Inspection·July 17, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to provide care and services to prevent a resident fall. This affected one (#32) resident of the three residents reviewed for falls. The facility census was 78. Findings include: Review of the medical record for the Resident #32 revealed an admission date of 02/28/2020 with medical diagnoses of diabetes mellitus, vascular dementia, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage IV, hypertension, and history of transient ischemic attack. Review of the medical record for Resident #32 revealed the resident was hospitalized on [DATE], returned to the facility on [DATE], and then discharged to the hospital on [DATE]. Review of the medical record for Resident #32 revealed a quarterly Minimum Data Set (MDS) assessment, dated 05/22/24, which indicated Resident #32 had severe cognitive impairment and required supervision to light touching for eating, ambulation up to ten feet, and bed mobility. The MDS revealed Resident #32 required substantial/maximum staff assistance with toilet hygiene and bathing and partial/moderate staff assistance with personal hygiene and transfers. The MDS also indicated Resident #32 used a wheelchair and a walker for mobility, received Hospice services, and no falls were indicated. Review of the medical record for Resident #32 revealed a fall risk assessment dated [DATE] which indicated Resident #32 was at a high risk for falls. Review of the medical record did not contain documentation to support the facility had completed any other fall risk assessment since admission to the facility on [DATE]. Review of the medical record for Resident #32 revealed a fall care plan, dated 06/19/2020, which stated Resident #32 was at risk for falls related to muscle weakness and dementia. The care plan included interventions dated 02/02/23 for resident to be toileted after meals and assisted to her recliner, 06/14/24 to position chair behind the resident so she can sit down, do not have her turnaround, 06/20/24 to use gait belt for transfers/ambulation, and 07/06/24 for staff to stay in bathroom when resident was on the toilet. Further review of the medical record for Resident #32 revealed an Activities of Daily Living (ADL) care plan, dated 12/02/21, which stated Resident #32 required limited to extensive staff participation with transfers. Review of medical record for Resident #32 revealed physician orders dated 04/04/24 for non-skid socks/shoes when out of bed and 06/28/24 Broda chair when out of room as needed for patient safety. (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 5 Event ID: 365497 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 07/17/2024 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)