Inspection·November 2, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and examined in his room with his wife at the bedside. There was noted ecchymosis (skin discoloration) and small laceration to the left eyebrow after a fall. The NP noted baseline mental status was disoriented and he required total care for all ADLs. Review of the facility investigation revealed a witness statement given to the Director of Nursing (DON) via telephone dated 10/12/23 and provided by STNA #454. STNA #454 stated she went into the room of Resident #75 on 10/08/23, moved the bed away from the wall, stood on the side of the bed and rolled him onto his left side with her left hand holding his shoulder while she used her right hand to wipe his buttocks. Resident #75's feet began to move towards the edge of the bed and he began falling off the bed. STNA #454 tried to catch him but he fell and landed on his left side. STNA #454 moved the bed to roll him onto his back, went and got the nurse who completed an assessment then they both put him back into bed using hoyer lift. The witness statement noted STNA #454 was from a staffing agency. An observation was conducted on 11/01/23 at 10:54 A.M. of Resident #75 sitting in his wheelchair in a common area with Licensed Practical Nurse (LPN) #380 present in the area. Resident #75 was alert, nonverbal and unable to communicate any wants or needs to the surveyor when asked simple questions. LPN #380 verified Resident #75 had healing bruises on the left side of his face. An interview was conducted on 11/01/23 at 10:55 A.M. with LPN #302 who revealed Resident #75 prior to the fall on 10/08/23 was a two person assist for all care and bed mobility for checking and changing incontinence care. LPN #302 stated the STNA should have had another STNA help with Resident #75's care. LPN #380 was also interviewed at this time and revealed no STNA should work with Resident #75 alone because Resident #75 needed two people to assist with checking and changing briefs. An interview was conducted on 11/01/23 at 2:47 P.M. with the DON and Administrator who revealed the STNA rolled Resident #75 by herself to check and change the resident's brief. The DON explained most residents will reach out to assist staff by grabbing the bed bar and for any agency staff or new STNA's care needs were communicated via a document labeled Transfer Bed Mobility Instruction sheet kept in all resident's closets for reference by staff. The DON stated not all Transfer Bed Mobility Instruction sheets are automatically updated when the care plan is updated. The DON and Administrator verified the Transfer Bed Mobility Instruction Sheet for Resident #75, dated 07/11/23, was in Resident #75's room on 10/08/23. The DON and Administrator also verified bed mobility status for Resident #75 was not checked off on the document for communication to new staff, and the form did indicate Resident #75 required a two people transfer with the Maxi (mechanical lift). Interview on 11/01/23 at 3:00 P.M. with RNS #393 revealed she was the nurse who assessed Resident #75 on 10/08/23 after the fall out of bed. RNS #393 stated she did not witness the fall but did witness Resident #75 on the floor between the bed and the wall and verified his injuries sustained from the fall. RNS #393 stated the bed was pulled away from the wall. RNS #393 stated Resident #75 required full care because he needed everything done for him. Interview on 11/01/23 at 4:09 P.M. with Physical Therapist ( PT) #350 revealed it was possible for one STNA to roll a resident for bed mobility if the resident had adequate trunk control, but Resident #75 did not have adequate trunk control. PT #350 verified the last PT assessment dated [DATE] revealed Resident #75 was a total dependence for care and Resident #75 did not attempt or initiate trunk control. Interview on 11/01/23 at 4:41 P.M. with STNA #324 revealed Resident #75 was a two person assist to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roll because Resident #75 did not understand to grab the bar on the bed and would not have been able to help or stabilize himself when the STNA rolled him in the bed for incontinence care on 10/08/23. Interview on 11/01/23 at 4:43 P.M. revealed STNA #340 used two person assist to check and change Resident #75 because he was a bigger man, and Resident #75 could not move from side to side or understand to grip the grab bar for safe rolling. STNA #340 verified Resident #75 had healing bruising on his face caused by a fall. Interview on 11/01/23 at 5:25 P.M. with LPN #452 revealed two staff members were needed to change Resident #75's brief because of Resident #75's weight and Resident #75 had no trunk control. Review of facility education titled Mastering Bedside Care revealed staff were to verify if a resident was a two person assist, if so, be sure to have a second staff member present. This deficiency represents non-compliance investigated under Complaint Number OH00147407 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 3 of 3