Inspection·October 30, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, review of the facility policy, staff interview, and review of the facility self-reported incident, the facility failed to prevent staff-to-resident physical abuse. This affected one (Resident #1) of four residents reviewed for abuse. The facility census was 15. Findings include: Review of the medical record for Resident #1 revealed an admission date of 12/14/17. Diagnoses included peripheral venous insufficiency, polyarthritis, macular degeneration right and left eye, dementia, chronic kidney disease, hemiplegia and hemiparesis following a cerebral vascular accident. An additional diagnosis of cerebral atherosclerosis was added on 10/21/24. Review of the quarterly Minimum Data Set (MDS) assessment completed on 10/09/24 Resident #1 was highly impaired visually and had severe cognitive impairment. Resident #1 was dependent on staff for toilet hygiene, bathing and bed mobility and required the physical assistance of two people for transfers using a lift device. Resident #1 was also incontinent of bowel and bladder. Review of the care plan for Resident #1 revealed an activities of daily living (ADL) deficit due to impaired cognition and hemiparesis. Interventions included for caretakers to provide assistance without rushed care, anticipate needs, allow of rest periods with care and to ensure a safe environment. Review of the skin assessment completed on 09/18/24 at 4:35 P.M. revealed Resident #1 had bruising to the right hand and wrist. The skin assessment completed on 09/19/24 at 5:30 P.M. revealed Resident #1 had bruising to bilateral forearms. Additional skin assessments completed on 09/19/24 and 09/20/24 revealed bilateral forearm bruising. The provider progress note dated 09/19/24 revealed Resident #1 had bruising to the right and left arm and wrist. The left forearm bruise was darkening, and the right wrist continued to improve. Review of the facility self-reported incident (SRI) dated 09/18/24 revealed on 09/18/24 at approximately 4:00 P.M., a family member of Resident #1 reported to the Director of Nursing that State Tested Nursing Assistant (STNA) #75 was rough when providing care on the midnight shift. The facility's investigation revealed the family's video camera footage was reviewed and found STNA #75 did provide improper care and had disrespectful communication with Resident #1. (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: 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 10/30/2024 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)