Health inspection·February 7, 2024

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of maintenance repair logs, review of Resident Council meeting minutes, staff interview, Ombudsman interview, and review of manufacturer instructions, the facility failed to ensure processes were in place to ensure the resident call light system was tested and maintained in a fully functioning manner, and staff had required equipment to be alerted to resident call lights. This had the potential to affect all 44 residents residing in the facility. The census was 44. Residents Affected - Many Findings include: Review of the facility maintenance repair log for the past three months revealed on 11/12/23 both call lights in room [ROOM NUMBER] were broken, the call light was broken in room [ROOM NUMBER], and the call light in room [ROOM NUMBER] would not go off. On 11/15/23 the call light in room [ROOM NUMBER] and in room [ROOM NUMBER], and in room [ROOM NUMBER]'s bathroom were not working. On 01/03/24 the call light was not working in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. Review of Resident Council meeting minutes dated 11/02/23 revealed call light system concerns were voiced, and review of Resident Council meeting minutes dated 12/28/23 revealed the call light system was replaced. Interview with Assistant Director of Nursing (ADON) #45 on 02/07/23 at 7:18 A.M. confirmed the facility call light system used pagers that staff members carried during their shift. The call light signal go to the pager and that was how staff are notified when a resident activated their call light. ADON #45 confirmed when agency staff work they are not provided a pager because as they kept leaving the facility with the pagers. ADON #45 stated there was a computer screen at the Oak Hill nursing station that also listed when call lights were activated. ADON #45 stated the staff can come to the Oak Hill nursing station to see when lights are activated. Interview and observation with Registered Nurse (RN) #31 occurred on 02/07/23 at 7:20 A.M. confirmed she recently started working a the facility a few weeks ago. RN #31 confirmed she was not provided a pager and verified she did not currently have one in her possession. RN #31 confirmed if she was on the other side of the facility there was no way for her to know a resident activated their call light and needed assistance. Interview with State Tested Nurse Aide (STNA) #15 was completed on 02/07/24 at 7:23 A.M. and confirmed agency staff members do not receive a pager to be notified if residents call for assistance when they work. STNA #15 was not aware how staff members who worked on the other side of the facility would know when residents activated their call lights. Interview with the facility Ombudsman occurred on 02/07/24 at 9:33 A.M. confirmed there were concerns the facility call light system was not working properly, and there were concerns from residents wondering if staff knew when the residents activated their call lights. Observation of the facility call light system was completed with Maintenance Director (MD) #36 and the Director of Nursing (DON) on 02/07/24 a 1:35 P.M. A random check of the call light functionality was completed and noted room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]'s call lights were not functioning properly. room [ROOM NUMBER] was noted to illuminate the call box located in the room; however, the signal was not going to the pager system. room [ROOM NUMBER]'s call light was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 2 of 3 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pressed and the activation string pulled, but the call light did not activate. The box did not illuminate and no signal was sent to the pager. room [ROOM NUMBER]'s call light was not functioning when tested. The observations were confirmed in interview with MD #36 and the DON. Interview with MD #36 and the DON, at the time of the observation, confirmed the resident room call boxes frequently needed batteries replaced, and the call system should sent alerts to the computer when the boxes are getting low battery signals. Observation of the call light computer screen located at the Oak Hill nursing station on 02/07/24 at 1:53 P.M. revealed the screen was noted to include 23 alerts dating back to 02/02/24. The alerts identified low battery and missing device. The missing device alerts were noted on the screen dated 02/02/24 for Rooms #16, #18, #19, #37, #40, #41, #54, #71, #72, #73, #76, and #79. The computer also listed nine alerts dated 02/07/24 for low batteries for Rooms #18, #19, #20, #33, #37, #40, #41, #76, and #79. Interview with MD #36 and the DON, at the time of the observation on 02/07/24 at 1:53 P.M., stated no one was currently in charge of fixing call light system alerts or checking the status of the alerts. Interview with MD #36 and the DON confirmed they did not really know what some of the alerts on the call system were or what the alerts meant. Observation and interview with MD #36 on 02/07/24 at 1:53 P.M. revealed MD #36 brought the call light box from room [ROOM NUMBER] and opened the box. MD #36 stated sometimes when the boxes were dropped something inside the box breaks loose and will illuminate; however, it will not send a signal to the pagers. MD #36 confirmed residents could think they activated their call light when in reality the signal was not being sent to the pagers. MD #36 confirmed the facility has no documented evidence of any ongoing testing of the call light system. MD #36 stated the issue with the call light boxes not sending a signal occurred a lot, and confirmed he needed to fix the boxes or replace the batteries almost daily. MD #36 stated in December 2023 the computer system for the call light system was replaced, because the entire system went down, but there was no evidence of him being trained on how to maintain the new call light system. Review of the facility call light system manufactures instruction contained an undated form letter that revealed a footprint test of the system was vitally important to be completed at least weekly. The instructions further revealed when using a pendent, send a test alarm from each of your test points and then validate that your call has registered on the Arial® computer and/or a pager carried by staff. Also, record your test results so that you will know if any system variances occur. Failure to perform these tests could result in inquiry to, or death of, someone in your care. Staff are to test your Arial® system regularly. Test all devices at least monthly as described in the product instructions/documentation for each installed device and be sure that alert and notification signals are received at all Arial PCs and at any other devices your facility uses to communicate alerts, such as pagers, signs, and smart-phones. Additionally, you should test your system after power outages, programming changes or upgrades, or after reconfiguring any system equipment. Failure to regularly test your Arial system could cause you to be unaware of a system failure. Do not ignore low battery alerts on your devices and replace batteries immediately. Failure to replace batteries could result in a call not reaching the Arial system. The Arial system should only be operated by properly trained personnel. This deficiency represents non-compliance investigated under Master Complaint OH00150540. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 3 of 3