Health inspection·October 31, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to report and investigate an injury of unknown origin. This affected one (Resident #17) of one resident reviewed for injury of unknown origin. The facility census was 56. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/01/23 with diagnoses including unspecified severe protein calorie malnutrition, acute kidney failure, dementia, anxiety, depression, osteoporosis, repeated falls, and dislocated left shoulder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had significant cognitive impairment with physical behaviors towards others. Resident #17 required extensive assistance of two persons for bed mobility, transfers and toileting. Resident #17 had no falls documented on the assessment. Review of the nursing progress notes for Resident #17 dated 09/08/23 at 11:30 A.M. revealed the State Tested Nursing Assistant (STNA) reported to the nurse that Resident #17 was crying and requesting Tylenol. The nurse administered the medication and the resident stated her shoulder was hurting. On 09/08/23 at 12:15 P.M. the nurse was approached by the hospice nurse stating the resident was crying and saying she was in pain. The nurse and hospice nurse palpated the residents shoulder to assess the exact location of the residents shoulder pain. The left shoulder was deformed in shape and swollen in the back. The hospice nurse notified the hospice physician to explain the condition of the resident and received an order to get an X-ray of the left shoulder. On 09/08/23 at 7:32 P.M. the Director of Nursing (DON), Nurse Practitioner (NP) and the family were made aware of the X-ray. On 09/08/23 at 7:46 P.M. the results of the X-ray were received and hospice was notified. The nurse was waiting on a return call from hospice nurse for any further orders. On 09/09/23 at 7:44 A.M. the hospice NP called and gave an order to send Resident #17 out for a second left shoulder X-ray. The family was notified. On 09/09/23 at 4:50 P.M. Resident #17 returned from the hospital and was noted to have left shoulder dislocation with no fracture. The left shoulder was put back in place and a sling in place on the left shoulder/arm. The family was notified. Review of the facility initiated Self Reporting Incidents revealed the injury of unknown origin, discovered on 09/08/23, was not reported to the state agency or investigated. Interview on 10/25/23 at 1:45 P.M. with the DON revealed she was made aware of the injury to Resident #17 left shoulder on 09/08/23. The DON stated she did not submit an injury of unknown origin form (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: 366424 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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)