Inspection·September 18, 2025

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. Event ID: Facility ID: 365911 If continuation sheet Page 2 of 4 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 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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of electronic mail (e-mail) correspondence, and review of the facility policy, the facility failed to maintain a clean, safe and sanitary environment. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:Observation on 09/17/25 at 3:03 P.M. of the courtyard entrance, located near the front doors, revealed a laminate type flooring that was raised and buckled. The flooring was not secured to the floor and could be lifted off of the floor. Further observation revealed spaces between the flooring slats. Observation on 09/17/25 at 3:10 P.M. of the Malabar Lane Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Across from Resident # 33's room was a large tear in the carpet, and the carpet was able to be lifted, exposing the floor underneath.Observation on 09/17/25 at 3:15 P.M. of the Oakhill Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Further observation revealed a large tear in the carpeting in front of Resident #1's, which exposed the subflooring. Additional observations revealed in front of room [ROOM NUMBER] (unoccupied) the carpeting was lifted from one wall to the other, and in front of room [ROOM NUMBER] (unoccupied) the carpet was lifted.Observation on 09/17/25 at 3:30 P.M. of the Oakhill Circle Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Additionally, the carpeting in front of Resident #44 and Resident #20's room had tears, exposing the subfloor. Observation on 09/17/25 at 3:35 P.M. of the [NAME] Court Hall revealed large brown stains and fraying carpet in front of Resident #42 and Resident #41's room. Observation on 09/17/25 at 3:40 P.M. of the [NAME] Avenue Hall revealed the carpeting in front of the therapy and oxygen room had large tears exposing the subfloor and large areas of discoloration/staining was observed throughout the hallway carpeting. Interview on 09/17/25 at 12:30 P.M. with Maintenance Director (MD) #244 revealed that the courtyard drains clogged with mulch from the flower beds anytime there was a hard rain, causing the rainwater to back up into the facility. MD #244 stated the last time water backed-up into the facility was on 08/20/25. MD #244 stated he came to the facility on [DATE] and tried to clean up the water with a floor scrubber and another machine that extracted water. MD #244 stated fans were used to help dry the flooring. MD #244 stated the dining room had a strong musty odor from water and the facility had to close the dining room temporarily until it could dry and air out. MD #244 confirmed the above observations and stated the carpeting throughout the facility needed to be replaced due to tearing, lifting, and fraying in each of the hallways.Interview with the Director of Nursing (DON) on 09/17/25 at 12:15 P.M. revealed the facility had a flooding issue due to the drains in the courtyard backing up. DON stated that FM #600 had been e-mailed on multiple occasions revealing the need for new flooring, with no response received. The DON confirmed that the carpet throughout the facility had tears, lifting, and fraying. The DON also confirmed stains on the carpeting throughout the facility and stated the facility had professional cleaners come to the facility, without improvement.Review of an electronic mail (e-mail) correspondence dated 08/09/25 from the Director of Nursing (DON) to Facility Manager (FM) #600 confirmed the DON identified the following areas of concern that remained following professional carpet cleaning: large stains on the carpet in the lobby entrance, in the hall by room [ROOM NUMBER], in the hall near room [ROOM NUMBER] and 35, in the hall by room [ROOM NUMBER], and in the hall by room [ROOM NUMBER] and 41. Further review revealed the DON identified that new carpet pieces by the dining room were fraying, the carpet at the entrance of the dining room was rippling, the carpet near room [ROOM NUMBER] was fraying, the carpet by room [ROOM NUMBER] was fraying and had white spots, the carpet by room [ROOM NUMBER] had white/light spots (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 3 of 4 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 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. Event ID: Facility ID: 365911 If continuation sheet Page 4 of 4