Inspection·February 27, 2020

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, review of Resident Council meeting minutes, staff interview, resident interview, and a resident group interview, the facility failed to address resident concerns regarding call lights being turned off by staff and needs not being met. This affected thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) who attended Resident Council during the months of December 2019, January 2020, and February 2020 and one resident (#23) whose light was turned off twice without care. This had the potential to affect all 59 residents in the facility. Findings include: Review of Resident Council minutes from 12/20/19, 01/17/20, and 02/19/20 revealed residents had a concern of call lights being turned off and staff not coming back. Thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) were in attendance over the three months. Observation on 02/24/20 at 8:58 A.M. revealed Resident #23's call light was activated. State Tested Nurse Aide (STNA) #400 was observed to exit the resident's room and the call light was turned off. Interview on 02/24/20 at 9:14 A.M. to 9:22 A.M. with Resident #23 revealed staff do not answer call lights quickly and will turn off the call light without providing care. Resident #23 verified he pressed his call light, staff came in, stated they were busy, and would return. Resident #23 verified staff had not returned. Observation on 02/24/20 at 9:22 A.M. revealed Resident #23 initiated the call light again. STNA #401 entered the room, turned off the call light, and stated she was finishing up with another resident, and would return. Observation at 02/24/20 at 9:43 A.M. revealed STNA #401 entered Resident #23's room and shut the door to provide care. Resident waited from 8:58 A.M. to 9:43 A.M. to receive personal care and the call light was turned off twice during this timeframe. On 02/25/20 at 10:30 A.M. in a group interview with seven current residents (#5, #12, #21, #22, #47, #57, #60) revealed the residents have reported staff for turning call lights off and not returning to assist with resident concerns. They stated this had been reported at the December 2019, January 2020, and February 2020 Resident Council meetings and no resolution has occurred. Interview on 02/26/20 at 2:06 PM with Activities Director #403 verified residents' concern regarding call lights being turned off without care continues to be remain unresolved. (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 7 Event ID: 366060 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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)