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 (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 2 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 01/02/2025 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)