Otterbein St. Marys Retirement Community

Inspectors wroteBased on medical record review, staff interview, observation, and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (#4) of three residents reviewed for skin alterations. The census was 49.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to assess a resident timely after a fall. The affected one (Resident #34) out of five residents reviewed for accidents. The facility census was 49. Review of Resident #34's medical record revealed an admission date of 10/03/25 with diagnoses of Parkinson's disease with dyskinesia, with fluctuations, primary osteoarthritis, psychotic disorder with delusions, dementia with agitation, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #34 had moderate cognitive impairment, required partial assistance with ambulation, and resident did not have any falls prior to assessment. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's urinary catheter tubing and collection bag was changed as ordered. Additionally, the facility also failed to provide timely incontinence care to a resident. This affected two (#4 and #5) of three residents reviewed for incontinence care. The census was 49.

Inspectors wroteBased on staff interviews, resident interviews, and record review, the facility to follow Bilevel Positive Airway Pressure (BiPAP) orders as prescribed. This affected one Resident (#16) of three reviewed. The facility census was 49.

Inspectors wroteBased on staff interview and record review, the facility failed to follow medication parameters during medication administration which resulted in significant medication errors. This affected one Resident (#16) of three reviewed for medication administration. The facility census was 49.

Inspectors wroteBased on observation, Centers for Disease Control (CDC) Guidelines, and staff interviews, the facility failed to ensure infection procedures were followed during incontinence care. This affected one resident (#5) of two reviewed for incontinence care and infection control. The facility census was 49.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide wound care as ordered. This affected one (Resident #20) of three reviewed for wounds. The facility census was 47.

Inspectors wroteBased on record review, review of facility policy, and staff interview the facility failed to ensure care was not delayed and a fall was properly assessed for one resident, Resident #1, out of three residents reviewed for falls. The current census is 46.

Inspectors wroteBased on medical record review, staff interview, review of facility investigations, review of a Sheriff's Office incident report, review of the weather forecast, review of hospital discharge documents, and review of facility policy, the facility failed to prevent the elopement of confused residents from the secured memory care unit. This resulted in actual harm when one resident (#20) eloped from the facility without staff knowledge, was outside for approximately three hours in cool weather temperatures and light rain, was subsequently admitted to the hospital for evaluation and stabilization and was diagnosed with hypothermia (a significant and potentially dangerous drop in body temperature most commonly caused by prolonged exposure to cold) and a hypothermic blanket was applied. [...]

Inspectors wroteBased on medical record review, staff interview, review of facility investigations, and review of facility policy, the facility failed to report instances of potential neglect related to resident elopement to the state agency. This affected two (#20 and #21) of three residents reviewed for elopement. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an admission date of 03/03/21. Diagnoses included major depressive disorder, schizoaffective disorder, dementia, Alzheimer's disease delusional disorder, and mood disorder. Resident #20 resided on the secured memory unit. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #20 was severely cognitively impaired. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to provide each resident or representatives with education regarding the risk and benefits of influenza immunization yearly when influenza vaccines were offered. This affected four (#2, #27, #31 and #36) out of five residents reviewed for immunizations. The facility census was 47.

Inspectors wroteBased on medical record review, staff and resident representative interviews, and policy review, the facility failed to include resident representative in the development of a baseline care plan and failed to provide resident representative with a copy of the baseline care plan. This affected one (#198) out of five residents reviewed for baseline care plans. The facility census was 47.

Inspectors wroteBased on medical record review, observation, staff, physician and resident representative interviews, the facility failed to follow the physicians orders for treatment of a wound. This affected one (#8) of one reviewed for wound care. Additionally, the facility failed to provide care and services to treat a resident's constipation. This affected one (#198) out of one resident reviewed for constipation. The facility census was 47.

Inspectors wroteBased on medical record review, staff and hospice staff interviews and review of a hospice contract, the facility failed to collaborate hospice services for the completion of a comprehensive plan of care for a resident admitted hospice services. This affected one (#13) of one reviewed for Hospice services. The facility census was 47.

Inspectors wroteBased on medical record review, resident and staff interview, review of the facility's shower schedules, shower/bath body audit sheets, and review of the state tested nurse aide (STNA) job summary, the facility failed to provide routine showers to a resident who was totally dependent on staff for bathing. This affected one (#15) of one resident reviewed for activities of daily living (ADLs). The facility census was 45.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure non-pressure skin impairments were accurately assessed and routinely monitored. This affected one (#15) of two residents reviewed for non-pressure skin impairments. The facility census was 45.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility's policy, the facility failed to accurately assess and routinely monitor residents with pressure ulcers. This affected two (#4 and #25) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 45.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to have a diagnosis for the need of a catheter and failed to have physician orders for catheter care for a resident. This affected one (#93) of two residents reviewed for urinary catheters. The facility identified three residents with an indwelling catheter. The facility census was 45.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to ensure their medication error rate of less than five percent (%). There were 35 medication opportunities with 11 medication errors, resulting in a 31% significant medication error rate. This affected one (#94) of six residents observed for medication administration. The facility census was 45.

Inspectors wroteBased on observation, staff interview, manufacturer's instructions and facility policy review, the facility failed to properly store medications. This affected one resident (#237) whose medications were found to be preset in one medication cart of two medication carts observed and one medication room of two medication rooms observed for medication storage. The facility had a total of three medication carts and two medication rooms. The facility census was 45.