Inspection·December 7, 2023

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 record review and interview, the facility failed to ensure Resident #9 received proper assistance with activities of daily living to prevent a fall. This affected one resident (Resident #9) out of three residents reviewed for falls. Findings include: Review of Resident #9's medical records revealed an admission date of 09/06/17. Diagnoses included vascular dementia, neoplasm of endometrium, atrial fibrillation, cerebrovascular disease, obesity, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depressive disorder, anxiety disorder, and diastolic congestive heart failure. Review of Minimum Data Set (MDS) dated [DATE] revealed resident required extensive two plus assistance for bed mobility, transfers, toileting and extensive one person assistance with dressing and personal hygiene. Review of care plan dated 09/21/23 revealed resident was at risk for falls related to dependence on staff for transfers using lift equipment, balance deficits, obesity, use of psychoactive medication, pain, diuretic medications, history of fall, history of left ankle fracture, impaired mobility, left weakness and neglect related to history of TIA with residual effects, debility, malaise, cognitive declines, impaired safety awareness, seizure disorder. Interventions included assist with mobility as needed, do not leave alone/unsupervised in bathroom, keep frequently used items in reach, offer to lay resident down after dinner, provide and encourage use of adaptive equipment, mobility devices as ordered, therapies as ordered and transfers per orders. Review of undated [NAME] revealed resident was assist of two staff for all hands-on care. Review of progress note dated 11/16/23 at 6:49 A.M. authored by Licensed Practical Nurse (LPN) #242 revealed she was alerted by state tested nursing assistant (STNA) that Resident #9 rolled out of bed while being changed. Upon inspection, the patient was sitting on her bottom, on the left side of her bed. Vital signs completed as followed blood pressure 110/62, heart rate 74, temperature 98.3, respirations 20 and pulse oxygenation 94 % on room air. Patient had no injuries noted at this time. LPN #242 and STNA's assisted patient back into bed via Hoyer lift. Notification to Director of Nursing (DON), Unit Manager, and Nurse Practitioner (NP). NP to see the resident and evaluate. Family was notified. Interview on 11/29/23 at 2:12 P.M. with DON verified Resident #9 was to be two persons assist for (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 2 Event ID: 365783 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 12/07/2023 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)