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. (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: 365898 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 06/23/2025 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)