Otterbein Loveland

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure staff stored and prepared food in a sanitary manner, failed to ensure dishwasher temperatures reached safe levels, and failed to ensure hot food was held at safe and proper temperatures. This affected 21 (#22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, and #43) residents who received food prepared in the House Five kitchen of 56 residents residing in the facility. The facility census was 56 residents.

Inspectors wroteBased on medical record review, review of police report, staff interview, resident representative interview, and review of the facility policy manual, the facility failed to ensure the privacy of resident's health information. This affected one (Resident #71) of one resident reviewed for privacy of medical records. The facility census was 56 residents.

Inspectors wroteBased on medical record review, review of police report, staff interview, resident representative interview, and review of the facility policy, the facility failed to provide a safe and orderly resident discharge from the facility. This affected one (Resident #70) of two residents reviewed for discharge. The facility census was 56 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #100) of six residents reviewed for medication availability. The facility census was 56 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned proper personal protective equipment (PPE) for residents with physician's orders for enhanced barrier precautions (EBP). This affected one (Resident #31) of two residents with indwelling catheters. The facility census was 56 residents.

Inspectors wroteBased on observation, staff interview, review of dishwasher, refrigerator, freezer, and food temperature logs, and policy review, the facility failed to ensure foods were stored in a manner to prevent spoilage and contamination and failed to ensure the kitchen and dishware were maintained in a sanitary manner. This had the potential to affect all 58 residents residing in the facility. The census was 58.

Inspectors wroteBased on staff interview, review of Quality Assurance meeting sign-in sheets, and policy review, the facility failed to provide evidence the Medical Director attended and Quality Assurance committee meetings at least quarterly. This had the potential to affect all 58 residents. The census was 58. Findings Include:Review of the sign-in-sheets of the quarterly Quality Assurance (QA) committee meetings dated 09/30/24, 12/20/24, 03/28/25, and 06/19/25 revealed Medical Director #306 did not sign the sign-in attendance paperwork to show attendance. Interview on 08/25/25 at 1:58 P.M. the Administrator verified the MD must attend and participate at each quarterly QA committee meeting. The Administrator stated MD #306 did not sign the sign-in attendance sheet, and stated the MD #306 attended by telephone. [...]

Inspectors wroteBased on observation, resident and staff interview, review of water temperature logs, review of a repair quote, and policy review, the facility failed to ensure the residents environment was safe, comfortable, and homelike. This affected nine (#14, #17, #19, #23, #34, #52, #54, #56, and #59) of nice residents reviewed for environment. The census was 58.

Inspectors wroteBased on observation, medical record review, resident, resident representative, and staff interviews, review of activity calendars, and policy review, the facility failed to ensure activity programs were provided for residents to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected five (#16, #20, #36, #43, and #48) of five residents reviewed for activities. The census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the Medical Director visited residents once every 60 days. This affected four (#4, #16, #43, and #61) of four reviewed for physician visits. The census was 58.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review. the facility failed to ensure soiled linens were properly handled and failed to ensure proper hand sanitation during wound treatments. This affected two (#2 and #62) of four residents reviewed for infection control measures during care and services. The census was 58.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to obtain written documentation in the medical record of the code status of one (#41) resident of three residents reviewed for advance directives. The facility census was 58.

Inspectors wroteBased on medical record review, review of self-reported incidents, staff interview, and review of a policy, the facility failed to timely report an allegation of abuse. This affected one (#23) of one residents reviewed for abuse. The facility census was 58.

Inspectors wroteBased on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall incidents were reviewed and interventions put in place in a timely manner and failed to ensure established fall interventions were in place as care planned. This affected two (#25 and #64) of six residents reviewed for falls. The census was 58.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure incontinence care was provided timely and adequately. This affected two (#4 and #41) of two residents reviewed for bowel and bladder. The census was 58.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure the facility was adequately staffed to provide timely care and services for residents. This affected one (#41) of two residents reviewed for bowel and bladder. The census was 58.

Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to perform appropriate hand hygiene while preparing food for residents. This affected four (#13, #20, #21, and #22) of six residents sampled for food preparation. The facility census was 58.

Inspectors wroteBased on record reviews, staff interviews, and review of facility incident log, the facility failed to ensure residents received adequate supervision to prevent a fall with injury. Actual harm occurred when Resident #24 who was assessed and care planned for two staff assistance for toileting fell and sustained a fracture which required hospitalization and surgical intervention after being left unattended while toileting. This affected one resident (#24) out of the three residents reviewed for falls during the annual survey. The facility census was 57.

Inspectors wroteBased on record reviews, staff interviews, and review of on line medication guidance, the facility failed to ensure as needed (prn) psychotropic medications were not prescribed for longer than 14 days and failed to ensure psychotropic medications were only used for appropriate indications. This affected five residents (#5, #11, #21, #34, and #39) out of the six residents reviewed for unnecessary medications and hospice services. The facility census was 57.

Inspectors wroteBased on record review, observation, resident and staff interviews, and review of the menu, the facility failed to provide food portions as approved by a Registered Dietitian and offer food choices. This affected thirteen residents, (#11,#10,#09,#16,#19,#02,#36,#15,#48,#33,#40,#47, and #216) of 55 residents who received food from the kitchen. The total facility census was 57. Findings Include: 1. Review of the Resident #33 chart revealed Resident #33 admitted to the facility on [DATE] with diagnoses including hemiplegia, anorexia nervosa, gastro- esophageal reflux disease, vitamin D deficiency and iron deficiency anemia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and the physician ordered a regular pureed texture with nectar thick liquid diet. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to obtain and document dishwasher and food temperatures, failed to label and date foods, and discard expired foods. This had the potential to affect 55 residents who receive food from the kitchen. The facility census was 57.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed after residents received new mental health diagnoses. This affected two residents (#3 and #23) out of the three residents reviewed for PASARR's during the annual survey. The facility census was 57.

Inspectors wroteBased on record review and interview, the facility failed to complete an initial baseline plan of care to include fluid restrictions and daily weights monitoring for three Residents ( #216, #214 and #212 ) of three residents reviewed for baseline care plans. The facility census was 57. Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. [...]

Inspectors wroteBased on record reviews, interviews, and review of online guidance, the facility failed to ensure hospital discharge instructions were ordered and implemented, failed to ensure surgical follow-up appointments were made, failed to ensure surgical wounds received adequate monitoring and treatment, and failed to ensure adequate care of a Portacath (an implanted venous access device). This affected one resident (#21) identified as having an implanted Portacath device and one resident (#24) who returned from the hospital after surgical intervention of a hip fracture. The facility census was 57.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to monitor fluid restrictions and daily weights as ordered by the physician for three residents (#216, #214 and #212) of four residents reviewed for fluid restrictions and daily weights. The facility census was 57. Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. [...]

Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure three State Tested Nursing Assistants (STNAs) of five reviewed received at least 12 hours of on-going training annually. This had the potential to affect all 42 residents of the facility.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely respond to pharmacy recommendations. This affected one Resident (#35) of five residents reviewed for unnecessary medications. The facility census was 42.