Otterbein Union Township

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure resident care conferences were held quarterly for all residents. This affected Residents #1, #4, #5, #7, #9, #10, #36, and #51. The facility census was 51 at the time of survey.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected four residents,(Residents #42, #15, #39 and #16) of four residents reviewed for activities. The facility census was 51. Findings Include: 1. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, hypertension and diabetes mellitus type II, Resident #16 currently serves as the House Council President. Review of the Minimum Data Set (MDS) Medicare Five-Day assessment dated [DATE] revealed Resident #16 had intact cognition and was occasionally incontinent of bowel and always incontinent of bladder. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide an activity program directed by a qualified professional. This had the potential to affect 50 residents of the 51 residents receiving the activity program. This did not affect Resident #22. The facility census total was 51. Findings Include:

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide an Advanced Beneficiary Notice of Non-Coverage (ABN) prior to discharge from Medicare Part A services as required. This affected one (Resident #39) of two residents reviewed for ABNs. The facility census was 51.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide equipment to prevent physical decline . This affected two residents,(Residents #24 and #42) of two residents reviewed for equipment to prevent physical decline. The facility census was 51. Findings Include: Record review of Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #24 include Alzheimer's disease, malnutrition, osteoporosis, adult failure to thrive, and congested heart failure. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive staff assistance for Activities of Daily Living skills. The resident received hospice care. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide adaptive feeding devices as ordered by the physician. This affected two residents (Residents #22 and #42) of two residents for adaptive feeding utensils. The facility census was 51. Findings Include:1. Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #42 include heart failure, malnutrition, myocardial infarction, quadriplegia, and stenosis of carotid artery and left leg amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 12/20 25 revealed the resident had intact cognition and required assistance for feeding. The resident received a regular diet with a order for a built up plate and spoons only. [...]

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 51 residents who received food from the kitchen. The facility census was 51.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of self-reported incidents (SRI), review of witness statements, review of personnel files, review of X-ray results, and review of facility policy, the facility failed to ensure Resident #32 was transferred per physician orders and in a manner consistent with her plan of care. This resulted in Actual Harm on 06/22/25 at 4:01 P.M. when Certified Nursing Assistant (CNA) #168 attempted to transfer Resident #32 from the bed to a wheelchair by carrying her without additional staff and without the use of a mechanical Hoyer lift. CNA #168 tripped and fell with Resident #32 and the resident sustained an acute fracture of the right humerus, with mild displacement, and soft tissue swelling. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, incident investigation review, and staff interview, the facility failed to provide the appropriate level of assistance during resident transfers. This affected one (Resident #34) of the four residents reviewed for falls. The facility census was 58 residents.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to verify a resident's (Resident #55) identity prior to medication administration, resulting in Resident #55 being given another resident's medication. This resulted in actual harm when Resident #55 had a subsequent episode of vomiting and lethargy, leading to the resident being transferred to the emergency room. Additionally, the facility failed to administer pain medication in a timely manner and as ordered by the physician for Resident #107. This affected two (Residents #55 and #107) of six residents reviewed for medication administration. The facility census was 58.

Inspectors wroteBased on observation, staff interviews, review of manufacture directions, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58.

Inspectors wroteBased on observation, record review, staff interviews, resident interviews, and review of facility policy, the facility failed to provide sufficient staffing to meet the needs of the residents. This affected one (Resident #107) and had the potential to affect twelve residents (#207, #47, #46, #156, #206, #111, #106, #107, #45, #108, #40 and #31) who resided in House #15. The facility census was 58.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide food portions and menus as approved by a Registered Dietitian. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings Include: Review of the facility's approved menu dated 08/01/22 for House #15's lunch meal revealed the following was to be served: Six ounces (oz) of spaghetti with meatballs, four oz of broccoli, four oz of cottage cheese with peaches, one slice of garlic bread and a beverage. Observation on 08/01/22 at 12:40 P.M. revealed Resident #207 was served five slices of peaches, less than one cup of chicken noddle soup, and one slice of bread with butter. Interview on 08/01/22 at 12:41 P.M. Resident #207 reported the lunch portion was, not much food for anyone. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to timely notify a physician of a resident's significant weight loss. This affected one resident (#55) out of five residents reviewed for nutrition. The facility census was 58.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected three (Residents #29, #30, and #50) of four residents reviewed for activities. The facility census was 58.

Inspectors wroteBased on observation, staff inteview, and resident interview, the facility failed to provide timely incontinence care. This affected one (Resident #107) of three residents reviewed for incontinence care. The facility census was 58.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to timely monitor and address Resident #55's weight loss and failed to ensure weekly weights were completed as ordered by the physician. This affected one (Resident #55) of five residents reviewed for nutrition. The facility census was 58.

Inspectors wroteBased on staff interview and review of personnel files, the facility failed to ensure an annual performance review was completed for State Tested Nursing Assistant (SNTA) #2. This affected one (STNA #2) of two STNAs reviewed for annual performance reviews. This had the potential to affect all residents at the facility. The facility census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to identify the reason for the use of as needed (PRN) narcotic pain medications and provide other interventions prior to the administration of pain medications for one (#22) of six residents reviewed for unnecessary medications. The facility census was 58.

Inspectors wroteBased on observation and staff interview, the facility failed to properly label insulin medication. This affected two (Residents #13 and #21) and had the potential to affect 10 residents (#13, #21, #206, #41, #29, #48, #4, #49, #43, #40) who received insulin at the facility. The facility census was 58.

Inspectors wroteBased on observation, record review, policy review and staff interview, the facility failed to discard expired medications, failed to date medications when open to ensure efficacy, and failed to secure controlled medications. This had the potential to affect all residents of the facility. The facility census was 44.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure a written notice including reasons for transfer/discharge was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected one (#35) of three residents reviewed for hospitalization. The facility census was 46.

Inspectors wroteBased on record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (#8 and #32) of 13 residents reviewed for MDS accuracy. The facility census was 46.

Inspectors wroteBased on observation, record review, review of facility policy and staff interviews, the facility failed to revise care plans with fall interventions and specific medical devices in use. This affected two (#21 and #33) of thirteen residents reviewed for care planning. The facility census was 46.

Inspectors wroteBased on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure that residents received treatment for hearing loss. This affected one (Resident #8) of two residents reviewed for communication and sensory concerns. The facility census was 46.

Inspectors wroteBased on record review and staff interview, the facility failed to administer a resident's medication as ordered by the physician. This affected one (#5) of thirteen residents reviewed in the final sample. The facility identified all 46 residents receive medications administered by the facility nurses.