Health inspection·September 10, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of staff statements, observation of a video recording, interviews, and review of the Ohio Nursing Home Residents [NAME] of Rights, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#26) of three residents reviewed for dignity and respect. The facility census was 48. Findings include: Review of the medical record for Resident #26 revealed an admission date of 08/25/23. Diagnoses included dementia, pulmonary fibrosis, and chronic obstructive pulmonary disease. Review of the quarter Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was always incontinent of bladder and occasionally incontinent of bowel. Review of an undated and unsigned statement by Registered Nurse (RN) #600 revealed on 08/13/24 Resident #26's daughters called and expressed after reviewing a video from their father's room, they saw and heard a nursing assistant yelling at their father and scolding him for urinating on himself. The daughter explained the nursing assistant's behavior appeared to be aggressive as she was in their fathers face yelling at him and again scolding him for urinating on himself. The daughter requested the nursing assistant to no longer be allowed in the resident's room and to no longer take care of the resident. RN #600 identified the nursing assistant and notified the Director of Nursing. RN #600 then spoke with the nursing assistant who denied yelling or scolding the resident. The nursing assistant stated the resident was hard of hearing and she had to speak loudly into his ear so he could hear her. The nursing assistant explained she was just telling the resident he should not pee on himself and he needed to call for assistance so he was not sitting in urine and for safety so he would not fall taking himself to the bathroom without assistance. RN #600 told the nursing assistant she could no longer go into the residents room or provide care for the resident. The nursing assistant was also educated on the importance of offering incontinent residents assistance to the bathroom every two hours and the proper way to approach and talk to a resident who was hard of hearing. Review of an undated and unsigned statement by State Tested Nursing Assistant (STNA) #210 revealed she walked into Resident #26's room and told him he was wet. The resident put his hand to his ear and stated he could not hear. STNA #210 took her hands up and down trying to explain to the resident that he was wet. STNA #210 went to closet and got a clean pair of pants and took the resident to the bathroom. STNA #210 stated there was urine on the floor and she helped the resident change. When STNA #210 walked out of the room, the nurse stopped her and told her the resident's daughter did not (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 3 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 09/10/2024 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)