Health inspection·June 23, 2025

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, observations, staff interview, and review of the facility policy, the facility failed to ensure all safety injury prevention interventions were in place as care planned for residents identified at risk for falls. This affected one (#35) of three residents reviewed for falls. The facility census was 60. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic pain syndrome, anxiety, muscle spasm, tremor, altered mental status, weakness, seizures, and schizophrenia. Review of the fall risk assessment dated [DATE] revealed Resident #35 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired. Resident #35 was dependent on assistance from staff for the activities of daily living. Review of the plan of care, revised 05/12/25, revealed Resident #35 was at risk for falls. Interventions included enabler bars attached to bed, body pillow for positioning, and being sure call light was within reach. Observation on 06/16/25 at 9:55 A.M. revealed Resident #35 was lying in bed. There were no enabler bars attached to the resident's bed. There was also no body pillow on the resident's bed or visible within the resident's room. The resident's call light cord was stretched across the room and the button used to activate the call light was sitting on their wheelchair, which was not within the resident's reach. Interview on 06/16/25 at 10:05 A.M. with Certified Nursing Assistant (CNA) #448 verified Resident #35's call light was out of reach. CNA #448 also verified Resident #35 did not have a body pillow or enabler bars in place or in the room. CNA #448 reported they were assigned to care for Resident #35 on a regular basis and they had no knowledge of the resident ever having a body pillow. Subsequent observations on 06/18/25 at 10:36 A.M. and 3:23 P.M. revealed Resident #35 was lying in bed. There were no enabler bars attached to the resident's bed, and there was no body pillow on the resident's bed or visible within the resident's room. Page 1 of 2 365898 365898 06/23/2025 Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/18/25 at 3:34 P.M. with CNA #295 revealed the staff member was assigned to care for Resident #35 on a regular basis. CNA #295 verified Resident #35 did not have a body pillow or enabler bars in place. CNA #295 reported the resident did not have a body pillow at all, and only had regular pillows to use for positioning. Review of the facility policy titled Fall Prevention Program, revised 09/26/24, revealed the facility would provide interventions as needed. This deficiency represents non-compliance investigated under Master Complaint Number OH00166561. 365898 Page 2 of 2