Health inspection·October 27, 2022

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, record review, and policy review the facility failed to ensure monitoring and evaluation of bilateral wrist restraints was documented while used for Resident #28. This affected one resident (Resident #28) of two residents reviewed for abuse, neglect, and exploitation. The facility reported one resident (Resident #28) who had physical restraints. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/12/12. Diagnoses included respiratory failure, cord compression, dependence on respiratory ventilator status, encounter for attention to tracheostomy, encounter for attention to gastrostomy, severe intellectual disabilities, spastic quadriplegic cerebral palsy, malignant neuroleptic syndrome, unspecified convulsions, anxiety disorder, bipolar disorder, abnormal involuntary movements, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/14/22, revealed Resident #28 had severely impaired cognition. Resident #28 was dependent on two staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and was dependent on one staff assistance for eating. Resident #28 was always incontinent of urine and bowel. Review of the plan of care completed 09/29/22 revealed Resident #28 had cognitive impairment secondary to severe intellectual abilities which affected decision making skills; had impaired communication skills related to dysphasia (deficiency in generation of speech) and difficulty being understood due to usually nonverbal secondary to history of cerebral palsy, intellectual disability and tracheostomy; would blink eyes to communicate yes and no answers or used lips and tongue to respond in affirmative or negative and said a couple of words at times; used bilateral wrist restraints as needed related to risk of interruption of life sustaining devices and risk for decannulation with least restrictive measures previously attempted were unsuccessful. Interventions included to administer medications as ordered; to allow independent functioning to safest degree possible; provide cues and supervision; use simple one word commands; observe for signs of frustration and anxiety, change activity if observed ; with increased anxiety attempt to calm or refocus attention; ensure correct position and proper body alignment while restrained; monitor, document, and report as needed any changes regarding effectiveness, least restrictive devices, any negative or adverse effects noted including: decline or change in behavior, decrease in ADL (activities of daily living) self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, signs or symptoms of delirium, accidents or injuries, agitation, or weakness; apply bilateral wrist restraints as needed and release every two hours for ten minutes for range of motion (ROM) and hygiene; and document restraint use and release per facility protocol. (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: 366062 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 366062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprice Health Care Center 9184 Market St North Lima, OH 44452 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)