Health inspection·January 23, 2025

F 0551 Give the resident's representative the ability to exercise the resident's rights. 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, staff interview and review of the facility resident rights document, the facility failed to ensure requests made by a resident's guardian were adequately addressed. This affected one (#36) of one resident reviewed for requests made by a guardian. The facility census was 46. Residents Affected - Few Findings include: Review of the medical record revealed Resident #36 admitted to the facility on [DATE]. Diagnoses included dementia, severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness. Further review revealed Resident #36's daughter was appointed legal guardian on 12/04/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively impaired. The resident required supervision or touching assistance for chair/bed-to-chair transfers. Review of the plan of care dated 09/06/23, and revised 01/21/25, revealed Resident #36 had an activities of daily living (ADLs) self-care and/or physical mobility performance deficit related to impaired mobility. Interventions included multiple assistive signs hung in room per family request. Further review revealed no evidence of what specific care or needs were identified on the signs hung in Resident #36's room or what requests the facility implemented. Observation on 01/21/25 at 11:40 A.M. revealed Resident #36 was in bed in his room. Further observation revealed numerous signs were posted throughout the resident's room. A sign posted on the wall to the side of the resident's bed stated, Leave wheelchair next to bed as he will get out of bed when he realizes he has to go to the bathroom, not always so please check on him often. The sign also stated to contact the resident's guardian with any questions or concerns and provided a contact phone number. Resident #36's wheelchair was in the bathroom and not next to the resident's bed. Continued observations on 01/21/25 from 11:40 A.M. through 12:47 P.M. revealed Resident #36 remained in bed, with his wheelchair located in the bathroom. Interview on 01/21/25 at 12:47 P.M. with Unit Manager (UM) #386 verified Resident #36 was in bed, while his wheelchair was located in the bathroom. UM #386 confirmed the wheelchair was supposed to be next to Resident #36's bed when he was in it per his guardian's request. Interview on 01/21/25 with Resident #36's legal guardian confirmed she requested the resident's wheelchair be left next to the bed when he was in it and left a sign next to the bed as a reminder to staff. The resident's guardian stated Resident #36 would sometimes attempt to get up independently to (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 01/23/2025 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)