Inspection·April 1, 2024

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of admissions documents, staff interview, and review of facility policy, the facility failed to ensure admission agreements were provided and signed timely for newly admitted residents. This affected three (#10, #11, and #12) of three residents reviewed for admissions. The facility census was 20. Finding Include: 1. Review of Resident #10's medical record revealed an admission date of 02/02/24 and a discharge date of 02/18/24. Diagnoses included sepsis, prostate cancer, type II diabetes, cognitive communication deficit, chronic kidney disease, hypertension, and acute respiratory infection. Review of Resident #10's admission agreement revealed Resident #10 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #10 was not provided his agreement for signature until 02/11/24, nine days after his admission to the facility. 2. Review of Resident #11's medical record revealed an admission date of 02/02/24 and a discharge date of 02/14/24. Diagnoses included fracture of the right clavicle subsequent encounter, urinary tract infection, anxiety disorder, heart disease, spinal stenosis, and cognitive communication deficit. Review of Resident #11's admission agreement revealed Resident #11 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #11 was not provided his agreement for signature until 02/11/24, nine days after his admission to the facility and three days prior to his discharge. 3. Review of Resident #12's medical record revealed an admission date of 02/05/24 and a discharge date of 02/13/24. Diagnoses included aftercare following joint replacement surgery, obesity, atrial fibrillation, ventral hernia, long term use of anticoagulants, and cognitive communication deficit. Review of Resident #12's admission agreement revealed Resident #12 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #11 was not provided his agreement for signature until 02/12/24, seven days after his admission to the facility and one day prior to his discharge. (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 04/01/2024 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)