Health inspection·April 3, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure dependent residents were turned and repositioned every two hours per plan of care. This affected one (Resident #11) of four residents reviewed for turning and repositioning. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition and required extensive assistance of two people for bed mobility. Review of the care plan initiated 04/03/20 for Resident #11 revealed she required staff assistance to complete activities of daily life (ADL) tasks completely. Interventions included turning and repositioning every two hours. Observation on 03/29/23 at 5:24 A.M. revealed Licensed Practical Nurse (LPN) #202 in the room with Resident #11 waiting for State Tested Nurse Aide (STNA) #101. Interview on 03/29/23 at 5:24 A.M. with STNA #101 revealed she was the only aide in the facility, along with two LPNs. STNA #101 revealed Resident #11 required two staff to assist with repositioning and incontinence care. STNA #101 stated she previously provided care for Resident #11 at approximately 1:00 A.M. Review of the Point of Care (POC) History on 03/29/23 at 1:02 P.M. for Resident #11 revealed the resident was turned and repositioned on 03/29/23 at 12:44 A.M. No additional entries for care were entered in the POC at the time of review. Observation 04/03/23 at 5:20 A.M. revealed LPN #201 and LPN #207 conducting checks and repositioning rounds for Resident #11. A concurrent interview with LPN #201 revealed Resident #11 was last checked and repositioned at 1:00 A.M. LPN #207 revealed residents were checked and changed twice during the eight-hour shift, usually every three to four hours. Interview on 04/03/23 at 1:00 P.M. with the Director of Nursing confirmed the care plan for Resident #11 revealed she should be turned and repositioned every two hours. Review of the facility policy titled Turning and Repositioning, reviewed 12/31/22, revealed (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 6 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 04/03/2023 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)