Inspection·May 2, 2019

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, family interview, staff interview and review of facility policy, the facility failed to ensure dependent residents were able to participate in activities outside of their rooms. This affected one resident, (Resident #3), of four residents reviewed for activities. The facility identified 17 residents who were dependent on staff for mobility and transfer. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed an admission date of 01/09/19. Diagnoses included complete traumatic amputation of left great toe subsequent encounter, acquired absence of right leg above the knee, dysphagia, neuromuscular dysfunction of the bladder, type II diabetes, moderate protein calorie malnutrition, major depressive disorder, dementia, hypertension, chronic kidney disease, hyperlipidemia hyperlipidemia, convulsions, and cellulitis. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #3 was rarely or never understood. Resident #3 was totally dependent on staff for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. Resident #3 displayed no behaviors during the review period. Review of Resident #3's care plan revised 03/27/19 revealed supports and interventions for dementia and not being able to verbally communicate his needs, seizure disorder, risk for falls, risk for skin breakdown, limited verbal communication, impaired cognition, required staff assistance for activities of daily living (ADL) and activities. Specific interventions for Resident #3's activity supports, goals, and interventions included; Resident #3 would not exhibit boredom/isolation as evidenced by attending one to two group programs weekly. Review of Resident #3's Life Enrichment Report since admission revealed activities were provided but the report did not indicate where Resident #3's activities took place. Interview on 04/29/19 at 11:09 A.M. with Resident #3's wife revealed Resident #3 was not taken out of his room for activities. Resident #3's wife reported she visited often and had only ever found Resident #3 in bed or up in his wheelchair in his room. Resident #3's wife reported it had been a long time since he was taken by staff down for activities. Resident #3's wife stated she didn't want Resident #3 to be in his room every day all the time. Resident #3's wife stated she would like to see Resident #3 taken out of his room for activities like they talked about. Observation on 04/29/19 at 3:12 P.M. of Resident #3 found Resident #3 in his room, seated in his (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: 366452 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw Road 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)