Inspection·March 7, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility documentation review, and facility policy review, the facility failed to ensure an allegation of medication diversion was reported to the Administrator in a timely manner. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a facility document dated 02/19/24 revealed Licensed Practical Nurse (LPN) #324 took a chewable baby aspirin from the over the counter bottle located in the top drawer of medication cart. LPN #324 forgot to take morning aspirin before work. LPN #324 was talked to by the Director of Nursing (DON) as soon as the incident was reported and was instructed to not take over the counter medication off the medication cart again. Further review revealed LPN #324 was very sorry about this mistake and promised to never repeat the mistake again. LPN #324 did not think about how the act could be perceived, and LPN #324 was embarrassed and very sorry. The documented was signed by LPN #324. A telephone interview with LPN #324 on 03/07/24 at 10:37 A.M. stated on 02/19/24 at approximately 9:00 A.M., while preparing medications for Resident #71, she placed a chewable 81 milligram (mg) aspirin tablet in a medication cup and a second chewable aspirin tablet in a second medication cup. LPN #324 verified she proceeded to consume the 81 mg chewable aspirin at the medication cart. When taking the aspirin, Student Nurse (SN) #442 was exiting a resident room behind her and observed LPN #324 take the medication. As a result, later that morning, LPN #324 was counseled by the DON not to take over the counter medications from the medication cart for personal use. No further investigation was conducted and LPN #324 continued to work the remaining shift. Interview with the DON on 03/07/24 at 12:15 P.M. revealed on 02/19/24 an allegation of LPN #324 taking medication from the medication cart was reported to her by Clinical Nurse Instructor Registered (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 5 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 03/07/2024 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)