have a plan of care developed to address risk factors and implement interventions in order to decrease risk of fall and or injury. 3. In the unfortunate event of a resident fall Interdisciplinary Team shall: B. Investigate for cause, probable cause and or causative factors that could have resulted in this fall. G. After a fall, resident's care plan shall be reviewed and revised as warranted to prevent further falls and or injury. New and revised plan of care interventions shall be communicated to the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number 2661527.

Event ID:

Facility ID:

If continuation sheet