Health inspection·July 23, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interviews, the facility failed to ensure a resident who was dependent on staff for eating was assisted with eating with her meal. This affected one (Resident #16) of one resident observed for eating and had the potential to affect eight residents (#2, #4, #14, #28, #30, #31, #42, and #43) the facility identified as requiring assistance with eating. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed she was admitted on [DATE] with diagnoses of intracerebral hemorrhage with left sided paralysis and dysphagia. Review of the care plan revised 06/2024 revealed Resident #16 was care planned for Activity of Daily Living (ADL) self-care and/or physical mobility performance deficit. Interventions included to provide extensive assistance of one staff member for eating. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired and dependent on staff assistance for eating. Review of the current physician orders for 07/2024 revealed Resident #16 was ordered a regular diet, mechanical soft with thin liquids. Review of the State Tested Nursing Assistant (STNA) documentation sheet dated 07/22/24 and timed 9:45 A.M. and 2:03 P.M. for Resident #16 revealed she required total dependence for those meals, indicating full staff performance. Review of the nursing progress notes for Resident #16 revealed a nursing note dated 07/22/24 at 3:00 P.M. verifying the lunch tray for Resident #16 was left in her room and appearing untouched, and the silverware was still wrapped. The nursing progress note further stated the STNA was asked to heat the food for Resident #16 and attempt to feed and her it was reported to the nurse Resident #16 ate 100% of her meal and drank 100% of her Ensure shake (a high calorie nutritional supplement). Observation on 07/22/24 at 2:45 P.M. revealed the lunch tray for Resident #16 was left in her room on the overbed table. The lunch tray was sitting with the covered dome lid in place, the silverware rolled in linen napkin and completed rolled up, a glass of juice with a straw in the glass and a glass of white milk. Further observation revealed the food under the dome lid appeared to be untouched, there were no divots or smear marks on the plate indicating the food was touched or offered to Resident #16. (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: 365571 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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)