Otterbein Springboro

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medication carts were locked. This affected one of four medication carts observed and had the potential to affect 11 Residents (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, and #57) whose medications were stored in the cart. The facility census was 57.

Inspectors wroteBased on observation, staff interview and review of the week at a glance menu, the facility failed to ensure the menu portion sizes were followed. This affected twelve (Resident #09, #10, #16, #19, #20, #32, #35, #37, #39, #40, #41 and #51) out of 57 residents that resided in the facility. The facility census was 57. Findings Include:Review of the facility's a week at a glance menu for house 9349 dated 04/27/26 revealed residents on a regular and bite sized diets were to receive five ounces of grilled chicken, four ounces of broccoli, a half of a cup of rice pilaf and one breadstick for lunch on 04/27/26. Observation of the kitchen in house 9349 on 04/27/26 at 12:36 P.M. [...]

Inspectors wroteBased on observations, staff interviews, facility documentation, review of manufacturers recommendations, and policy review, the facility failed to serve food in a manner that protected against cross-contamination. This affected 21 (Residents #5, #7, #14, #15, #18, #27, #33, #34, #52, #54, #55, #56, #57, #64, #65, #66, #68, #69, #70, #71, and #72) residents. Additionally, the facility failed to maintain appropriate dishwashing equipment. This had the potential to affect 12 (Residents #2, #6, #8, #22, #23, #28, #30, #31, #46, #48, #49, and #50) residents in unit 9335. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview, review of the resident funds accounting record and policy review, the facility failed to ensure resident funds were conveyed within 30 days of discharge from the facility. This affected one (Resident #73) out of five residents reviewed for resident funds. The facility census was 57. Findings Included:Review of Resident #73's medical record revealed Resident #73 admitted to the facility on [DATE]. Diagnoses included cerebral infarction, adult failure to thrive, osteoarthritis, hypertension, chronic kidney disease, dementia moderate with agitation, and anxiety disorder. Resident #73 discharged from the facility on 10/13/25. Review of Resident #73's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a resident had an activities care plan. This affected one (Resident #23) out of 20 residents sampled. The facility census was 57. Findings Included: Review of Resident #23's medical record review revealed Resident #23 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure care plans reflected resident's needs regarding tube feeding. This affected one (Resident #3) out of four residents reviewed for care planning. The facility census was 57. Findings Included:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies and dysphagia oropharyngeal phase. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #3 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00. Resident #3 was dependent for activities of daily living (ADLs) and required a Hoyer lift for transfers. [...]

Inspectors wroteBased on medical record review, observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure insulin pen administration devices were primed. This affected one (Resident #37) out of three residents observed during medication administration. The facility census was 57.

Inspectors wroteBased on medical record review, observation, staff interviews, and policy review, the facility failed to provide Enhance Barrier Precautions (EBP) for residents with wounds. This affected two (Residents #67 and #68) of four residents observed for infection control. In addition, the facility failed to ensure appropriate hand sanitization during wound treatments. This affected one (Resident #51) of two residents sampled for wound care. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview and review of the Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to ensure a pneumococcal vaccine was offered to a resident. This affected one (Resident #43) out of five residents reviewed for vaccinations. The facility census was 57. Findings Included:Review of the medical record revealed Resident #43 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, dysphagia, hyperlipidemia, spinal stenosis, heart failure, constipation, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, epilepsy, generalized anxiety disorder and insomnia. [...]

Inspectors wroteBased on observation, staff interview, and review of employee orientation documents, the facility failed to ensure a safe environment in the kitchen. This had the potential to affect four facility-identified cognitively impaired and independently-mobile (Residents #4, #6, #18, #22) of 12 residents residents residing in the house. The facility census was 58 residents.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly to potentially prevent spoilage. This had the potential to affect 24 (Residents #19, #5, #46, #32, #11, #16, #48, #30, #54, #50, #25, #38, #40, #23, #37, #6, #49, #33, #12, #47, #21, #9, #35, and #155) who resided in House #49 and House #35. The facility's census was 57.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a comprehensive care plan to reflect the resident's risk for Urinary Tract Infections (UTIs). This affected one (Resident #18) of three residents reviewed for comprehensive care plans. The facility census was 57.

Inspectors wroteBased on review of personnel files, and staff interviews, the facility failed to ensure State Tested Nurse Aides (STNAs) received 12 hours of yearly in services. This affected five STNAS (#15, #35, #65, #69 and #76) of six STNAs reviewed for yearly in services. This had the potential to affect all residents residing in the facility. The facility census was 42.

Inspectors wroteBased on record review and interview, the facility failed to ensure as needed psychotropic medication orders were limited to 14 days or that a rationale and duration of the as needed (PRN) psychotropic medication was indicated in the medical record. This affected four Residents (#6, #16, #18 and #27) of five residents reviewed for unnecessary medications. The facility census was 42.

Inspectors wroteBased on observation, interviews and facility policy review, the facility failed to ensure food items were maintained, distributed and stored in a manner to prevent and protect food against contamination and spoilage. This had to potential to affect 35 Resident's (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42.

Inspectors wroteBased on record review, and staff interviews, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a significant change in their physical health condition. This affected one (Resident #5) of one resident reviewed for significant change PASARR. The facility census was 42.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to implement a resident's skin integrity care plan. This affected one (Resident #15) of 14 residents reviewed for implementation of care plans. The facility census was 42.

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to ensure staff did not falsify records in regard to dressing changes they did not personally complete. This affected one (Resident #21) of four residents reviewed for skin management. The census was 42.

Inspectors wroteBased on observation, medical record review, staff, nurse practitioner, and resident interviews, and review of facility policies, the facility failed to ensure staff monitored a wound for signs of infection and failed to report an odor to the physician. This affected one (#Resident 21) of four residents reviewed for skin conditions. The facility census was 42.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review the facility failed to ensure a resident with an indwelling catheter had an order for the catheter and failed to ensure catheter care was provided and/or the catheter was changed on a regular basis. This affected one (#21) of one resident for an indwelling catheter, The facility identified there were two residents with an indwelling catheter. The census was 42.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to ensure a resident's physician evaluated and addressed a resident's significant weight loss. This affected one (Resident #15) of one resident reviewed for nutrition. The facility census was 42.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure a resident that discharged from the facility had a written, signed and dated order from the physician. This affected one (Resident #46) of one resident reviewed for discharges to the community. The facility census was 42.

Inspectors wroteBased on record review and interview, the facility failed to ensure drug regimen review recommendations were addressed by the attending physician in a timely manner. This affected one (Resident #33) of five residents reviewed for unnecessary medications. The facility census was 42.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a resident received routine or annual dental services. This affected one (Resident #33) of one resident reviewed for dental services. The facility census was 42.

Inspectors wroteBased on observation, interviews and facilty menu spreadsheet review, the facility failed to follow menus that were prepared in advance or to notify residents when menu items changes. The facility also failed to follow menu spreadsheets for portion sizes. This had to potential to affect 35 Residents (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42.