Avalon by Otterbein at Perrysburg

In the surveyor’s words

From the most serious findings on record at Avalon by Otterbein at Perrysburg, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Mar 28, 2022

  Based on closed medical record review, staff interviews, nurse practitioner interview, review of laboratory (lab) draw log, and review of facility policy regarding a change in a resident's condition, the facility failed to timely notify the physician of a significant change in condition for one resident (Resident #03). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #03 was refusing medications, refusing oral intake of food and fluids, and showing signs of dehydration with no notification to the physician. The lack of notification resulted in the resident not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to provide timely notification to Resident #03's family of the resident's change in condition. […]

• Immediate jeopardy, isolatedF684Mar 28, 2022

  Based on closed medical record review, nurse practitioner interview, review of facility policy, and staff interview, the facility failed to provide monitoring and assessments of a significant change of condition for one resident (Resident #03). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #03 was refusing medications, refusing oral intake of food and fluids, and showing signs of dehydration with no assessments of the resident's physical condition, monitoring of the resident's oral food and fluid intake, and not monitoring the resident's frequency of urinary output. The lack of assessment and monitoring resulted in the resident's physician not being notified of her condition, not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF678Nov 8, 2021

  Based on a closed medical record review, staff interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the facility policy for Advanced Directives, review of the facility policy for Code Status, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) for one (#50) resident found unresponsive, without a pulse, and who was identified as a Full Code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or ultimate death when Resident #50 did not receive CPR for 14 minutes after she was discovered unresponsive, with no pulse, and cold to the touch. […]

• Actual harm, isolatedF686Nov 8, 2021

  Based on medical record review and staff interview, the facility failed to assess and treat a pressure ulcer. This resulted in Actual Harm when one resident (#21) was admitted with an open area on the coccyx, no assessment of the area was completed, and no treatment was provided to aide in the healing of the pressure ulcers, resulting in the pressure ulcer increasing in size and developing slough tissue. This affected one (#21) of one resident with current pressure ulcers. The facility census was 44. Findings include: Review of the medical record of Resident #21 revealed an admitted [DATE] and a readmit of 10/16/21 after a hospital stay related to COVID-19. […]

• No harm, potential for more than minimal, widespreadF761Aug 18, 2025

  Based on review of the refrigerator temperature logs, staff interview, and review of facility policy, the facility failed to ensure the medication refrigerator temperature was monitored to ensure safe storage of medications. This had the potential to affect all residents at the facility. The facility census was 58. Findings include:Review of the medication refrigerator temperature logs for January 2025 through August 2025 revealed no evidence the facility monitored the temperature on nine days in January 2025, 13 days in February 2025, 18 days in March 2025, 15 days in April 2025, 26 days in May 2025, 14 days in June 2025, and 26 days in July 2025. Interview on 08/13/25 at 8:15 A.M. […]