Inspection·October 10, 2023

F 0600 Level of Harm - Actual harm #12) tip of the finger in Resident #23's mouth. Resident #12's (fingertip) was chewed and bit off. The nurse immediately pulled the residents apart and notified EMS/Police while assessing the roommate's injury. All management team, physician and emergency contacts were notified of the incident. Resident #23 was sent to the emergency room for evaluation and treatment. Residents Affected - Few Review of Resident #23's emergency room record dated 09/14/23 revealed the resident arrived from the nursing home with a report that he bit off a roommate's finger. The resident would not speak for the Registered Nurse but spoke for the officer at his bedside. The resident was noted with blood on his clothing, his beard, and the left side of his face. The final diagnosis was aggressive behavior due to dementia. Review of Resident #12's medical record revealed an admission date of 02/09/21, with diagnoses including: dementia and atrial fibrillation. Resident #12 resided on the memory care unit. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. He was not documented as having any negative behavior. Review of Resident #12's care plan dated 10/17/22 revealed the resident had the potential to be physically aggressive. Resident #12 asserted male dominance in situations with other male residents due to anger, dementia, and depression. Interventions included: to de-escalate by redirecting with activities. Review of Resident #12's progress note dated 09/14/23 at 8:17 A.M., revealed the resident-to-resident altercation occurred at 5:55 A.M. The nurse found Resident #12 to be a victim of physical aggression by roommate (Resident #23). The nurse was able to get the roommate off the resident, but noticed the resident's fingertip was in their roommate's mouth. The nurse immediately put pressure on the resident's wound and called emergency medical services (EMS) and police. All management personnel were notified. The physician and resident's daughter were notified of the incident. Resident #12 was sent to the emergency room for evaluation and treatment. Review of Resident #12's emergency room hospital note dated 09/14/23 revealed Resident #12 arrived at the hospital via EMS with the tip of his finger bitten off. Resident #12's final diagnosis was: bite wound to finger and open displaced fracture of the distal phalanx of right little finger. Prescriptions for pain medications and antibiotic therapy were provided. Review of Resident #12's progress note dated 09/21/23 at 6:14 P.M., revealed Resident #12 had an appointment today with plastic surgeon regarding resident having surgery on pinky finger. Resident #12's daughter transported the resident to the appointment. Resident #12 is back at the facility in a pleasant mood, no complaints of or signs and symptoms of pain at the present time, resident remains on antibiotic therapy and temperature of 98.4 degrees Fahrenheit. Review of Resident #12's progress note dated 09/21/23 11:54 P.M., revealed the resident had an appointment today with plastic surgeon regarding resident having surgery to necrotic finger. Resident #12 complained of pain and was given (narcotic pain medication) and the finger was wrapped to give cushioning and support. Resident continues on antibiotics and is afebrile (without temperature). Review of Resident #12's progress note dated 09/26/23 at 2:47 P.M., revealed the resident went with daughter. Resident #12 has no present complaints of or signs and symptoms of pain or distress. Resident #12 has been given additional as needed over the counter pain medications for 7 day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 2 of 4 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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 0600 Level of Harm - Actual harm Residents Affected - Few Interview on 10/06/23 at 7:32 A.M., with the Director of Nursing (DON) revealed after the incident on 09/14/23, Resident #23 stated he blacked out for a minutes then when he awoke, he realized that he bit off Resident #12's finger. Residents #12 and #23 were roommates for a long time and had done well together. Resident #12's finger was reattached but didn't heal well and the fingertip may have to be removed. Resident #12 continues to go to surgical follow up appointments and was forgetful as to what happened to his finger. Interview on 10/06/23 at 11:16 A.M., with the Administrator revealed Residents #12 and #23 were roommates for a long time and had no issues. Resident #23 informed the Administrator that he was remorseful for injuring Resident #12. Review of the undated policy titled Abuse, Neglect and Exploitation revealed the facility was to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00146662. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 3 of 4 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with nail care. This affected two (#54 and #55) of three residents reviewed for activities of daily living. The facility census was 92. Residents Affected - Few Findings included: 1. Review of Resident #54's medical record revealed an admission date of 02/27/23. Diagnoses included hemiplegia left side post cerebral vascular accident, congestive heart failure, and cirrhosis of the liver. Review of Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had no cognitive impairment. The resident required extensive assistance for bed mobility, bathing, and personal hygiene. Observation of Resident #54 on 10/06/23 at 8:32 A.M., revealed he had long, unkept fingernails. Interview with Resident #54 on 10/06/23 at 8:32 A.M., revealed he wished to have his fingernails trimmed but it was difficult to find someone to complete the task. 2. Review of Resident #55's medical record revealed an admission date of 03/10/22. Diagnosis included encephalopathy, diabetes mellitus and congestive heart failure. Review of Resident #55's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. He required extensive assistance for personal hygiene. Review of Resident #55's most recent care plan revealed staff were to check nail length, trim and clean on bath days and as necessary. Report any changes to the nurse. Observation of Resident #55's fingernails on 10/06/23 at 8:33 A.M., revealed his fingernails were long and jagged. Interview with Resident #55 on 10/06/23 at 8:33 A.M., revealed he wished his nails to be trimmed and the staff failed to complete the task on shower days. Interview with the Director of Nursing (DON) on 10/06/23 at 8:34 A.M., verified Residents #54 and #55 were lacking nail care and it should have been completed by staff on shower days. Review of the undated policy titled Nail Care revealed routine nail care, to include trimming and filing, will be provided on an as needed basis. Nail care will be provided between scheduled occasions as the need arises. Routine cleaning and inspection of nails will be provided during activities of daily living care on an ongoing basis. This deficiency represents non-compliance investigated under Complaint Number OH00146311. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 4 of 4