Health inspection·April 12, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion. This affected one (Resident #51) of one residents reviewed for position/mobility. The facility census was 79. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus, acute respiratory failure with hypoxia, congestive heart failure, spinal stenosis, contracture left hand, and dementia. Review of the Care Plan, dated 08/25/23 and revised on 04/10/24, revealed Resident #51 required double washcloth rolls to hands as tolerated to help prevent further decline in range of motion. Review of the Minimum Data Set (MDS) quarterly assessment, dated 02/14/24, indicated Resident #51's Brief Interview for Mental Status (BIMS) score was 05, which indicated severe cognitive impairment. The resident was dependent on physical assistance from staff for bed mobility, transfers, dressing, eating, and toileting. The assessment indicated impairment of the upper and lower extremities. During observation on 04/10/24 at 10:17 A.M. and on 04/11/24 at 9:05 A.M. and 11:19 A.M., Resident #51 was observed lying in bed and both hands were noted without rolled washcloths. Review of Resident #51's current [NAME] and Task Log revealed the intervention to place double rolled washcloths into hands as tolerated to prevent contractures. The task was documented as completed for 04/11/24, day shift. During interview on 04/11/24 at 11:35 A.M., State Tested Nursing Assistant (STNA) #255 confirmed Resident #51 did not have washcloths in both hands per his plan of care and she had not placed the washcloths in his hands during her shift. STNA #51 stated that she would get the washcloths and apply them. During interview on 04/11/24 at 11:40 A.M., Registered Nurse (RN) Supervisor #259 confirmed Resident #51 should have had washcloths in both hands due to contractures and as documented in the electronic medical record by the STNA. 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 3 Event ID: 366052 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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)