Health inspection·October 18, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to reflect the resident's risk for Urinary Tract Infections (UTIs). This affected one (Resident #18) of three residents reviewed for comprehensive care plans. The facility census was 57. Findings include: Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE]. Diagnoses included heart failure, type II diabetes, morbid obesity, paroxysmal atrial fibrillation, acute respiratory failure, specified disorders of kidney and ureter, depression, anxiety, and rheumatoid arthritis. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 required extensive two person assist for all activities of daily living. The MDS also revealed Resident #18 was frequently incontinent of urine and bowel. Review of the hospital discharge documents dated 07/19/22 revealed Resident #18 was admitted to the hospital for sepsis due to a UTI, with acute sepsis-related organ dysfunction, acute hypoxic, and respiratory failure. Review of Resident #18's care plan dated 07/22/22 revealed the facility failed to address the resident's risk for UTIs. There were no goals or interventions in place to potentially prevent UTIs. Interview on 10/12/22 at 1:00 P.M. with the Director of Nursing (DON) verified the facility failed to address the Resident #18's history of urinary tract infections or urosepsis in the resident's care plan. 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 3 Event ID: 366368 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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)