Health inspection·November 30, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on medical record review and staff interview, the facility failed to ensure all staff working in the facility were aware of and trained on all available services, resources and treatment opportunities. This affected one (#45) of three residents reviewed for falls, with the potential to affect all residents of the facility. The facility census was 42. Findings include: Review of Resident #45's medical record revealed an admission date of 11/15/23 and discharge date of 11/27/23. Diagnoses included femur fracture, compression fracture of T5-T6 vertebra, osteoporosis and dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/21/23, revealed Resident #45 was cognitively impaired and required substantial/maximum assistance for bed mobility. Review of the plan of care, dated 11/16/23, revealed Resident #45 was at risk for falls. Interventions included to keep the bed low to the floor. Further review revealed on 11/15/23, a new intervention was added to place mats on the floor. Review of a nursing progress note, dated 11/15/23, revealed Resident #45 was found on the floor, face down, in her room near her bed. The bed was in a low position and the resident appeared to have rolled out of bed to use the bathroom. Review of a Nurse Practitioner (NP) progress note dated 11/15/23 revealed Resident #45 had a fall and was found on the floor. The NP had offered a telehealth visit as resident was post-surgery from fractures of the femur and vertebra after a fall at home and then fell out of bed onto her face at the facility. Further review revealed the facility nurse declined the telehealth visit, stating she was an agency/travel nurse and did not have access to the telehealth software. Interview on 11/30/23 at 12:20 P.M. with NP #200 confirmed she had offered a telehealth visit following Resident #45's fall due to the previous injuries the resident had sustained. NP #200 verified the nurse declined the telehealth visit as she was unable to access the software and was not trained on the telehealth software. Interview on 11/30/23 at 4:35 P.M. with the Executive Director (ED) revealed regular staff had been trained on the telehealth software system. The ED verified agency staff did not have access to this resource. The ED declined to acknowledge agency staff should have access to the same care and treatment resources, such as telehealth services, as facility staff. Page 1 of 4 366242 366242 11/30/2023 Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 11/30/23 at 4:49 P.M. with Licensed Practical Nurse (LPN) #150 confirmed she contacted NP #200 following Resident #45's fall. LPN #150 verified NP #200 offered a telehealth visit due to the resident's previous fall injuries, but she did not have access to the telehealth software, had received no training on the telehealth software, and was unable to facilitate the visit. As a result, LPN #150 stated she declined the telehealth visit for NP #200 to assess Resident #45 after falling out of bed. LPN #150 stated she would appreciate the same treatment resources being available to agency staff as available to facility staff. This was an incidental finding discovered during the investigation of Complaint Number OH00148457. 366242 Page 2 of 4 366242 11/30/2023 Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an Emergency Medical Services (EMS) Run Report and staff interview, the facility failed to ensure timely and accurate documentation in the resident medical record. This affected one (#46) of of three reviewed for change in condition. The facility census was 42. Findings include: Review of Resident #46's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), diabetes, atrial fibrillation, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #46 was cognitively impaired and required moderate partial assistance for mobility. Review of a nursing progress note, dated [DATE], revealed resident expired at 6:45 P.M. at the facility. The family, management staff and on-call Nurse Practitioner (NP) were informed and Resident #46's body was released to the funeral home. No additional information related to Resident #46's death was documented on [DATE]. Further review of a late entry nursing progress note, entered [DATE] for [DATE], revealed at 5:05 P.M., Licensed Practical Nurse (LPN) administered dinner medications and obtained the resident's blood sugar. The resident was sitting on the edge of the bed at that time with no complaints. At 5:40 P.M., State Tested Nurse Aide (STNA) informed the LPN the resident was not feeling well and wanted to see the nurse. The LPN was in the process of administering medications to another resident and stated she would be in shortly to see Resident #46. At 5:45 P.M., the LPN entered the resident's room. The resident was sitting in her reclining chair, leaning over to the left side. The nurse called out to the resident, without response, touched the resident's shoulder, without her becoming alert, and felt for a pulse at her wrist and throat, with no pulse noted. The LPN called a code. Unable to physically move Resident #46 from the recliner to the floor, the LPN pulled the resident into a flat position in the recliner and began to administer Cardiopulmonary Resuscitation (CPR). A second nurse arrived with the crash cart and assisted with moving the resident to the floor to continue CPR while the STNA contacted 911. CPR continued until EMS arrived at 6:05 P.M. and took over the resident's care. At 6:45 P.M., EMS informed staff they were discontinuing CPR and called time of death. Review of the EMS Run Report, dated [DATE], revealed dispatch received the call from the facility at 6:02 P.M., arrived to the facility at 6:11 P.M. and arrived to Resident #46's room at 6:12 P.M. The report revealed Resident #46 was found laying on the floor, receiving CPR from facility staff. Per facility staff, Resident #46 was last seen at 5:30 P.M. and found unresponsive at 6:00 P.M. Staff had been performing CPR for about 15 minutes. Resident #46 remained pulseless and apneic (not breathing) for the remainder of the code. Time of death was 6:42 P.M. Interview on [DATE] at 2:21 P.M., and follow-up interview at 5:50 P.M., with LPN #101 revealed she was Resident #46's assigned nurse on [DATE]. LPN #101 verified she did not enter a nursing progress note detailing the resident's change in condition and care provided on [DATE] until [DATE]. Additionally, LPN #101 verified the note entered on [DATE] for [DATE] was an estimated timeline of events, as best as she could remember, from the previous week. 366242 Page 3 of 4 366242 11/30/2023 Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560

F 0842 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 4:35 P.M. with the Director of Nursing (DON) revealed she noticed the nurse had not documented the details of Resident #46's change in condition on [DATE] and requested she enter a note on her next shift. The DON verified progress notes should be entered timely to ensure an accurate timeline of events and the timeline provided in the progress note dated [DATE], five days after the event, did not match the time-stamped timeline in the EMS report. Residents Affected - Few This was an incidental finding discovered during the course of the investigation for Master Complaint Number OH00148499. 366242 Page 4 of 4