Otterbein Monclova

Inspectors wroteBased on observation, medical record review, staff interview, manufacturer representative interview, and review of a manufacturer's handbook, the facility failed to ensure a MaxiSky Lift (a ceiling mounted lift that was utilized to transfer and reposition residents) was maintained in safe working condition prior to completing a resident transfer. This affected one (#21) of five residents identified by the facility to use a MaxiSky Lift. The facility census was 54. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications as ordered by the physician, resulting in a significant medication error. This affected one (#7) of three residents reviewed for medication administration. The facility census was 54. Findings Include: Review of the medical record for Resident #7 revealed an admission date of 11/13/25 with diagnoses including end stage renal disease (ESRD), presence of a left artificial knee joint, hyperlipidemia, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis, anemia, renal dialysis, atherosclerotic heart disease, obesity, lumbar spinal stenosis, weakness, chronic kidney disease (CKD), and type two diabetes mellitus. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure newly identified wounds were timely assessed and measured, and failed to ensured proper treatment timely implemented. This affected one (#20) of three residents reviewed for pressure ulcers. The facility census was 55.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to wear appropriate personal protective equipment for residents on enhanced barrier precautions and failed to maintain proper infection control measures related to hand hygiene during wound care. This affected one (#16) of three residents reviewed for wounds. The facility census was 55.

Inspectors wroteBased on observation, staff interview, and review of facility menu, the facility failed to ensure the approved menu was followed as indicated. This affected 12 residents ( #1, #6, #9, #15, #16, #18, #21, #29, #30, #37, #47, #52) residing in home number 85. The facility census was 54.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to follow proper sanitation and food storage practices. This had the potential to affect all residents who eat food from the facility kitchens. The facility identified that all residents receive food from the facility kitchens. The facility census is 54.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, the facility failed to ensure resident bathing preferences were honored. This affected one (#32) of one resident reviewed for choices. The facility census was 54.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of a change in condition. This affected one (#10) of one resident reviewed for notification of change of condition. The facility census was 54.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a nursing plan of care was implemented to address a dependent resident need for assistance with activities of daily living including grooming. This affected one (#53) of 24 residents reviewed for the provision of hygiene and grooming in a facility census of 54.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure dependent residents were provided with effective or sufficient assistance with activities of daily living including grooming. This affected two (#53 and #11) of 24 residents reviewed for the provision of hygiene and grooming. The facility census was 54.

Inspectors wroteBased on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure interventions were in place to promote healing of pressure ulcers. This affected two residents (#8 and #11) of four residents (#8, #10, #11, and #30) reviewed for pressure ulcers. The facility census was 54.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure devices to prevent contractures were applied in accordance with physician orders. This affected one resident (#53) reviewed for the application of range of motion interventions. The facility census was 54.

Inspectors wroteBased on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure medications were secured and not left at the bedside. This affected one (#19) of seven residents reviewed for medications and had the potential to affect two residents the facility identified as cognitively impaired and independently mobile. The facility census was 54.

Inspectors wroteBased on review of the medical record, observation, staff interview, resident interview, and review of a skills procedure, the facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and failed to ensure catheter tubing was secured. This affected one (#48) of two residents reviewed for urinary catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54.

Inspectors wroteBased on review of the medical record, observation, staff interview, review of facility skills checklist and policy review, the facility failed to ensure infection control standards were in place. This affected one (#48) of two residents reviewed for indwelling catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54.

Inspectors wroteBased on observation, review of the facility electronic medical record (EMR), resident interview, and staff interview, the facility failed to provide a sanitary and comfortable environment. This affected two (#33 and #212) residents of five (#11, #18, #33, #35, and #212) residents reviewed for environment. The facility census was 54.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 57 residents in the facility. The census was 57.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents except 12 (#13, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, and #68) residents residing in House #5. The facility census was 57.

Inspectors wroteBased on review of the medical record, staff interviews and policy review, the facility failed to timely notify the physician of signs and symptoms of a wound infection leading to a delay in treatment. This resulted in actual harm when Resident #23's toe wound began to show signs and symptoms of infection and the facility staff had not notified the physician. Resident #23 required care from the emergency room for treatment of osteomyelitis (severe wound infection). Additionally, the facility failed to correctly implement wound treatments per physician orders and timely administer antibiotics per physician orders. This affected one (Resident #23) of three residents reviewed for wound care. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview, resident interview, policy review, and review of manufacturer guidelines, the facility failed to monitor the position and inflation of a wheelchair back support cushion, resulting in avoidable skin breakdown. Additionally, the facility failed to effectively monitor and assess skin breakdown. This resulted in Actual Harm when Resident #08 developed a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum. This affected one (Resident #08) of three residents reviewed for wound care. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to notify the physician of changes in resident condition. This affected two (Residents #23 and' #8) of three residents reviewed for changes in condition. The facility census was 48.

Inspectors wroteBased on review of a physician wound note, review of physician orders, review of the medication administration record, staff interview, and policy review, the facility failed to ensure intravenous (IV) medications were administered per physician orders. This affected one (Resident #23) of one resident reviewed for medication administration. The facility census was 48.

Inspectors wroteBased on observation, medical record review, and policy review, the facility failed to ensure residents rinsed and swished out their mouths following the administration of an inhaled medication. This affected one resident (#13) of two residents observed for medication administration. The facility census was 55.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure weights were obtained per physician order, and ongoing monitoring was provided for residents identified at nutritional risk and sustaining weight loss. This resulted in Actual Harm when Resident #39 experienced a severe weight loss of 9.33 percent from 08/18/22 to 11/15/22 and a severe weight loss of 12.76 percent from 06/06/22 to 11/15/22. There was no evidence weekly weights were obtained per physician order or subsequent monitoring or interventions were considered or implemented during this time. This affected one resident (#39) out of six residents reviewed for nutrition. The facility census was 53.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure foods were properly stored in accordance with safe food handling procedures. This had the potential to affect all 52 residents who ate meals from the facility kitchen. The facility identified one resident (#04) received no food from the kitchen. The facility census was 53.

Inspectors wroteBased on observation and staff and resident interview, the facility failed to maintain a clean and well-maintained environment. This affected six residents (#06, #12, #20, #24, #30, and #39) and had the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, review of the safety data sheets, and policy review, the facility failed to ensure potentially hazardous chemicals were properly stored. This had the potential to affect four residents (#01, #27, #36 and #52) out of 11 residents residing in building 5060 identified by the facility as being cognitively impaired and independently mobile. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure timely physician and representative notification of a significant and severe weight loss. This affected two residents (#20 and #39) out of six residents reviewed for nutrition. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was updated to include interventions related to fluid restrictions. This affected one resident (#50) out of six resident care plans reviewed for nutrition. The facility identified Resident #50 as the only resident with orders for a fluid restriction. The facility census was 53.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to ensure residents that required assistance with bathing were provided adequate care and services. This affected two residents (#29 and #6) out of four residents reviewed for activities of daily living. The facility identified 52 residents that required staff assistance with bathing. The census was 53.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure wound care supplies were available to provide treatments as ordered. This affected one resident (#50) out of three residents reviewed with wounds. The facility identified six residents with non-pressure related skin wounds. Additionally, the facility failed to ensure compression stockings were applied per physician order. This affected one resident (#13) out of one resident reviewed for edema. The facility census was 53.

Inspectors wroteBased on record review, staff interview, observation, and policy review, the facility failed to ensure treatments were provided as ordered to promote wound healing. This affected one resident (#12) out of three residents reviewed for pressure ulcers. The facility census was 53.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to provide adequate services for the respiratory care needs. This affected one resident (#11) out of two residents reviewed for respiratory care. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure medications were available from the pharmacy for administration as ordered. This affected one resident (#06) out of one resident reviewed for pharmacy services. The facility census was 53.

Inspectors wroteBased on medical record review, observation, family and staff interview, and policy review, the facility failed to ensure resident meal textures were served as physician ordered. This affected one resident (#01) out of six residents reviewed for nutrition. The facility identified one resident (#01) received a physician ordered puree texture diet. The facility census was 53.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure appropriate hand hygiene between resident contacts during medication administration. This affected four (Resident #10, #23, #33, #37) of five residents observed for medication administration. In addition, the facility failed to implement their policy for water management to reduce the risk of Legionella in the facility water. This had the ability to affect all 47 residents residing in the facility.

Inspectors wroteBased on observation, staff interview and policy review revealed the facility failed to date mark and label food stored in the freezer. This had the ability to affect 10 residents (#1, #7, #8, #9, #18, #20, #22, #24, #28 and #36) residing in House 5069. The facility census was 47.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of weekly cleaning schedules, review of resident council meeting minutes, review of work request forms, and review of facility policy, the facility failed to ensure resident rooms were clean and sanitary. Additionally the facility failed to ensure adequate room temperatures. This affected three (#16, #29, #37) of four residents reviewed for environment. The facility census 47.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to notify the physician of a new pressure ulcer, failed to perform treatments only upon order of physician, failed to update the care plan and interventions when a pressure ulcer was present, and failed to provide weekly monitoring and assessment of the pressure ulcer which included assessment of wound bed, staging of the area, and documentation of any drainage. This affected one (#29) of one resident reviewed for pressure ulcers. The facility identified one resident with pressure ulcers. The facility census was 47.

Inspectors wroteBased on medical record review, observation, staff interviews and review of facility policy, the facility failed to implement a verbal physician order to schedule a resident's gastrostomy tube replacement after the feeding tube dislodged. This affected one (#41) of one resident reviewed for tube feedings. The facility had two residents with tube feedings. The facility census was 47.

Inspectors wroteBased on record review, staff interview, and review of the dialysis center transfer agreement, the facility failed to document ongoing communication with the dialysis center. This affected one (Resident #40) of one dialysis residents in the facility. The census was 47.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of work request forms, and review of facility policy, the facility failed to take steps to eradicate ants from the room of one (#29) of one residents reviewed for pest control. The facility census was 47.