Inspection·December 22, 2023

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, staff interview, and facility policy review, the facility failed to provide proper bed mobility assistance to a dependent resident resulting in a avoidable fall. This affected one (#19) of three resident falls reviewed. Facility census was 66. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include multiple sclerosis, type II diabetes, pseudobulbar affect, major depressive disorder, mild cognitive impairment, osteoarthritis, dementia, hypertension, attention and concentration deficit, difficulty walking, and anxiety disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 11/01/23, revealed she had a severe cognitive impairment. Resident #19 required partial/moderate assistance with rolling from left to right. Review of Resident #19 fall incident report and progress notes, dated 11/23/23, revealed State Tested Nursing Aide (STNA) #101 was assisting Resident #19 with moving in bed by herself. STNA #101 informed the nurse that she was rolling Resident #19 in bed and her arm went over the side of the bed and she then rolled off the bed. Resident #19 fell and hit her head against the wall, before falling to the floor. She was sent to the hospital for evaluation; the only injury was a bump above her left eye. Review of Resident #19 care plan, dated 07/31/23 to 12/22/23, revealed she was to have one person assistance for bed mobility. Interview with Administrator on 12/22/23 at 12:45 P.M. confirmed STNA #101 was assisting Resident #19 in her bed when Resident #19 fell from her bed. The Administrator confirmed when they did an investigation related to this fall, STNA #101 admitted she had been drinking until very late the night before, and then came to work still hungover. She stated she was not drunk, but was not herself either. Review of facility Fall Prevention Program, dated 01/01/22, revealed each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall was defined as an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The facility utilizes a standardized risk assessment for determining a resident's fall (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: 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 12/22/2023 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)