Otterbein Sunset House

Inspectors wroteBased on staff interview and review of facility staffing documentation, the facility failed to ensure the facility was staffed with sufficient Registered Nursing staff each day. This affected all residents residing in the facility. Facility census was 14.

Inspectors wroteBased on interview, facility documentation, and a policy for water management, the facility failed to ensure a sufficient water management program based on an accurate risk assessment. This had the potential to affect all residents. The census was 14.

Inspectors wroteBased on staff interview and review of fire drill reports, corrective action plans, and a state fire marshal report, the facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. This had the potential to affect all residents. The census was 14.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident toilet facilities were maintained in a sanitary manner. This affected one of 14 residents (#125) reviewed for environmental and housekeeping services. Facility census was 14.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident pharmacy medication regimen reviews were conducted monthly. This affected two of five sampled residents (#4, #1) reviewed for unnecessary medications and related pharmacy services in a facility census of 14.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to ensure psychoactive medication recommendations were implemented as directed by the physician. This affected one of five sampled residents (#4) reviewed for the provision of unnecessary medication administration in a facility census of 14.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were provided as ordered by the physician and without error. This resulted in three errors of 37 medications being administered with a 8.11% error rate. This affected one of three residents (#20) observed for medication administration in a facility census of 14.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered to prevent the occurrences of significant medication errors. This affected two of four sampled residents (#20, #125) reviewed for the administration of medications in a facility census of 14.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility policy, staff interview, and review of the facility self-reported incident, the facility failed to prevent staff-to-resident physical abuse. This affected one (Resident #1) of four residents reviewed for abuse. The facility census was 15.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to seal and date opened food items in the freezer. This had to potential to affect all 19 residents residing in the facility.

Inspectors wroteBased on medical record review, review of admissions documents, staff interview, and review of facility policy, the facility failed to ensure admission agreements were provided and signed timely for newly admitted residents. This affected three (#10, #11, and #12) of three residents reviewed for admissions. The facility census was 20. Finding Include: 1. Review of Resident #10's medical record revealed an admission date of 02/02/24 and a discharge date of 02/18/24. Diagnoses included sepsis, prostate cancer, type II diabetes, cognitive communication deficit, chronic kidney disease, hypertension, and acute respiratory infection. Review of Resident #10's admission agreement revealed Resident #10 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician orders to obtain daily weights to monitor for fluid overload. This affected two (#20 and #1) of three residents reviewed for daily weights. The facility census was 18.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure frozen food was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to affect all 19 residents in the facility. The facility census was 19.

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions (TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming was provided to a dependent resident. This affected one (Resident #7) of one resident reviewed for activities of daily living (ADLs). The facility census was 19.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place as care planned. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 19.

Inspectors wroteBased on observation, staff interview, medical record review and review of the medication administration policy, the facility failed to ensure two medications of 26 were provided within prescribed timeframe's, resulting in a medication error rate of 7.69 percent (%). This affected one (Resident #7) of four residents reviewed for medication administration. The facility census was 19.

Inspectors wroteBased on observation, staff interview, and review of facility guidelines, the facility failed to ensure residents were provided the proper portion sizes for meals. This affected all 18 residents who received food from the kitchen. The facility census was 18. Findings Include: Observation 09/03/19 at 11:30 A.M. of tray line from the serving kitchen found Dietary Staff (DS) #205 using a #16 (two ounce) scoop for the scalloped potatoes and the pureed fish sticks. DS #205 was observed placing a single scoop of scalloped potatoes and a single scoop of pureed fish sticks on resident plates. DS #205 was observed placing varying amounts of French fries, soup, fish sticks, chicken salad, and mashed potatoes on residents' plates. Review of the spreadsheet being used by DS #205 revealed no portion sizes were present. [...]

Inspectors wroteBased on observation, staff interview, and review of facility guidelines, the facility failed to ensure opened food items were stored properly and food thermometers were cleaned between use. This had the potential to affect all 18 residents who received food from the kitchen. The facility census was 18.

Inspectors wroteBased on observation, resident interview, staff interview, and review of facility training, the facility failed to ensure residents choices on when to arise for the day were honored. This affected one (#2) of one resident reviewed for choices. The facility census was 18. Findings Include: Review of Resident #2's medical record revealed an admission date of 04/24/19. Diagnoses included atrial fibrillation, hypertension, anemia, lymphedema, moderate protein calorie malnutrition, chronic kidney disease, hypothyroidism, major depressive disorder, insomnia, anxiety disorder, gout, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 07/16/19, revealed Resident #2 was cognitively intact. Resident #2 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. Resident #2 was dependent on staff for transfer. [...]

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to issue timely notifications of the ending of skilled Medicare Part A services for two (#168 and #169) of three reviewed for liability notices. The facility identified four residents with Medicare as their primary payor source. The facility census was 18.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure individualized activity involvement was provided for one (#1) of twelve residents reviewed for the provision of ongoing activities. The facility census was 18.

Inspectors wroteBased on observation, staff interview, medical record review and manufacturer recommendations for use instructions, the facility failed to ensure the administration of insulin included the proper dosage which resulted in a medication error rate of 6.25%. This affected two (#14, #5) of three residents reviewed for medication administration. The facility census was 18.

Inspectors wroteBased on observation, staff interview, medical record review and manufacturer recommendations for use instructions, the facility failed to ensure the administration of insulin included the proper dosage which resulted in a significant medication error for two (#14, #5) of three residents reviewed for medication administration. The facility census was 18.