Winchester Terrace

Review of the facility policy titled Activities of Daily Living (ADLs)/ Maintain Abilities, dated 09/03/24, revealed the facility would provide care and services for mobility, transfers and ambulation.The deficiency was corrected on 09/16/25 when the facility implemented the following corrective actions: On 08/20/25 at approximately 6:30 A.M., RN #252 assessed Resident #03 for injury. Resident #03 was transferred to the hospital for further evaluation and treatment. On 08/20/25, Maintenance Director (MD) #244 completed an inspection of all Hoyer lifts, with no concerns identified.

Verification was received confirming the inspection was completed.

Beginning on 08/26/25, the DON or designee will audit four Hoyer lift transfers weekly for four weeks, then bi-weekly for one month, and then monthly for two months.

Results of the audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to ensure on-going compliance.

Review of audit documentation from 08/26/25 through 09/16/25 verified completion of the audits, with no negative findings. On 08/26/25, the DON educated all direct care staff on the safe use of Hoyer lifts.

Verification was received verifying the education was completed. On 08/28/25, the DON completed a Hoyer lift competency with all direct care staff to ensure safe use of the lifts.

Verification was received verifying the competencies were completed.

Interviews on 09/17/25 from 2:38 P.M. through 2:56 P.M. with CNA #230 and CNA #234 confirmed education and competencies were completed on the safe use of Hoyer lifts.

Review of two (Residents #6 and #10) additional open residents records, reviewed for Hoyer lift transfers, revealed no related concerns.This deficiency represents non-compliance investigated under Complaint Number 2601158.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Winchester Terrace

70 Winchester Rd Mansfield, OH 44907

SUMMARY STATEMENT OF DEFICIENCIES