Inspection·November 22, 2023

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to ensure a resident received dental services in a timely manner. This affected one (Resident #33) of one reviewed for dental services. The facility census was 50. Residents Affected - Few Findings include Review of the medical record for Resident #33 revealed an admission date of 01/15/23. Diagnoses included kidney disease, emphysema, bipolar disorder and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact with a BIMS of 15 and required limited assistance of one staff member and for mobility and transfers. Review of the baseline care plan dated 01/15/23 revealed Resident #33 was noted to have broken teeth with intervention to ensure lighting in resident room was appropriate. Review of the progress notes dated 02/22/23 revealed Resident #33 was seen by the 360 care dentist and was found to need all top teeth (quantity of eight) extracted. The dental group recommended resident to be seen by an oral surgeon. The resident and family was provided the information to review. Review of the progress note dated 03/01/23 revealed social services spoke with the resident and daughter regarding dental follow up and the resident and family were interested in her getting scheduled for the oral surgeon to have teeth extracted with the possibility of getting dentures. Social Services informed family of process in getting dentures with Medicaid insurance and timeline of taking potentially several months for authorization. Social Services agreed to call around for a local oral surgeon who would accept the resident's insurance and be able to provide her services and confirmed family and the resident were unable to pay privately for dental extractions. Review of the progress note dated 03/07/23 revealed multiple dental offices were contacted and did not accept the resident's insurance. 360 dental service was contacted requesting a list of oral surgeons that accept Medicaid. Review of the progress note dated 03/14/23 revealed 360 dental provider sent list of possible providers further outside of [NAME] and resident and family were agreeable to offices being contacted for possible services. Review of the progress note dated 03/16/23 revealed social services contacted the four locations (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: 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 11/22/2023 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)