Inspection·September 13, 2018

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, resident interview, and staff interview, the facility failed to ensure residents received a bed hold notice prior to going to the hospital. This affected two (#29 and #37) of three residents reviewed for hospitalization. The facility census was 45. Findings included: 1. Medical record review revealed Resident #29 was admitted to the facility originally on 06/02/17 and was readmitted on [DATE]. Diagnoses included heart failure, chronic obstructive pulmonary disease, and cerebral infarction (stroke). Review of the resident's quarterly Minimum Data Set (MDS) assessment completed on 07/26/18 revealed the resident had moderate cognitive impairment. Continued medical record review revealed Resident #29 was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was provided a bed hold notice upon transfer to the hospital. Interview with Resident #29 on 09/11/18 at 10:21 A.M., confirmed he had not received a bed hold notice during his last hospitalization. 2. Medical record review revealed Resident #37 was admitted to the facility originally on 06/07/12, and was readmitted on [DATE]. His diagnoses included fracture of the lower end of the femur, diabetes type two, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the resident's quarterly MDS assessment completed on 08/22/18 revealed the resident was cognitively intact. Continued review of Resident #37's medical record revealed the resident was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was given a bed hold notice upon discharge to the hospital. Interview on 09/11/18 at 6:15 P.M., with the Administrator confirmed there was no documentation Residents #29, or #37 were given a bed hold notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366043 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 366043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, review of the Food and Drug Administration guidelines, and staff interview, the facility failed to ensure residents had side rails/enabler bars that were the size recommended for safety to prevent entrapment. This affected four residents (#6, #13, #29 and #33) of 14 identified as having side rails or enabler bars in the facility. The facility census was 45. Findings included: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, muscle wasting and atrophy, and altered mental status. Review of the annual Minimum Data Set (MDS) assessment completed on 06/14/18 revealed Resident #6 had severe cognitive impairment. She required extensive assist of two staff for bed mobility. Observation of Resident #6 with the Administrator on 09/10/18 at 12:56 P.M, revealed the resident was in bed with an enabler bar, with a large opening on her right side. The Administrator measured the opening. The gap measured 15 inches, by 13 inches. The facility placed a cover over the bar to prevent entrapment. 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, aphasia, dysphagia, convulsions, and contracture. Review of the resident's MDS assessment completed on 07/03/18 revealed the resident had severe cognitive impairment. She was totally dependent on two staff for bed mobility, transfer and locomotion. Review of Resident #13's side rail assessment dated [DATE] revealed a recommendation for bilateral side rails to be used with an air mattress. Observation of Resident #13 with the Administrator on 09/10/18, at 12:57 P.M., revealed the resident was in bed on an air mattress with bilateral side rails. There was a large opening at the center of the side rails. The Administrator measured the opening in the side rail and found it was seven inches by seven and a half inches. She covered the opening by placing bilateral rail padding on the inside. 3. Medical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included heart failure, abnormal posture, chronic obstructive pulmonary disease, and muscle weakness. Review of the resident's MDS assessment completed on 07/26/18 revealed the resident had moderate cognitive impairment. He required extensive assist of one staff for bed mobility. Observation of Resident #29 with the Administrator 09/10/18 at 12:59 P.M., revealed the resident was in bed with an enabler bar to his right side measuring 14 inches wide, by 12 inches from the top, to the mattress. A cover was placed over the enabler bar immediately covering the large opening. 4. Medical record review revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the left lower limb, cerebral infarction (stroke), and recurrent major depressive disorder, severe with psychotic symptoms. Review of the resident's annual MDS assessment completed on 08/09/18 revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366043 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 366043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005 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 0909 cognitively intact. He required limited assistance of one staff for bed mobility. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #33 with the Administrator on 09/10/18 at 1:03 P.M., revealed the resident had an enabler bar with a large opening to his right side against the wall. The facility placed a cover immediately over the opening to prevent entrapment. Residents Affected - Some Interview with the Director of Nursing (DON) on 09/10/18 at 12:55 P.M., revealed she was monitoring the distance between the mattress and rails, however was unaware there were safety recommendations regarding the space within the rails. She confirmed this had not been monitored. She confirmed there had never been any residents entrapped in a rail. Review of the FDA Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/16, revealed to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The recommendations for the dimension was to be no more than 4 3/4 inches. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366043 If continuation sheet Page 4 of 4