Winchester Terrace

F 0689 Level of Harm - Actual harm Residents Affected - Few

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

to stop moving completely. Resident #03 then fell to the floor and hit her head.Review of the statement provided by RN #252, dated 08/20/25 at 2:00 P.M., revealed RN #252 assisted CNA #236 with a Hoyer transfer and the Hoyer became snagged on the wheelchair and bed. When staff attempted to release the Hoyer lift from the snag, the Hoyer strap came off and the resident fell to the floor.Review of the nursing progress note dated 08/25/25 at 11:37 A.M. revealed new orders to clean Resident #03's right forearm skin tear with normal saline and pat dry, apply xeroform and bordered foam three times a week and as needed.During an interview on 09/17/25 at 10:19 A.M., the Director of Nursing (DON) stated CNA #236 and RN #252 were in Resident #03's room to complete a Hoyer lift transfer on 08/20/25. CNA #236 and RN #252 believed the Hoyer lift strap disconnected after they forcefully pulling on the Hoyer lift after it became stuck. The Hoyer lift was immediately pulled from the floor and checked by maintenance, who found no issues with the Hoyer lift. The DON verified Resident #03 sustained a laceration above her right eyebrow that required five sutures and a laceration to the wrist that required wound treatments three times per week.

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.

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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

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Winchester Terrace

70 Winchester Rd Mansfield, OH 44907

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

and holes present, the carpet by room [ROOM NUMBER] had fraying, and the carpet by room [ROOM NUMBER] and 79 and staining. Lastly, the carpet at the entrance of the soiled laundry room had a large stain. Review of the facility policy titled, Resident Right- Safe/Clean/Comfortable/Homelike Environment, dated 09/03/24, revealed the facility must provide a safe, clean, comfortable, and homelike environment.

Review of the facility policy titled, Safe Environment dated 09/03/24, revealed the facility will maintain the facility premises and conducts its operations in a safe and sanitary manor.This deficiency represents non-compliance investigated under Complaint Number 2601158.

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