Inspection·January 22, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to follow physician orders to obtain daily weights to monitor for fluid overload. This affected two (#20 and #1) of three residents reviewed for daily weights. The facility census was 18. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 10/12/23 and a discharge date of 12/18/23. Diagnosis included congestive heart failure (CHF). Review of the physician orders for Resident #20 revealed an order for daily weight and to notify the physician of a greater than two-pound weight gain in 24 hours, or greater than five pound weight gain in one week. Review of Resident' #20's Treatment Administration Record (TAR) for 10//23 revealed no daily weights were obtained for the following days: 10/17/23, 10/18/23, 1022/23, 10/24/23, 10/25/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23. Review of the TAR for the month of 11/23 revealed revealed no daily weights were obtained for th following days: 11/02/23, 11/04/23, 11/05/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Review of the TAR for the month of 12/23 revealed revealed no daily weights were obtained for th following days: 12/04/23, 12/07/23, 12/08/23, 12/09/23, 12/10/23, 12/11/23, and 12/17/23. 2. Review of the medical record for Resident #1 revealed an admission date of 01/17/19 with a diagnosis of heart failure. Review of the current physician orders for Resident #1 revealed an order to obtain a daily weight and notify the physician for weight gain of greater than two pounds in 24 hours or greater than five pounds in one week. Review of the TAR for Resident #1 for 11/23 revealed revealed no daily weights were obtained for the following days: 11/02/23, 11/03/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23/11/11/23, 11/12/23, 11/15/23, 11/17/23, 11/20/23, and 11/26/23. Review of the TAR for Resident #1 for 12/23 revealed revealed no daily weights were obtained for the following days: 12/04/23, 12/09/23, 12/21/23, 12/23/23, 12/24/23, and 12/25/23. Interview on 01/22/24 at 12:45 P.M. with the Director of Nursing (DON) verified daily weights were (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: 366148 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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)