Inspection·December 28, 2023

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the Diet Manual, the facility failed to provide a mechanically altered diet as ordered. This affected one (#15) of four residents (#12, #15, #16, and #17) who receive a mechanical soft diet. The facility census was 42. Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/23/22, with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition. Review of a physician order dated 09/06/22 revealed Resident #15 received a regular diet with mechanical soft textures and thin liquids. Review of the current care plan for Resident #15 she was at possible nutrition risk due to cognitive impairments, swallowing difficulty related to dysphagia, with need for altered texture diet. Interventions included providing the diet as ordered. Observation on 12/28/23 at 12:15 P.M., revealed Resident #15 sitting at the dining table in the common area of the secured unit. State Tested Nurse Aide (STNA) #102 placed a plate in front of Resident #15 with a chicken sandwich and a bowl of canned fruit. Observation of the chicken sandwich revealed an untoasted hamburger bun with pieces of chicken inside. The chicken was breaded, and was cut up and appeared to be large pieces of meat. Interview and observation on 12/28/23 at 12:17 P.M., with Speech Therapist (ST) #502 confirmed Resident #15's chicken appeared chopped. After further inspection, ST #502 stated the texture of the chicken was not appropriate for a mechanical soft diet due to the texture of the breading and the size of the pieces. Follow-up observation on 12/28/23 at approximately 12:20 P.M., with ST #502 revealed ST #502 asked the nurse to call the kitchen to send ground meat for Resident #14's sandwich. Interview on 12/28/23 at 12:40 P.M., with Dietary Aide #300 revealed she did not prepare the mechanical soft food, it was sent already prepared from the main kitchen. (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 4 Event ID: 366242 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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)