Inspection·December 7, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, staff interview, and facility investigation review, the facility failed to ensure appropriate staff supervision/assistance was provided when Resident #6 was rolled out of bed by an State Tested Nursing Assistant (STNA) during bathing. Actual harm occurred when STNA #400 completed a bed bath for Resident #6, who was totally dependent on staff for bathing with two person physical assist, and Resident #6 fell from the bed and sustained a closed fracture of the right tibial plateau and fractured the right sixth tooth. This affected one (Resident #6) of three sampled residents reviewed for bed mobility and transfer assistance. The facility census was 70. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, paralytic syndrome following cerebral infarction, quadriplegia, dysphagia, urinary retention, hypertension, chronic kidney disease stage 3, anemia, and left elbow contracture. Review of the Minimum Data Set (MDS) assessment, dated 09/27/23 revealed Resident #6 was cognitively intact and required the extensive assistance of two plus staff for bed mobility and personal hygiene. Resident #6 was dependent on staff for bathing with two person physical assist and functional limitation in range of motion impairment affecting upper and lower extremities bilaterally. Review of the plan of care, dated 03/14/23, documented Resident #6 was at risk for activities of daily living (ADL) self-care performance related to weakness, limited mobility, quadriplegia, cardiac impairments, respiratory failure, and cerebral vascular accident (CVA). Interventions included requires one person assist with bathing/showering and bed mobility requires two person assist. On 10/04/23, the plan of care was updated to require two staff members at all times when providing care. Review of the [NAME] care detail noted on 10/04/23 the resident required the assistance of two persons for bed mobility and transfers. The transfer required a Hoyer lift. Review of the nursing notes dated 10/31/23 at 5:32 A.M. documented Licensed Practical Nurse (LPN) #800 was standing at the nursing cart and heard someone yell help. LPN #800 and an STNA began to run down the hall. Upon entering Resident #6's room, LPN #800 noticed Resident #6 laying on his side next to the bed. STNA #400 was kneeling down next to Resident #6. LPN #800 noticed blood was coming from the resident's mouth. LPN #800 applied a cold towel to the resident's mouth and began to assess vital signs. Resident #6's blood pressure was 122/82 millimeters of mercury (mm/Hg), pulse 78 beats (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: 365849 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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)