Health inspection·August 1, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #18's fall investigation dated 07/07/23 at 8:50 A.M. for Resident #18, revealed the nurse on the unit stated Resident #18 was on the toilet having a bowel movement. The STNA was in the bathroom with her and the STNA turned her back on the resident to remove the wheelchair out of the bathroom when Resident #18 began to fall forward. The STNA held onto Resident #18 as she lowered her to the floor. A head-to-toe assessment was provided, and neurological checks were within normal limits. Staff were educated to stay with Resident #18 while on the toilet and not to turn their back towards her. No injuries were observed. Resident #18's physician and resident representative were notified of her fall on 07/07/23. Review of a fall review assessment dated [DATE] for Resident #18, revealed the resident was at moderate risk for falls. Review of a nurse's progress note dated 07/07/23 for Resident #18, revealed around 8:40 A.M. the STNA called for the nurse as Resident #18 was on the ground. Resident #18 was on the ground in the hallway scooting along the side of the wall to get up. Resident #18 was in a shirt, brief and socks. When asked what Resident #18 was doing, Resident #18 stated she wanted to get up. Resident #18 was asked why she did not use her call light and Resident #18 stated, I'm too chicken and stated I wish mommy would come back. Resident #18 stated she did not hurt herself or hit her head. Resident #18 lowered herself onto the floor mat and scooted out of her room. Resident #18's wheelchair was in the doorway. The STNA put pants and nonskid socks on Resident #18 and the nurse helped the STNA put Resident #18 in the wheelchair. Resident #18 was wheeled back to her room. The nurse went back to pass medications and a few minutes later the STNA yelled for help. Resident #18 was found on the bathroom floor. While that STNA was moving the wheelchair, Resident #18 fell forward off the toilet. The STNA saw her going forward was able to break the fall and place her on the ground. The STNA and nurse picked Resident #18 back up and placed her on the toilet. Resident #18 had a large bowel movement. The Director of Nursing (DON) was made aware. Review of STNA #46's witness statement dated 07/07/23, revealed she laid eyes on Resident #18 in morning report and Resident #18 was still in bed at 7:45 A.M. STNA #46 was serving breakfast and was feeding residents in the dining room area. Once STNA #46 finished feeding residents, she was walking around the hall and saw Resident #18 sitting on the floor with her legs crossed holding the rail on the wall scooting across the floor. STNA #46 called for the nurse to help her. Resident #18 was transferred to the wheelchair and taken to the bathroom. Resident #18 was placed on the toilet and as STNA #46 turned to grab a brief, Resident #18 began to fall forward, and she broke her fall and placed her on the floor and called for the nurse again. The nurse came back and placed Resident #18 back on the toilet where STNA #46 stayed until Resident #18 was finished. Resident #18 was standing and transferred fine after each fall. Review of the fall care plan updated 07/07/23 for Resident #18, revealed the resident was at risk for falls. Further review of Resident #18's care plan revealed an intervention was added on 05/11/23 that stated Resident #18 was to have two-person transfer assistance when toileting. Interview with the Director of Nursing (DON) and Administrator in Training (AIT) #09 on 07/31/23 at 2:29 P.M., revealed Resident #18 fell on [DATE] while Resident #18 was being assisted from the toilet to the wheelchair. The DON stated Resident #18's resident representative and physician were notified and an intervention was put in place to have two-person assistance with toileting and transfers. The DON stated Resident #18 fell two times on 07/07/23. The DON reported Resident #18 was found scooting herself in the floor in the hallway and then was placed back in the wheelchair and toileted. The DON stated Resident #18 fell while in the bathroom when the STNA turned around to grab something (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365497 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 365497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at the Greene 4381 Tonawanda Trail Dayton, OH 45430 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Resident #18. The DON reported the intervention put in place was to not turn around while Resident #18 was being toileted. The DON verified only one staff member, STNA #46, was in the bathroom when Resident #18 was being transferred to the toilet and toileted on 07/07/23. The DON also confirmed that Resident #18's care plan stated Resident #18 was to have two-person transfer assistance when toileting. Interview on 08/01/23 at 11:18 A.M. with Licensed Practical Nurse (LPN) #95 revealed Resident #18 fell two times on 07/07/23. LPN #95 stated she was doing medication pass on 07/07/23 and STNA #46 yelled down the hallway that Resident #18 was on the floor. Resident #18 was on the floor in a shirt, an incontinence brief, and socks. LPN #95 stated Resident #18 had scooted herself from the bed to the floor mat and was scooting herself down the hallway. LPN #95 reported she asked Resident #18 why she did not use her call light and Resident #18 replied that she was too chicken to use the call light. LPN #95 stated she and STNA #46 put pants and gripper socks on Resident #18, and they got the resident in her wheelchair. LPN #95 stated she went back out to do medication pass and two minutes later STNA #46 came, and stated Resident #18 fell again. LPN #95 reported she went into Resident #18's room and Resident #18 was in the floor in front of the toilet. LPN #95 reported STNA #46 told her that she put Resident #18 on the toilet and was moving the wheelchair out of way when Resident #18 started going forward. LPN #95 stated STNA #46 informed her that she slid Resident #18 to the ground on her leg. LPN #95 verified STNA #46 did not have any additional staff members in the room while toileting or transferring Resident #18 onto the toilet. Telephone interview on 08/01/23 at 4:00 P.M. with STNA #46, revealed Resident #18 fell two times on 07/07/23. STNA #46 stated she observed Resident #18 sitting on her bottom scooting herself on the floor on 07/07/23 after breakfast. STNA #46 stated she called for LPN #95 and Resident #18 was assessed and placed in her wheelchair. STNA #46 stated she took Resident #18 to her room and toileted her. STNA #46 reported Resident #18 was on the toilet and she turned around to get a brief for Resident #18 and Resident #18 started to fall forward off the toilet. STNA #46 stated she broke Resident #18's fall and slid her to the ground. STNA #46 verified she transferred Resident #18 on the toilet, and she was toileting Resident #18 without assistance from any additional staff members. Review of the facility's fall reduction policy dated 04/29/16 revealed the facility will identify residents at risk for falls and will implement a fall reduction program to reduce the risk of falls and possible injury. This deficiency represents non-compliance investigated under Complaint Number OH00144776. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365497 If continuation sheet Page 3 of 3