Health 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. Page 1 of 2 366148 366148 04/01/2024 Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/01/24 at 10:02 A.M. with Admissions Director (AD) #237 revealed typically resident admission packets were signed within 72 hours of admission, though there was not defined timeframe for signature. AD #237 Verified Resident #10, #11, and #12 had not signed their admission agreements until seven to nine days after admission to the facility. AD #237 verified the agreements contained the consent to treat, cost of stay, services offered, photo release, Health Insurance Portability and Accountability Act (HIPAA) policy, resident rights, and consent for ancillary services. Review of the facility policy titled, admission Policy, revised 12/06/16, revealed potential residents must sign the facility's admission agreement and agree to abide by the facility's policies and procedures. Prospective residents would be given a copy of the facility's description of services, payment options, resident rights, and all other applicable prior to the signing of the admission agreement whenever practical. On admission the facility would explain to residents the special characteristics or services limitations of the facility which were also to be identified in the admission material. This deficiency represents non-compliance investigated under Complaint Number OH00152165. 366148 Page 2 of 2