Inspection·June 10, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 05/27/25 when one staff attempted to transfer Resident #103 from the wheelchair to the bed with the mechanical lift and the strap to the lift pad tore and Resident #103 dropped to the floor. Resident #103 was observed by staff to have one missing tooth, and one tooth was broken in half at the time of the incident. Resident #103 was sent to the hospital and returned to the facility with no other injuries noted. The resident has a follow up appointment with the emergency dentist. This affected one resident (#103) of three residents reviewed for mechanical lift transfers. The facility census was 117. Findings Include: Resident #103 was admitted to the facility on [DATE]. His diagnoses included but were not limited to absence of right leg and left leg above knee, multiple sclerosis, disorder of muscle, muscle wasting, morbid obesity, legal blindness, schizoaffective disorder, paraplegia, and weakness. Review of his Minimum Data Set (MDS) assessment, dated 03/04/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #103's care plan, dated 11/19/24, revealed a care area of Resident #103 having an activity of daily living (ADL) deficit. An intervention within this care plan revealed he needed two-person assistance due to having to use a mechanical lift for transfers. Review of Resident #103 Incident Report and Progress Notes, dated 05/27/25, confirmed that Resident #103 was being transferred from his wheelchair to his bed via mechanical lift. It was confirmed that Resident #103 was being transferred by CNA #148 alone; she did not have a second nursing staff with her while performing the transfer. During the transfer, the mechanical lift pad strap broke on one side, causing Resident #103 to fall from the mechanical lift to the floor. Resident #103 was assessed by the nurse for injury and found that he had one tooth missing and another tooth was broke in half. He was sent to the emergency room for further evaluation. In review of the findings, the facility confirmed CNA #148 should have had a second staff person with her while transferring Resident #103, and there should have been a better assessment of the mechanical lift pad prior to using it; which contributed to Resident #103 fall. Interview with Resident #103 on 06/04/25 at 9:30 A.M. confirmed he fell from the lift about a week (continued on next page) 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 4 Event ID: 365077 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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)