Health inspection·May 2, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and review of the facility policy the facility failed to notify a resident and their representative of a room change. This affected one resident, Resident #2, out of three residents reviewed for rooms changes. The current census is 55. Findings include: Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include acute respiratory failure with hypoxia, heart failure, diabetes type two, and absence of right lower leg. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and had no behaviors during the assessment period. Further review of Resident #2's medical record including scanned documented, progress notes, and assessments revealed no evidence of any notification of a room change. Interview on 05/02/25 at 9:50 A.M. with Resident #2 revealed the resident was pleasantly confused. Resident #2 stated she was unsure of any notification of a room change and stated she did not know the day she was transferred to the new room. Resident #2 stated she was comfortable and denied any concerns with her care at the facility. Interview on 05/02/25 at 12:20 P.M. with Social Services Designee (SSD) #300 verified there was no documentation of notification of Resident#2 or the resident's Power of Attorney (POA) in the medical record regarding the room change in 03/2025. Per SSD #300 the other residents in house three, where Resident #2 was residing, had reported a concern to the SSD regarding Resident #2's yelling. Per SSD #300, the POA was contacted via telephone but there was no record of the call. SSD #300 stated she did text back and forth via the phone with the POA regarding the room change option, however SSD #300 stated she did not have any text messages to show as notification or the POA's agreement of the room transfer. SSD #300 verified there was no written documentation of the notification of the room change. SSD #300 stated on 03/07/25 Resident #2 was moved from house three to her current room in house one. Review of the facility policy titled, 'Discharge/Transfer Policy and Procedure', dated 03/07/25 revealed the facility will provide and document the preparation and orientation to the residents to ensure a safe and orderly transfer or discharge. Per the policy a transfer includes moving from one bed in the facility to another. Per the policy the facility will notify the resident or representative (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: 366354 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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)