Winchester Terrace
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure mechanical lifts were operated safely. This affected one (#21) of one resident reviewed for mechanical lift transfers. The facility census was 53. Findings include:Review of the medical record for Resident #21 revealed an admission date of 10/23/19. Diagnoses included normal pressure hydrocephalus, hemiplegia, and dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 11/01/25, revealed Resident #21 was cognitively impaired and required total (staff) assistance with Activities of Daily Living (ADLs). Resident #21 utilized a mechanical lift for transfers. Review of the care plan dated 10/23/19 revealed Resident #21 had an ADL deficit related to dementia and hemiplegia. Interventions included using
a mechanical lift with two staff to transfer Resident #21 in and out of bed.Review of the physician orders revealed an order dated 12/20/22 for Hoyer (mechanical) lift for all transfers.Observation on 12/30/25 at 11:39 A.M. revealed Certified Nursing Assistant (CNA) #200 entered Resident #21's room with a mechanical lift. No other staff were present. Further observation on 12/30/25 at 11:59 A.M. revealed CNA #200 exited Resident #21's room with the mechanical lift. No other staff were present in the room. Interview
on 12/30/25 at 11:59 A.M. with CNA #200 verified she transferred Resident #21 utilizing a mechanical lift without a second staff person present. Further interview with CNA #200 confirmed Resident #21 was to be transferred utilizing a mechanical lift with two staff person assistance. CNA #200 confirmed she was trained
on how to transfer a resident utilizing a mechanical lift and knew two staff were to assist with the transfer.
Review of the facility policy titled, Hoyer Lift Education-Long Term Care, dated 08/20/25, revealed to always use two staff members when transferring a resident using a mechanical lift. This was an incidental finding discovered during the complaint investigation.
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
Event ID:
WINCHESTER TERRACE in MANSFIELD, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MANSFIELD, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINCHESTER TERRACE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.