Health inspection·January 2, 2025

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. Based on medical record review, resident family interviews, facility staff interview, hospice staff interview, and review of facility policy, the facility failed to ensure a complete and accurate medical record was maintained for Resident #30. This affected one resident (#30) of three residents reviewed to accurate medical record. The facility census was 43. Findings Include: Review of the facility electronic medical record for Resident #30 revealed an admission date of 03/27/24 with diagnoses including hemiplegia, other signs and symptoms involving the nervous system, type two diabetes mellitus (DM2), non-pressure chronic ulcer of other part of unspecified foot, neuromuscular dysfunction of bladder, unspecified convulsions, non-pressure chronic ulcer of unspecified heel and midfoot, atherosclerotic heart disease, depression, fatigue, pure hypercholesterolemia, hypertension (HTN), pain in unspecified ankle and joints of unspecified severity, peripheral vascular disease (PVD), Charcot's joint-right ankle and foot, malignant neoplasm of head, face, and neck, neoplasm of unspecified behavior of digestive system, other signs and symptoms involving cognitive functions and awareness, myopia, bilateral astigmatism, presbyopia, combined forms of age related cataract, squamous cell carcinoma of skin of unspecified parts of face, transient ischemia attack (TIA), cerebral infarction, personal history of venous thrombosis and embolism, personal history of pulmonary embolism, benign prostatic hyperplasia (BPH), retention of urine, disorder of urinary system, nontoxic single thyroid nodule, and long-term use of insulin. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating Resident #30 was unable to complete the interview. Resident #30 required substantial/maximal assistance for all functional abilities and was dependent for transfers. Review of the Medicare 5-Day MDS assessment dated , dated 03/31/24, revealed a BIMS score of 07, indicating Resident #30 was severely cognitively impaired. An interview on 12/31/24 at 10:34 A.M. with Resident #30's daughter revealed Resident #30 had orders to have dressing on his left foot changed Monday, Wednesday, Friday, and Saturday. Concurrent interview with Resident #30's daughter revealed the facility nurse is supposed to change the dressing every Wednesday and Saturday, and the hospice nurse is supposed to change the dressing every Monday and Friday. Further interview with Resident #30's daughter revealed Resident #30's dressing was not changed on Saturday, 12/28/24 by the facility nurse. Review of Resident #30's electronic treatment administration record (eTAR) revealed Licensed Page 1 of 2 366242 366242 01/02/2025 Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560

F 0842 Practical Nurse (LPN) #107 documented completion of Resident #30's dressing change on 12/28/24. Level of Harm - Minimal harm or potential for actual harm An interview on 12/31/24 at 11:05 A.M. with the Director of Nursing (DON) revealed LPN #107 did not change Resident #30's dressing on 12/28/24, despite documentation in the facility eMAR that she did. Further interview with the DON revealed she was made aware by Hospice Registered Nurse (RN) #177 on 12/30/24 that the facility nurse had not changed Resident #30's dressing on 12/28/24. Residents Affected - Few An interview on 01/02/24 at 11:07 A.M. with Hospice RN #177 revealed she changed Resident #30's left foot dressing on 12/27/24 and the dressing she placed on the resident on 12/27/24 was still in place when she provided care to the resident on 12/30/24. Hospice RN #177 states she knows the dressing she removed on 12/30/24 was the dressing she placed on 12/27/24, as the dressing had the date of 12/27/24 and her initials on it. Review of the facility policy titled, Skin Care Management Procedure, with a revision date of 12/09/22, revealed determination of the need for a dressing for an ulcer is based upon the individual practitioner's clinical judgement and facility protocols based upon current professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00160460. 366242 Page 2 of 2