Otterbein-Cridersville

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a witness statement, review of a police report, staff and resident interviews and policy review, the facility failed to ensure a resident's right to privacy was maintained. This affected one (#10) of three residents reviewed for privacy. The facility census was 48.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a witness statement, review of a police report, staff and resident interviews and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#10) of three residents reviewed for privacy. The facility census was 48.

Inspectors wroteBased on observation, staff interviews, review of dishwasher temperature logs and review of the dishwasher manual, the facility failed to ensure the dishwasher was washing and rinsing dishes at the proper temperatures to sanitize the dishes. This had the potential to affect all 44 residents residing in the facility. The facility census was 44.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure medication were stored securely and not at the bedside. Additionally, the facility also failed to ensure medication cart was securely locked when unattended on Rehab Hall. This affected three (#147, #22 and #38) of three residents reviewed for medication storage and had the potential to affect 13 (#20, #29, #41, #196, #197, #198, 199, #200, #201, #202, #203, #204, and #205) residents the facility identified as independently mobile and cognitively impaired. The facility census was 44.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure a resident was provided a dignified dining experience. This affected one resident (#197) of five residents observed in the rehab dining. The facility census was 44. Findings Include: Medical record review of Resident #197 revealed the resident was admitted [DATE] with diagnoses of rheumatoid arthritis, diabetes type two, chronic kidney disease, and angina. Review of Resident #197's Minimum Data Set (MDS) assessment, dated 04/10/25, revealed Resident #197 was cognitively intact, no psychological issues or behaviors, and was independent with Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to timely implement treatment orders for a newly identified pressure ulcer. This affected one (#38) out of three reviewed for pressure ulcers. The facility census was 44.

Inspectors wroteBased on medical record review, observation, and staff and resident interviews, the facility failed to ensure resident's toenails were adequately trimmed. This affected one (#01) of one resident reviewed for podiatrist visits. The facility census was 44.

Inspectors wroteBased on record review and staff interview, the facility failed to perform post dialysis assessments. This affected one (#199) out of one resident reviewed for dialysis. The facility census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This affected one (#15) out of six residents reviewed for medication administration. The facility census was 44.

Inspectors wroteBased on medical record reviews, observations, staff interviews and policy review, the facility staff failed to complete hand hygiene after resident contact and failed to wear proper Personal Protective Equipment (PPE) when providing resident care for a residents in Enhanced Barrier Precautions (EBP). This affected three (#2, #8 and #38) of four residents reviewed for the infection control. The facility census was 44.

Inspectors wroteBased on staff interview, review of facility policies, and review of the Centers for Disease Control (CDC) guidance, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 38 residents in the facility. The census was 38.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure hot water was within appropriate parameters to potentially avoid burns. This had the potential to affect three residents (#15, #296, and #297) whose water supply shared the same water heater. In addition, the facility failed to ensure resident fall interventions were in place as ordered. This affected one resident (#32) of three reviewed for falls. The facility census was 38. Findings Include: Observation on 06/21/23 at approximately 9:52 A.M. revealed Former Resident #298's resident room revealed the resident bathroom sink temperature tempted at 130 degrees Fahrenheit. Interview on 06/21/23 at 10:00 A.M. with the Administrator verified Former Resident #298's resident bathroom sink water tempted at 130 degrees Fahrenheit. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified when a resident's medications were not available and not administered as ordered. This affected one resident (#34) of one reviewed for mood and behaviors. The facility census was 38.

Inspectors wroteBased on record review, observation, and interview, the facility failed to to ensure mobility positioning devices were in place as ordered. This affected one (Resident #18) of two residents reviewed for position and mobility. The facility census was 38. Findings Include: Review of the medical record for Resident #18 revealed an admission date of 04/26/23 with medical diagnoses including diabetes type II, urine retention, acute kidney failure, and pain in left and right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and required extensive assistance for bed mobility, transfers, walking, dressing, personal hygiene, and toileting. Review of Resident #18's care plan dated 04/27/23 revealed a self-care deficit for impaired ability to perform or complete Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure a resident's pain was managed in a reasonable time. This affected one (Resident #295) of one resident reviewed for pain management. The facility census was 38.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications for sexualized behaviors were administered as ordered. This affected one resident (#34) of one reviewed for mood and behaviors. The facility census was 38. Findings Include: Review of Resident #34's medical record revealed an admission date of 01/18/23. Diagnoses included alcohol induced dementia, adult failure to thrive, anxiety disorder, conduct disorder, and emphysema. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating he was severely cognitively impaired. Resident #34 required supervision set up only with bed mobility, transfer, and toilet use. Resident #34 required limited assistance with dressing and personal hygiene. [...]

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to notify a physician when a resident had a fall. This affected one (#28) out of one resident reviewed for falls. The census was 35.

Inspectors wroteBased on medical record review, observation and resident and staff interviews, the facility failed to ensure residents plan of care reflected the residents use of hearing aids. This affected one (#9) out of one resident reviewed for vision and hearing. Facility census was 35.

Inspectors wroteBased on medical record review, observation and resident and staff interviews, the facility failed to ensure a resident was provided and/or assisted with her bilateral hearing aids each morning. This affected one (#9) out of one resident reviewed for vision and hearing. The census was 35.

Inspectors wroteBased on medical record review, staff interviews, review of incident report, and review of facility policies, the facility failed to ensure a resident received the correct medications when staff administered medications to the wrong resident resulting in significant medication errors. This affected one (#8) out of five reviewed for potential medication errors. The facilities census was 35.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to ensure a resident was not served and fed food listed as an allergy. This affected one (#5) out of one resident reviewed for nutrition. The facility's census was 35.

Inspectors wroteBased on medical record review, observations, staff interviews, review of an electronic mail (e-mail) communication and policy review, the facility failed to ensure visitors followed proper infection control guidelines while visiting a resident who was quarantined to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected one (#25) out of three residents reviewed who were quarantined. The census was 35.