How many inspection deficiencies does OTTERBEIN SPRINGBORO have?

OTTERBEIN SPRINGBORO has 31 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at OTTERBEIN SPRINGBORO?

OTTERBEIN SPRINGBORO has a four-star staffing rating from CMS with 0.87 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is OTTERBEIN SPRINGBORO located?

OTTERBEIN SPRINGBORO is located in CENTERVILLE, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does OTTERBEIN SPRINGBORO have?

OTTERBEIN SPRINGBORO has 60 certified beds.

Who owns OTTERBEIN SPRINGBORO?

OTTERBEIN SPRINGBORO is a non profit - other facility and is part of the OTTERBEIN SENIORLIFE chain.

What questions should families ask when visiting OTTERBEIN SPRINGBORO?

Families visiting OTTERBEIN SPRINGBORO should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does OTTERBEIN SPRINGBORO compare to other nursing homes?

OTTERBEIN SPRINGBORO has a 5-star overall rating, placing it above average compared to other nursing homes in OH. Higher-rated facilities typically have better inspection results and staffing levels.

OTTERBEIN SPRINGBORO

Name: OTTERBEIN SPRINGBORO
Address: 9320 AVALON CIRCLE, CENTERVILLE, OH, 45458, US
Telephone: (937) 885-5426
Rating: 5.0

9320 AVALON CIRCLE, CENTERVILLE, OH 45458 · (937) 885-5426

Non profit - Other 60 Beds OTTERBEIN SENIORLIFE Data: November 2025

Trust Grade

80/100

#142 of 913 in OH

Share this report:

OTTERBEIN SPRINGBORO nursing home in CENTERVILLE, OH - Photo 1 of 10

OTTERBEIN SPRINGBORO nursing home in CENTERVILLE, OH - Photo 2 of 10

Photo by Otterbein Springboro SeniorLife Neighborhood

OTTERBEIN SPRINGBORO nursing home in CENTERVILLE, OH - Photo 3 of 10

Photo by Otterbein Springboro SeniorLife Neighborhood

OTTERBEIN SPRINGBORO nursing home in CENTERVILLE, OH - Photo 4 of 10

Photo by Otterbein Springboro SeniorLife Neighborhood

OTTERBEIN SPRINGBORO nursing home in CENTERVILLE, OH - Photo 5 of 10

1 / 10 photos

Last Inspection: October 2022

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Otterbein Springboro has a Trust Grade of B+, indicating it is above average and recommended for families looking for care. It ranks #142 out of 913 facilities in Ohio, placing it in the top half, and #4 out of 16 in Warren County, meaning only three local options are better. The facility is improving, with issues decreasing from 13 in 2019 to just 2 in 2022. Staffing is a strength, with a 4/5 star rating and a turnover rate of 42%, which is better than the state average of 49%. There have been no fines, which is a positive sign of compliance, but recent inspections revealed concerns such as improper food storage practices and inadequate training hours for staff, which could affect residents' safety and care quality. Overall, while there are notable strengths, families should consider these weaknesses when making their decision.

Trust Score: B+
In Ohio: #142/913
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 42% turnover. Near Ohio's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
Violations: 31 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★★

5.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★★★☆

4.0

Inspection Score

↔

Stable

2019: 13 issues

2022: 2 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (42%)
6 points below Ohio average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 42%

Near Ohio avg (46%)

Typical for the industry

Chain: OTTERBEIN SENIORLIFE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 31 deficiencies on record

Oct 2022 2 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE]. Diagnoses included heart failure, type II diabetes, morbid obesity, paroxysmal atrial fibrillation, acute respiratory failure, specified disorders of kidney and ureter, depression, anxiety, and rheumatoid arthritis. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 required extensive two person assist for all activities of daily living. The MDS also revealed Resident #18 was frequently incontinent of urine and bowel. Review of the hospital discharge documents dated 07/19/22 revealed Resident #18 was admitted to the hospital for sepsis due to a UTI, with acute sepsis-related organ dysfunction, acute hypoxic, and respiratory failure. Review of Resident #18's care plan dated 07/22/22 revealed the facility failed to address the resident's risk for UTIs. There were no goals or interventions in place to potentially prevent UTIs. Interview on 10/12/22 at 1:00 P.M. with the Director of Nursing (DON) verified the facility failed to address the Resident #18's history of urinary tract infections or urosepsis in the resident's care plan.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based 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. Findings include: Observation on 10/11/22 at 10:32 A.M. in House #49's kitchen revealed following sanitation violations: 1. Open container of juice was unlabeled 2. Pitcher of dark liquid was unlabeled and undated 3. Opened package of cream cheese with no date 4. Container of bacon and turkey with no open date Interview on 10/11/22 at 10:32 A.M. with State Tested Nurse Aide (STNA) #14 working in House #49, verified food should be labeled and dated. Observation on 10/11/22 at 10:45 A.M. in House #35's kitchen revealed following sanitation violations: 1. Opened bologna package undated 2. Container applesauce undated 3. Opened juice bottle not dated Interview on 10/1122 at 10:45 A.M. with State Tested Nurse Aide, (STNA) #85 working in House #35, verified foods should be labeled and dated. Review of facility policies, Food Labeling and Dating, dated 06/01/08 and Food Storage Best Practice, dated August 2022 revealed once food is removed, the bulk foods may be stored in approved container, identified by name and dated. Once opened, foods should be marked open and dated.

Nov 2019 13 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with the following diagnoses; congestive heart failure, hypertension, anxiety disorder, bipolar disorder, unspecified schizophrenia, borderline personality disorder, hyperlipidemia and neuropathy. On 02/08/19 the resident was admitted to hospice services for congestive heart failure on 02/08/19. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required total dependence with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #5 also required supervision with eating. Further review of Resident #5's medical record revealed a PASARR was completed on 06/28/18. There was no information that the facility notified the state mental health authority with a significant change PASARR upon Resident #5's physical decline or admission to hospice services on 02/08/19. Review of Resident #5's counseling records revealed the resident was admitted to counseling services while residing at the facility on 02/15/19 and discharged from counseling services while residing at the facility on 10/16/19 due to resident being disinterested in continuing services. Interview on 11/13/19 at 4:38 P.M. with the Director of Nursing (DON) verified the facility did not notify the state mental health authority with a significant change PASARR when Resident #5 was admitted to hospice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a stage one pressure area. Review of Resident #15's progress notes dated 10/24/19 revealed the resident developed a small area that was 0.5 centimeters (cm) by 0.5 cm on his sacrum. The area was reported to be blanchable and pink with granulated tissue. Calmoseptine was put in place on 10/24/19. Further review of Resident #15's progress notes dated 11/08/19 revealed Resident #15's area on his sacrum was healed. Review of Resident #15's skin integrity care plan revealed the resident required a pressure reduction cushion. Observation of Resident #15 on 11/13/19 at 11:56 A.M. revealed Resident #15 was sitting in his wheelchair at the dining table in with no pressure reduction cushion in place. Observation on 11/14/19 at 8:16 A.M. revealed State Tested Nurse Aide (STNA) #32 and STNA #81 were providing care to Resident #15. Resident #15's wheelchair was observed to be in the room at the time of the observation. There was no cushion observed in Resident #15's wheelchair. Interview at the time of the observation with STNA #32 and STNA #81 revealed Resident #15 did not have a cushion for his wheelchair. Observation of Resident #15 on 11/14/19 at 11:36 A.M. revealed Resident #15 was sitting in his wheelchair at the dining table in his house with no pressure reduction cushion in place. Interview with the Director of Nursing (DON) on 11/14/19 at 11:36 A.M. verified Resident #15 was sitting in his wheelchair at the dining table in his house with no pressure reduction cushion in place. The DON also confirmed resident was to have a pressure reduction cushion as indicated on his care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of the Treatment Administration Record (TAR) for Resident #21 for November 2019 revealed she had daily dressing changes to both heels that were to be completed on day shirt. Further review revealed on 11/12/19, Licensed Practical Nurse (LPN) #50 signed that he completed the dressing to the right heel. Observation of the left heel wound on 11/13/19 at 1:23 P.M. with LPN #50 and the Director of Nursing (DON) revealed the old bandage was not dated. In a subsequent observation on 11/13/19 at 3:25 P.M. with LPN #50 of a dressing change to the right heel revealed the old dressing was dated 11/11/19. Interview with LPN #50 on 11/13/19 at 3:50 P.M. revealed in regards to the right heel he documented he changed it on 11/12/19, but didn't change it. He said he didn't want there to be any holes in his documentation and he thought second shift was going to change the dressing. He admitted there was no evidence the dressing was completed on 11/12/19 for the right heel. Interview with RN #47 on 11/14/19 at 5:30 P.M. revealed she took care of Resident #21 on 11/01/19, 11/06/19, 11/09/19, and on 11/10/19. She stated she did the dressing changes, but she didn't document them on the TAR. She stated she checked off all of her medications on the MAR, but didn't do the treatments on the TAR. She stated when she changed the dressings for the left heel there was a foul odor. She stated she didn't document this in the progress notes and didn't call the physician. She revealed she didn't feel like she needed to document or call the physician, since the appropriate people were following the residents wounds and felt it was normal for the wound to smell foul. She indicated the dressing changes were scheduled for day shift but the resident received a bath on second shift on Monday, Wednesday and Friday so the dressings were done on second shift. She explained there was no place to document on the TAR that the dressing changes were completed on second shift.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of physician orders dated 10/04/19 and discontinued on 10/26/19 revealed Hydrogel to apply to right and left heel topically one time a day. The wounds were to be cleansed with normal saline, pat dry, apply Hydrogel and cover with a ABD pad and wrap with kerlix. Further review of the orders revealed on 10/26/19 to cleanse left heel with antiseptic, wash, pat dry, apply hydrofera blue, place ABD pad and wrap in kerlix and change daily on day shift and this order was discontinued on 10/29/19. Further orders revealed on 10/30/19 to cleanse left heel with antiseptic, wash, pat dry, place hydrofera blue, ABD pad and wrap in kerlix and the wound was to be changed daily every day shift and this was discontinued on 11/01/19. A new order was placed on 11/02/19 to cleanse left heel with Vashe, pat dry, apply skin prep around the wound, apply silver alginate to the wound and cover with ABD pad and kerlix and to change daily and as needed on day shift. Review of the resident's care plan dated 10/25/19 revealed she had arterial ulcers to her bilateral heels. Interventions were to administer treatment as ordered, encourage and assist me to lay down in bed after lunch, heel lift boots to bilateral extremities at all times, as tolerated. low air loss mattress, monitor for effectiveness of my treatment and notify the physician as needed if area worsens or does not respond, monitor for infection at the site as evidenced by redness and edema, supplements per order, turn and reposition frequently and weekly skin screening of body. Review of Nurse Practitioner (NP) #200 notes dated 10/25/19 revealed Resident #21's left heel was a full thickness wound measuring 7.5 centimeters (cm) x 5.0 cm x 0.1 cm. The wound base was 70% eschar and 30% granulation tissue. The wound was slightly malodorous and had serosanguinous drainage. Periwound was without erythema, induration, edema, or crepitus. The resident did not demonstrate evidence of pain when affected area was palpated. Intervention in place was Doxycycline 100 mg twice a day for 10 days for wound infection. Review of Treatment Medication Record (TAR) dated from 10/26/19 through 11/13/19 for Resident #21 revealed no staff signed that the treatment for the residents left heel was completed on 10/26/19, 10/27/19, 10/31/19, 11/01/19, 11/06/19, 11/09/19, and 11/10/19. Review of report sheets dated 11/01/19 through 11/10/19 from Registered Nurse (RN) #47 revealed on 11/01/19 dressings were changed, on 11/06/19 dressings were changed, on 11/09/19 heel dressings were changed, and on 11/10/19 dressings were changed. Review of NP #200 notes dated 11/08/19 revealed full thickness wound of the left heel, measuring 6.5 cm x 4.0 cm x 0.1 cm. The wound base was 60% eschar and 40% granulation tissue. Moderate nonodorous serosanguinous drainage. Periwound was without erythema, induration, edema or crepitus. The resident did demonstrate evidence of pain when affected area was palpated. Observation of the left heel wound on 11/13/19 at 1:23 P.M. with Licensed Practical Nurse (LPN) #50 and the Director of Nursing (DON) revealed when they removed the bandage from the resident's left heel there was a foul odor. There was thick yellowish green drainage and the blood was coming out of the wound significantly. The DON stated the wound looked like it was 50% eschar and 50% slough The resident had pain when the wound was palpated. The old bandage was not dated. In a subsequent observation on 11/13/19 at 3:25 P.M. with LPN #50 of a dressing change to the right heel revealed the old dressing was dated 11/11/19. Interview with LPN #50 on 11/13/19 at 3:50 P.M. revealed the resident always had an odor to the left heel. LPN #50 denied notifying the physician about the odor. He stated he smelled the odor on 11/12/19 but didn't call the physician or the NP. He indicated he had done the dressing change on the left heel on 11/12/19 but forgot to date the dressing. He stated he didn't do the dressing change to the right heel on 11/12/19 even though he signed it off that he completed it. He said he signed it off because he didn't want to there to be any holes in his documentation. He thought the second shift nurse was going to change the dressing. He verified there was no evidence the dressing was completed to the right heel on 11/12/19. Interview with the DON on 11/14/19 at 9:19 A.M. revealed the NP had only been at the facility since 10/11/19. She revealed she spoke with the NP and explained to her the wound had been classified as an arterial wound for a long time, even though there was no evidence of testing that was completed to determine if the wounds were arterial wounds. She stated the resident had been on an antibiotic several times for infection in her left heel. She stated the wound had been getting better when using the hydrofera and if the treatment was changed it got worse. She stated the resident's wound was not without odor and after it was cleaned the odor went away. She stated she knew there was a problem with the holes in the documentation and the facility was working on that. She said RN #47 could not seem to document in the TAR for the treatments. She stated the NP was contacted about the odor on 11/13/19, after surveyor intervention, and a new order was received for Doxycycline. Interview with NP #200 on 11/14/19 at 1:02 P.M. revealed she was going to order vascular studies to determine if the wounds were arterial. She stated she also wanted an infectious disease physician to evaluate the resident. She revealed she didn't feel like the wounds had the typical shape for arterial wounds and those type of wounds were usually found on the ankle. She stated when she was in the facility on 10/25/19 she felt the wound on the left heel had worsened and she placed the resident on an antibiotic. She stated when she assessed the wound on 11/08/19, she felt like the wound was better and at that time she did not smell an odor. She said the staff called her on 11/13/19 and said the wound looked worse and had an odor, so she placed the resident on an antibiotic. Interview with RN #47 on 11/14/19 at 5:30 P.M. revealed she took care of Resident #21 on 11/01/19, 11/06/19, 11/09/19, and on 11/10/19. She stated she did the dressing changes, but she didn't document them on the TAR. She stated she checked off all of her medications on the MAR, but didn't do the treatments on the TAR. She stated when she changed the dressings for the left heel there was a foul odor. She stated she didn't document this in the progress notes and didn't call the physician. She revealed she didn't feel like she needed to document or call the physician, since the appropriate people were following the residents wounds and felt it was normal for the wound to smell foul. She indicated the dressing changes were scheduled for day shift but the resident received a bath on second shift on Monday, Wednesday and Friday so the dressings were done on second shift. She explained there was no place to document on the TAR that the dressing changes were completed on second shift. Review of the facility policy entitled Skin Care Management dated 11/02/18 revealed it is the policy of the facility to follow the state and federal regulations concerning skin care management. The policy revealed to implement, monitor and modify if needed appropriate strategies to attain or maintain intact skin, prevent complications, and promptly identify and manage complications and identify and manage potential for infection. Review of policy entitled Notification of Change in Condition dated 07/20/11 revealed the facility will adhere to the regulations of both the Federal and State guidelines pertaining to notification in change in condition of residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. She was coded for an indwelling catheter. Review of care plan not dated for an indwelling catheter related to history and potential for skin breakdown revealed to change catheter once monthly and report cloudiness to the physician. Review of physician orders, Treatment Administration Records and progress notes dated 01/01/19 through 11/13/19 for Resident #21 revealed they were silent for an indwelling catheter orders, care or changing of the catheter or even when it was placed in the resident. There was no evidence the resident had a urinary tract infection. Observation of catheter care for Resident #21 on 11/14/19 at 11:12 A.M. revealed she had an indwelling catheter and the tubing had cloudy urine with sediment noted. Interview with the Interim Director of Nursing (DON) on 11/14/19 at 4:00 P.M. verified there was not a physician order for the catheter, there was no progress notes about catheter care, and there was no documentation the catheter had been cleansed. The Interim DON stated the catheter had been changed recently, but could not produce documentation for it. She stated that for some reason the documentation had dropped off the electronic charting.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a weight loss of five percent or more in the last month or loss of ten percent or more in last six months. Resident #15 was not on a prescribed weight loss regimen. Review of Resident #15's nutrition care plan revealed resident was at risk for changes in his nutrition and that he was to have dycem under his plate at meals, evaluations by occupational therapy and speech therapy, review of his weights, lab and intakes and to be served soup in a cup instead of a bowl. Review of Resident #15's weights revealed Resident #15 weighed 177 pounds (lbs) on 05/05/19 and 155 lbs on 11/05/19 with Resident #15 having a significant weight loss 12.43 percent over six months. Review of Resident #15's nutrition screen dated 09/26/19 revealed resident had a weight loss of five percent or more in the last month or 10 percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #15's physician's notes dated 04/30/19, 06/18/19, 07/08/19, 08/14/19, 10/25/19 and 11/06/19, revealed resident's significant weight loss was not evaluated or addressed by the physician in the physician's notes. Further review of Resident #15's medical record revealed no documentation that Resident #15's physician evaluated or addressed Resident #15's significant weight loss of 12.43 percent from 05/05/19 to 11/05/19. Review of Resident #15's physician's orders revealed the resident was ordered bene-calorie one packet one time per day on 09/27/19 and high calorie boost four times a day on 01/23/18. Observation of Resident #15 on 11/12/19 at 12:06 P.M. revealed the resident was sitting at the dining room table in his house independently feeding himself a hamburger. Observation of Resident #15 on 11/12/19 at 11:56 A.M. revealed the resident was sitting at the dining room table in his house. State Tested Nurse Aide (STNA) #66 was assisting him with eating stir fry. Interview with Dietary Technician #300 on 11/13/19 at 1:48 P.M. revealed Resident #15 used adaptive utensils at times and also required staff to assist him with meals. Dietary Technician #300 reported resident was ordered bene-calorie one packet one time per day on 09/27/19 and high calorie boost four times a day on 01/23/18. Follow up interview with Dietary Technician #300 on 11/17/19 at 11:22 A.M. verified Resident #15's medical record contained no documentation that Resident #15's physician evaluated or addressed Resident #15's significant weight loss of 12.43 percent from 05/05/19 to 11/05/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #46 was admitted to the facility on [DATE] with the following diagnoses; unspecified fall, primary generalized osteoarthritis, vascular dementia without behavioral disturbance, vascular dementia without behavioral disturbance, muscle weakness, hypertension, hyperlipidemia, osteoporosis, iron deficiency, vitamin D deficiency and major depressive disorder. Resident #46 discharged to an assisted living facility on 08/22/19. Review of Resident #46's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #46 also required supervision with eating. Review of Resident #46's progress notes dated 08/22/19 revealed Resident #46 discharged to an assisted living facility in her resident representative's personal vehicle. Review of Resident #46's physician's orders revealed Resident #46's medical record did not contain an order for the resident to discharge from the facility on 08/22/19. Interview with Registered Nurse (RN) #43 on 11/13/19 at 3:43 P.M. verified Resident #46 did not have a written and signed discharge order to discharge from the facility on 08/22/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. Review of Resident #33's pharmacy recommendation dated 09/20/19 revealed the pharmacy recommended Resident #33's as needed hydroxyzine (antihistamine) 25 milligrams (mg) every eight hours as needed for anxiety have a stop date clarified. Further review of the 09/20/19 pharmacy recommendation revealed no documentation that Resident #33's physician addressed the pharmacy recommendation. Interview with the Director of Nursing (DON) on 11/13/19 at 1:12 P.M. verified Resident #33's pharmacy recommendation dated 09/20/19 was not addressed by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. The resident had obvious or likely cavity or broken natural teeth. MDS. Review of Resident #33's dental care plan revealed the resident had carious (decayed) and broken teeth due to poor oral hygiene. Resident #33's care plan indicated the facility would coordinate and arrange for dental care and transportation as needed, provide oral care as needed and to monitor for signs and symptoms of oral problems. Further review of Resident #33's medical record revealed no documentation that Resident #33 was seen by the dentist. Observation of Resident #33 on 11/12/19 at 11:34 A.M. revealed the resident had missing upper and lower teeth with areas of her teeth being black in color Interview with the Director of Nursing (DON) on 11/14/19 at 11:48 A.M. reported Resident #33 had not been seen by the dentist since 04/11/18. The DON stated the facility did not have any documentation of Resident #33's dental visit on 04/11/18.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based 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. Findings include: 1. Review of House 9336's menu spreadsheet for 11/13/19 revealed residents were to receive 0.5 cup of applesauce, 4 ounces (oz) chicken stir fry, 0.5 cup of fried rice, 4 oz of oriental blended vegetables, three mini egg rolls and a slice of banana bread. Observation on 11/13/19 at 11:27 A.M. revealed State Tested Nurse Aide (STNA) #73 served residents applesauce, chicken stir fry and egg rolls. STNA #73 was observed to give regular and mechanical soft diets an unknown amount of applesauce, an unknown about of chicken stir fry, an unknown amount of rice and an egg roll. Interview with STNA #73 at the time of the observation verified she served regular and mechanical soft diets an unknown amount of applesauce, an unknown about of chicken stir fry, an unknown amount of rice and an egg roll. STNA #73 reported House 9336 did not have any additional diet types besides regular and mechanical soft. STNA #73 confirmed she does not use scoop sizes as indicated on the menu spreadsheet when serving residents and she just poured or scooped an unknown amount onto the residents bowls and plates. Observation of House 9336 on 11/13/19 at 12:25 P.M. revealed residents were eating cookies for dessert for lunch. Interview with STNA #66 verified banana bread was not served per the menu spreadsheet. 2. Review of House 9350's menu spreadsheet for 11/13/19 revealed residents were to receive 4 oz of layered fruit salad, 4 oz of poppyseed chicken, 4 oz of buttered noodles, 4 oz of Brussels sprouts, one dinner roll, 8 oz of milk and a brownie. Observation of STNA #21 on 11/13/19 at 12:04 P.M. revealed STNA #21 served regular and mechanical soft diets an unknown amount of poppyseed chicken, an unknown amount of buttered noodles, an unknown amount of carrots and Brussels sprouts and one dinner roll. Interview with STNA #21 at the time of the observation verified she served regular and mechanical soft diets an unknown amount of poppyseed chicken, an unknown amount of buttered noodles, an unknown amount of carrots and Brussels sprouts and one dinner roll. STNA #21 verified she did not use scoop sizes as indicated on the menu spreadsheet to serve residents. 3. Review of the planned menu spreadsheet for House 9349 dated 11/12/19 for lunch revealed 4 oz of mandarin oranges, 4 oz breakfast casserole, 4 oz asparagus, toast two slices, 8 oz milk, fruit pizza one slice. Review of the menu that was actually served for lunch on 11/12/19 revealed the residents received 4 oz of pineapple, 4 oz of macaroni and beef, 4 oz of asparagus, sugar cookies and 8 oz of milk. Further review revealed the menu was changed on the hard copy but wasn't posted for the residents to see. Interview with STNA #76 on 11/12/19 at 2:47 P.M. revealed she had someone call off sick and the menu got changed. She stated she didn't want to serve toast with the meal and didn't have any rolls to serve with the meal. She revealed the sugar cookies that replaced the fruit pizza didn't get passed out because she was assisting other residents to eat. 4. Review of the planned menu spreadsheet for House 9335 dated 11/12/19 for dinner revealed 4 oz chilled pears, 8 oz stuffed ravioli with sauce, broccoli 0.5 cup, one slice of garlic bread, 8 oz milk and German chocolate cake. Review of the actual menu served for dinner on 11/12/19 revealed the residents were served mixed vegetables, ravioli, slice of garlic bread, and a glass of lemonade. Observation of the menu posted on the back wall of the kitchen revealed only the German chocolate cake was crossed off and replaced with banana cream pie and wasn't posted for the residents to see the changes. Interview with STNA #11 on 11/12/19 at 5:15 P.M. revealed the menu was changed. STNA #11 said she didn't serve the pears with the dinner. She further stated she didn't serve the milk because the residents didn't want any milk. She verified she didn't ask the residents if they wanted milk with their dinner. Interview with Dietary Technician #300 on 11/13/19 at 10:00 P.M. was aware the menu was changed for House #9349 and House #9335 or 400 rooms. She stated the STNA's call her or someone else to get the menu changed. She verified the residents didn't get everything they should have on their meal trays. She stated the residents were not alerted of the menu changes and it wasn't posted for the residents to see the change.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with the following diagnoses; essential hypertension, major depressive disorder, macular degeneration, psychosis, vascular dementia, and dysphagia. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, eating. Resident #18 also required total dependence with transfers, toileting and personal hygiene. Review of Resident #18's physician orders dated 02/19/19 revealed the resident was prescribed Ativan 0.5 milligrams (mg) PRN by mouth two times per day if vistaril was ineffective. Resident #18's PRN Ativan 0.5 mg was discontinued on 10/26/19. Review of Resident #18's Medication Administration Record (MAR) from 08/01/19 to 08/31/19 revealed Resident #18 received her Ativan 0.5 mg on 08/06/19, 08/07/19, 08/09/19, 08/19/19, 08/20/19, 08/21/19, 08/22/19, 8/25/19 and 08/30/19. Review of Resident #18's MAR from 09/01/19 to 09/30/19 revealed Resident #18 received her Ativan on 09/03/19, 09/04/19, 09/09/19, 09/10/19, 09/15/19, 09/19/19, 09/26/19 and 09/28/19. Review of Resident #18's MAR from 10/01/19 to 10/31/19 revealed Resident #18 received her Ativan on 10/02/19, 10/03/19, 10/05/19, 10/06/19 10/17/19, 10/22/19 and 10/23/19. Further review of Resident #18's medical record revealed no documentation of a duration, stop date or rational for Resident #18's PRN Ativan extending beyond 14 days. Interview with the Director of Nursing (DON) on 11/13/19 at 2:41 P.M. verified Resident #18 was prescribed PRN Ativan from 02/19/19 to 10/26/19 with no duration, stop date or rational documented in the chart. 3. Review of Resident #6's medical record revealed an admission date of 11/30/17. Medical diagnoses included Alzheimer's disease, osteoarthritis, anxiety, depression, psychosis, Vitamin D deficiency, muscle weakness, edema. Review of Resident #6's quarterly MDS assessment dated [DATE] revealed the resident's cognition was severely impaired. Resident #6's October and November 2019 Medication MAR revealed an order for Hydroxyzine (anti-anxiety) 25 mg one tablet by mouth every eight hours PRN for agitation dated 10/29/19 with no stop date indicated. Interview on 11/14/19 at 2:37 P.M. with the DON verified Resident #6 did not have a stop date or rationale for continuation of use of the PRN anti-anxiety medication and it had exceeded the allowable 14 day timeframe. 4. Review of Resident 16's medical record revealed an admission date of 07/21/19. Medical diagnoses included dementia, subarachnoid hemorrhage, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, restless leg syndrome, dysphagia, and chronic kidney disease. Review of Resident #16's significant change MDS dated [DATE] revealed Resident #16's cognition was severely impaired. Review of Resident #16's October and November 2019 MAR revealed an order for Ativan (anti-anxiety) medication 0.5 mg one tablet by mouth every 12 hours PRN for agitation. Another anti-anxiety medication noted on the October 2019 MAR was Haloperiodol 0.5 mg one tablet by mouth every four hours PRN for agitation, which was dated from 09/07/19 through 10/29/19. Continued review of Resident #16's October and November 2019 MAR revealed no side effect or behavior monitoring was documented related to the use of anti-anxiety medications. Interview on 11/14/19 at 2:37 P.M. with the DON stated side effect monitoring and behavior monitoring should have been done and documented for Resident #16 who was prescribed and taking anti-anxiety medications. The DON further verified the facility had no duration for the PRN medications that were prescribed beyond the 14 day allowable timeframe with no rationale and no end date. 2. Medical record review for Resident #27 revealed an admission date of 07/09/18. Medical diagnosis included anxiety disorder. Review of the quarterly MDS dated [DATE] for Resident #27 revealed she was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, and toilet use. She was supervision for eating. Review of Pharmacy Recommendations dated 05/24/19 for Resident #27 revealed a request to discontinue PRN Ativan. Further review of the recommendations dated 08/23/19 revealed a request for the physician to clarify a stop date for the resident's PRN Ativan 0.25 milligram (mg) every 12 hours for agitation. The recommendation indicated per the Centers for Medicaid and Medicare Services (CMS) PRN anxiolytics cannot extend beyond 14 days without a specifically stated duration and a documented rationale for the extension. Both of these recommendations were not signed or acknowledged by the physician. Review of physician orders dated 08/23/19 revealed an order for Ativan 0.25 mg every 12 hours PRN for agitation. The PRN Ativan 0.25 mg was discontinued on 10/29/19. Review of physician order dated 10/29/19 revealed Ativan 0.5 mg give 1/2 a tablet every 12 hours PRN for agitation. An order was received to discontinue PRN Ativan on 11/13/19 after surveyor questioned the order. Interview with the DON on 11/14/19 at 9:34 A.M. verified the physician did not address the pharmacy recommendations in regards to the PRN She stated she requested the physician to discontinue the PRN Ativan today after the surveyor brought it to her attention. Review of policy entitled Medication Regimen Review Policy dated 11/09/17 revealed it was the policy of the facility the medication regimen review of each resident will be reviewed by the Pharmacist according to the Federal and State guidelines as well as standards of practice. A written report for all of the irregularities and recommendations will be submitted to the facility for the attending physician. The policy further revealed if the attending physician failed to address a recommendation the DON should be contacted and the DON and Medical Director shall review the incomplete recommendation with the attending physician.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based 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. Findings include: 1. Observation of house 9336 on 11/12/19 at 9:35 A.M. revealed there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen. Interview with State Tested Nurse Aide (STNA) #81 at the time of the observation verified there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen of house 9336. 2. Observation of house 9350 on 11/12/19 at 9:48 A.M. revealed the following: there was one expired bag of hot dog buns dated 10/24/19, one expired loaf of honey wheat bread dated 11/10/19 and a expired half a loaf of honey wheat bread dated 11/10/19 located in the drawer in the kitchen. Continued observation revealed there was one unlabeled and undated sandwich bag with one frozen donut and one unlabeled and undated sandwich bag with two frozen donuts. Interview with STNA #21 at the time of the observation verified there was one bag of expired hot dog buns dated 10/24/19, one expired loaf of honey wheat bread dated 11/10/19 and a expired half a loaf of honey wheat bread dated 11/10/19 located in the drawer in the kitchen. STNA #21 also confirmed there was one unlabeled and undated sandwich bag with one frozen donut and one unlabeled and undated sandwich bag with two frozen donuts. Observation of STNA #21 on 11/13/19 at 12:04 P.M. revealed STNA #21 was taking the temperature of food items. STNA #21 was observed to take the temperature of the poppyseed chicken casserole and then ran the thermometer probe under water for appropriately 2 seconds before wiping the thermometer probe with a paper towel and then taking the temperature of the buttered noodles. Interview with STNA #21 on 11/13/19 at 12:04 P.M. verified STNA #21 ran the thermometer probe under water and wiped it with a paper towel before taking the temperature of the buttered noodles. STNA #21 also confirmed the facility provided thermometer probe wipes with alcohol but she did not use one. 3. Observation of House #9335 on 11/12/19 at 9:40 A.M. revealed there was a gallon of two percent milk dated 11/11/19, a whole apple pie expiration date of 11/09/19, opened package of jumbo hot dogs with a hand written date of 10/23/19, a 16 ounce package of sliced ham opened and dated 11/06/19, and a 16 ounce package of oven roasted turkey breast opened and dated 10/23/19. Interview with STNA #77 on 11/12/19 at 9:50 A.M. revealed the food was dated when it came into the facility, but STNA #77 didn't know how long it was good for and when to throw it away. She verified food that had a expiration date on it should have been thrown away. 4. Observation of House #9349 or 500 on 11/12/19 at 9:55 A.M. revealed there were two 22 ounce strawberry ice cream syrup that had been opened and was not dated when opened, a 15 ounce chocolate ice cream syrup was opened and not dated, a 16 ounce bottle of ranch dressing opened and not dated, head of lettuce that was opened and not dated, bag of romaine lettuce opened and not dated, a 16 ounce package of cheddar cheese opened and not dated, a 10 ounce container of fresh spinach not opened but with an expiration date of 11/09/19, green pepper not dated and opened, 12 halves of hot dogs that had been chargrilled and not dated, powdered donuts expired 11/07/19, assorted Danish with an expiration date of 11/10/19, and assorted cupcakes with an expiration date of 11/09/19. Interview with STNA #14 on 11/12/19 at 11:26 A.M. revealed anything in the kitchen that didn't have a date on it should be thrown out. She said the food in the kitchen should be dated the day it was bought, but didn't know how long it should be kept and when it should be discarded. Further observation of tray line on 11/12/19 at 11:51 A.M. revealed STNA #14 took temperature of asparagus and it was 120 degrees. She proceeded to take the temperature of the macaroni and beef that was taken from the oven and it was 159 degrees. The observation further revealed the pureed macaroni and beef had been sitting on the counter since 11:18 A.M. Interview with STNA #14 on 11/12/19 at 12:00 P.M. revealed the asparagus was supposed to 120 degrees and at a safe temperature to serve was supposed to 100-120. She proceeded to take the pureed macaroni and beef and place a scoop of the hot macaroni and beef and was going to serve it that way and the surveyor intervened and asked if she was going to microwave the item to get to a safe temperature, she said her practice was not to do it this way, but that could be wrong. She proceeded to place in the microwave and the temperature was 140 degrees. She said the safe temperature should be from 130-140 degrees. Review of the food thermometer policy dated 05/2013 revealed the thermometer should be sanitized before and between each food item using an alcohol swab to sanitize the stem as well as the holding clip. Review of policy entitled Food Storage Policy and Procedures dated 05/01/13 revealed prepared food shall be covered and dated with the month and day it was prepared. The label should also indicated the use by date which is 4-7 days after food was prepared. shelf stable items that have been opened need to be dated with month and day. Review of policy for entitled Food Temperatures-Hot and Cold Policy and Procedures dated 05/01/13 revealed holding hot food should be kept at a temperature of 135 degrees. Reheating foods that have been cooked and then refrigerated shall be heated to a temperature of 165 degrees and remain at that temperature before serving.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based 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. Findings include: 1. Review of STNA #15's personnel file revealed a hire date of 07/11/12. Further review of the personnel file revealed STNA #15 only received 4.25 hours of in services from 07/11/18 to 07/11/19. 2. Review of STNA #35's personnel file revealed a hire date of 12/06/17. Further review of the personnel file revealed STNA #35 only received one hour of in services from 12/06/17 to 12/06/18. 3. Review of STNA #66's personnel file revealed a hire date of 08/20/15. Further review of the personnel file revealed STNA #66 received no in services from 08/05/18 to 08/05/19. 4. Review of STNA #69's personnel file revealed a hire date of 04/26/11. Further review of the personnel file revealed STNA #69 received no in services from 04/26/18 to 04/26/19. 5. Review of STNA #76's personnel file revealed a hire date of 12/29/15. Further review of the personnel file revealed STNA #76 only received 1.25 hours of in services from 12/26/17 to 12/26/18. Interview with Business Office Manager #37 on 11/14/19 at 10:37 A.M. verified the above STNAs did not receive 12 hours of annual in services.

Sept 2018 16 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of Resident Rights the facility failed to ensure residents were treated with respect and dignity. This affected one Resident (#18) of 16 reviewed. The census was 43. Findings include: Medical record review for Resident #18 revealed an admission date of 07/09/18. Medical diagnoses included dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was cognitively impaired. She was an extensive assistance for bed mobility, transfers and toilet use and supervision for eating. Observation on 09/24/18 at 12:24 P.M., during lunch, revealed Resident #18 had two rings in her hands, which she had taken off of her fingers. She repeatedly asked for someone to take the rings from her. The resident would not eat her lunch as she was messing with her rings. Elder Assistant (EA) #193 told the resident several times he could not take her rings. Resident #10 spoke up in the course of the conversation and asked EA #193 if he could you take the rings from Resident #16 and give them to the Administrator. EA 3193 stated he could not take the rings from Resident #16. At 12:34 P.M., EA #112 came from behind the kitchen and took the rings from the resident and put them in the resident's room. An interview was conducted on 09/25/18 at 2:06 P.M. with EA #193, he revealed he was scared to take the rings, because they were valuable. He stated the policy was to call the Administrator or the nurse. An interview was conducted on 09/26/18 at 1:37 P.M. with the Director of Nursing (DON) who stated EA #193 did have the capability to take the rings and give them to the nurse so she could put them in a locked cupboard in the resident's room. Review of Resident Rights revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident' individuality. The facility must protect the rights of the residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, observation, staff interview and policy review the facility failed to ensure residents information was kept private. This affected one Resident (#41) of five residents reviewed during medication administration. The census was 43. Findings include: Medical record review for Resident #41 revealed an admission date of 03/16/17. Medical diagnoses included dementia and Parkinson's. Observation of medication administration on 09/26/18 at 8:11 A.M. revealed Registered Nurse (RN) #184 took the package of medications for Resident #41 and removed the top portion of the package, which had the resident's name listed, and threw it in the trash on the side of her cart. Interview with RN #184 on 09/26/18 at 8:15 A.M. revealed her practice was to tear off the top portion of the medication packages and put it in the trash. She stated in her pharmacy training she was taught as long as she separated the name from the package of medication it would be fine. She stated the bag of trash then goes into the big trash can after the end of her shift. She stated the portion of the package that contained the names of the residents were not shredded for privacy. Review of policy entitled Health Insurance Portability and Accountability Act (HIPPA) Compliance revised 07/20/11 revealed it is the policy of the facility to comply with the HIPPA of 1996 or specially the Administrative Simplification section of the act.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents, and/or the residents representative was provided a notice of transfer discharge. The facility also failed to notify the ombudsman when the resident was sent out to the hospital. This affected one Resident (#22) of eighteen reviewed for hospitalization. The census was 43. Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and a Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of progress notes dated 07/31/18 revealed Resident #22 was sent out to the hospital for high blood sugar. Further review of the notes revealed resident returned to the facility on [DATE]. There was no evidence the resident and/or the resident representative was discharge, transfer notice or that the Ombudsmen was notified. An interview was conducted on 09/26/18 at 2:08 P.M. with the Administrator verified there wasn't a discharge, transfer notice given to the resident and/or resident representative. The Administrator verified the Ombudsman was not notified.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to ensure residents were provided a bed hold policy when they were sent out to the hospital. This affected one Resident (#22) of eighteen reviewed for hospitalization. The census was 43. Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and supervision for eating. Review of progress notes dated 07/31/18 revealed Resident #22 was sent out to the hospital for high blood sugar. Further review of the notes revealed resident returned to the facility on [DATE]. An interview was conducted on 09/26/18 at 2:08 P.M., the Administrator verified a bed hold policy was not given to the resident. Review of the policy entitled Bed Hold Policy dated 11/13/17 revealed all residents and representative are notified of the bed hold policy on admission and prior to any transfer at the time of transfer. If the transfer is emergent, the resident and representative must be notified within 24 hours. The bed hold policy applies to all residents regardless of payment source.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview the facility failed to ensure a care plan was followed regarding teeth brushing. This affected one Resident (#18) of sixteen reviewed for dental. The census was 43. Findings include: Medical record review for Resident #18 revealed an admission date of 07/09/18. Medical diagnoses included dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was cognitively impaired. She was an extensive assistance for bed mobility, transfers, and toilet use and supervision for eating. She was coded for natural teeth. Review of the care plan for Resident #18 revealed oral care routine was to brush teeth in A.M., after meals, and at bedtime. Observation conducted on 09/24/18 at 1:53 P.M. of Resident #18 revealed her bottom teeth had yellow slimy matter on them. Subsequent observation on 09/26/18 at 11:17 A.M. revealed the resident had yellow slimy matter on the bottom teeth. An interview conducted with Elder Assistant #128 on 09/26/18 at 11:32 A.M. revealed the resident's teeth were only brushed once a day, in the A.M.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to insure a meaningful care conference was provided for residents. This affected one Resident (#10) of 16 reviewed for care conferences. The census was 43. Findings include: Medical record review for Resident #10 revealed she was admitted on [DATE]. Her medical diagnoses included peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Review of the care conference dated 04/30/18 revealed the resident or the Power of Attorney (POA) was not in attendance and the only one in attendance was Social Worker (SW) #154. It was documented in the note Resident #10 didn't have any concerns and to continue with the plan of care. It was also documented the resident wasn't available. It was checkmarked the plan of care was not reviewed. Review of care conference dated 01/24/18 revealed Resident #10 and POA were not in attendance and the only one in attendance was SW #154. Review of care conference dated 07/27/18 revealed the resident or the POA were not present for the conference and the only one in attendance was SW #154. Further in the note revealed the resident was asked of any concerns and there were no concerns at the time. The care plan and advanced directives were reviewed with no changes. It was checkmarked in this care conference the resident declined conversation. Interview with Resident #10 on 09/25/18 at 8:37 A.M. revealed she had not had a care conference since she had been admitted into the facility. She stated her daughter told her she was able to speak for herself and to ask for a care conference. She stated someone comes into her room and asks how she is doing, but doesn't inquire about anything else. Interview with SW #154 on 09/26/18 at 11:00 A.M. revealed she was the only one in the care conferences and she did not have anyone from the interdisciplinary team (IDT) at the conferences. She said normally the Director of Nursing would attend. She also stated a nurse could attend if the resident requested one to be in attendance. Interview with MDS Registered Nurse #116 on 09/26/18 at 1:40 P.M. revealed the IDT was involved with the care planning, but not all of the staff attended the care conference unless the resident requested the members. Review of policy entitled Comprehensive Care Planning Procedure dated 11/13/17 revealed the Care conference is held to discuss the current care plan, any quarterly updates and any significant changes in resident status. During the conference the IDT obtains input of the residents and/or the resident representative. Residents are encouraged to identify, express, and develop the potential they possess.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, family interview and staff interview the facility failed to provide ear care to a resident as ordered. This affected one Resident (#11) of one resident reviewed for hearing. The facility census was 43. Findings include: Review of Resident #11's medical record revealed an admission date of 10/09/15 with diagnoses that included atherosclerotic heart disease, anxiety disorder, insomnia, major depressive disorder and muscle weakness. Resident #11's brief interview for mental status (BIMS) score on 07/03/18 was rated a two, severe cognitive impairment. Further review of Resident #11's medical record revealed a physician order dated 01/23/18 to irrigate ears twice daily with half strength peroxide 1.5 %, then remove wax every Sunday evening. Review of Resident #11 treatment administration records (TARs) for 08/2018 and 09/2018 revealed ear wax removal was not documented as being completed on the following Sundays: 08/26/18, 09/09/18, 09/16/18 or 09/23/18. Further review of these TARs revealed there was no documentation of Resident #11's ears being irrigated with peroxide twice daily. Review of an audiologist appointment note dated 08/20/18 revealed a large white double dome (hearing aid ear piece) was found in Resident #11's left ear canal and was removed. A family member of Resident #11 stated in an interview on 09/25/18 at 9:20 A.M. that Resident #11 was supposed to be getting his ears flushed at the facility. This family member also stated a part of Resident #11's hearing aide was found in his hear at a recent audiologist appointment. Resident #11's family member was concerned Resident #11's ears were not being flushed and cleaned as ordered. The Director of Nursing (DON) confirmed during an interview on 09/27/18 at 10:40 A.M. that there was no documentation of Resident #11's ears being irrigated twice daily and that ear wax removal was not documented on 08/26/18, 09/09/18, 09/16/18 or 09/23/18.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview and policy review the facility failed to ensure a gait belt was used during a transfer. This affected one (#20) of three residents reviewed for accidents. The census was 43. Findings include: Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Observation on 09/24/18 at 12:16 P.M. revealed Resident #20 was sitting in a chair in the common area. Elder Aide (EA) #193 took the hands of the resident and pulled her out of the chair up to touch her walker, without using a gait belt. Interview on 09/24/18 at 12:36 P.M. with EA #193 verified he should have used a gait belt to get Resident #20 out of the chair, but stated he forgot. Review of policy entitled Use of Gait Belt dated October 2013 revealed the gait belt will be used by the EA and or nurse during every transfer or during ambulation of an elder that required assistance.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview and policy review the facility failed to ensure a resident was medicated for pain prior to a dressing change. This affected one (#22) of three residents reviewed for pressure/arterial ulcers. The census was 43. Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of physician orders dated 01/16/18 revealed Tramadol 50 milligram (mg) tablet give one every eight hours as needed for pain and also Tramadol 50 mg tablet give two every eight hours as needed for pain. Review of the care plan for pain dated 01/25/18 revealed to administer analgesia as per orders, give 1/2 hour before treatments or care and anticipate needs for pain relief and respond immediately to any complaint of pain. Review of medication administration record (MAR) from 09/01/18 through 09/27/18 revealed no evidence of pain medication being administered to Resident #22. Observation on 09/27/18 at 12:05 P.M. of a dressing change to the right heel of Resident #22 with Licensed Practical Nurse (LPN) #122 revealed when LPN #122 removed the sock from the resident's foot she said you are already hurting me. At this time, LPN #122 did not offer pain medication to Resident. #22. LPN #122 continued with the treatment and removed the Kerlix from the foot and the bandage from the wound. Resident #22 was observed to flinch. LPN #122 cleansed the wound and the resident winched when he touched the wound. As LPN #122 placed the ointment and the abdominal pad on the wound, Resident #22 flinched and said Ow. At the time of the observation, LPN #122 stated he had not medicated the resident right before the treatment but had medicated her earlier in the day with Tylenol. Further observation on 09/27/18 at 12:11 P.M. of the left heel wound dressing change of Resident #22 with LPN #122 revealed she moaned when the aide, who was assisting, lifted her leg. Resident #22 said it hurts, but I don't give into the pain. LPN #122 cleansed the wound and touched her heel. The resident said, ouch. LPN #122 placed the ointment on the residents heel and when he placed the Kerlix around her foot, she said ouch. Interview with LPN #122 on 09/27/18 at 12:20 P.M. verified he should have given the resident pain medication prior to the dressing change. At the time of the interview the MAR was reviewed with LPN #122, and he verified he did not give Resident #22 any Tylenol that morning. Review of policy entitled Pain Management dated September 2007 revealed to identify, significantly reduce, and/or abolish pain, resulting in an improved quality of life.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, resident interview and staff interview the facility failed to assess a resident's fistula. This affected one Resident (#26) of one resident reviewed for dialysis care. The facility census was 43. Findings include: Review of Resident #26's medical record revealed an admission date of 07/24/18 with diagnoses that included hypertension, end stage renal disease, anxiety disorder and muscle weakness. Resident #26's brief interview for mental status (BIMS) score on 08/07/18 was 13, cognitively intact. Review of Resident #26's physician orders revealed an order dated 08/25/18 to check for thrill over arteriovenous (AV) fistula every shift. Review of Resident #26's treat administration record (TAR) revealed there was no documentation of her AV fistula being checked for thrill on 09/01/18 second or third shift, 09/02/18 second or third shift, 09/04/18 third shift, 09/05/18 third shift, 09/06/18 all shifts, 09/07/18 first and second shift, 09/09/18 all shifts, 09/11/18 third shift, 09/12/18 second shift, 09/13/18 third shift, 09/14/18 all shifts, 09/15/18 third shift, 09/16/18 all shifts, 09/17/18 second shift, 09/18/18 third shift, 09/19/18 third shift, 09/20/18 third shift, 09/21/18 second shift, 09/22/18 third shift, 09/23/18 all shifts and 09/26/18 second shift. During an interview on 09/24/18 at 10:22 A.M. Resident #26 stated that facility staff did not assess her fistula. During an interview on 09/27/18 at 7:43 A.M. registered nurse (RN) #184 stated she had not yet checked Resident #26's AV fistula for the first shift. RN #184 confirmed that she had already documented checking for thrill on Resident #26's electronic TAR for 09/27/18 first shift. RN #184 was unable to define what a thrill was when asked by surveyor. The Director of Nursing (DON) confirmed during an interview on 09/27/18 at 10:30 A.M. that there was no documentation of staff checking for thrill over Resident #26's AV fistula for the above dates in September 2018.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, observation, staff interview and review of the facility's Medication Administration policy the facility failed to properly secure a resident's medications. This affected one Resident (#16) observed in the 9350 C cottage of the facility. No residents in the 9350 C cottage were identified as being cognitively impaired and independently mobile. The facility census was 43. Findings include: Review of Resident #16's medical record revealed an admission date of 09/01/17 with diagnoses that include atrial fibrillation, constipation, anxiety disorder, hypertension and generalized edema. Resident #16 was identified as being cognitively intact. During the initial tour of the facility cottage 9350 C on 09/24/18 at 9:18 A.M. medications were observed in a medication cup beside Resident #16 while she was eating breakfast in the dining area. There was no nurse in close proximity to Resident #16. At the time of the observation the Director of Nursing (DON) confirmed Resident #16's medications were in a medication cup beside her at he dining room table and that a nurse was not in close proximity to Resident #16. The DON confirmed medications should not be left with residents to take without a nurse present. Registered nurse (RN) #184 during an interview on 09/24/18 at 9:20 A.M. stated she left the medications with Resident #16 and did not observe her take the medications. RN #184 presented a list of medications that were left with Resident #16. Review of the facility's Medication Administration Policy revealed medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, staff interview and review of the facility's Dishwashing policy, the facility failed to prevent possible contamination of sanitized dishes. This had the potential to affect all eight Residents (#3, #5, #11, #17, #27, #35, #39 and #41) who reside in cottage 9336 B of the facility. The facility census was 43. Findings include: During an observation of lunch service in cottage 9336 B on 09/24/18 at 12:03 P.M. , Elder Assist (EA) #152 was observed washing dishes. At 12:07 P.M., EA #152 removed plates from a drying rack, picked a towel up from the top of the counter, wiped the plates dry and put them away in a cabinet. At 12:30 P.M. , EA #152 removed plates and coffee pots from a rack from the dishwasher/sanitizer and placed the rack on the counter. EA #152 took the plates and coffee pots from the rack and wiped them dry with a towel she had pulled from a cabinet drawer. EA #152 then put the plates in a cabinet and put the coffee pots back in the coffee makers. EA #152 confirmed during an interview on 09/24/18 at 1:04 P.M., she had wiped the plates and coffee pots dry with a towel before putting them away. Review of the facility's Dishwashing Policy revealed that upon completion of the dishwashing cycle, open the door and allow dishes to air dry.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview the facility failed to document medication administrations and monitor medication side effects for residents. This affected three Residents (##20, #22 and #35) of five reviewed for unnecessary medications. The facility census was 43. Findings include: 1. Review of Resident #35's medical records revealed an admission date of 02/27/10 with diagnoses that include dementia, psychosis, atrial fibrillation, hypertension, anorexia nervosa and major depressive disorder. Resident #35's brief interview for mental status (BIMS) score on 08/29/18 was 9, moderate cognitive impairment. Further review revealed a physician order (PO) for Percocet (narcotic pain medication) 5/325 milligrams (mg) every six hours by mouth for pain. Review of Resident #35's 09/2018 medication administration record (MAR) revealed Percocet was not documented as being administered on the following dates and times. 09/06/18 at 6:00 A.M., 09/08/18 at midnight and 6:00 A.M., 09/10/18 at 6:00 A.M., 09/14/18 at midnight and 6:00 A.M., 09/15/18 at 6:00 A.M., 09/16/18 at midnight and 6:00 A.M., 09/17/18 at midnight and 6:00 A.M., 09/20/18 at midnight and 6:00 A.M., and 09/24/18 at 6:00 A.M. A physician order dated 02/28/18 was to observe for anticoagulation medication side effects such as discolored urine, black tarry stools, sudden severe headache, etc. Staff wee to document Y if side effects noted and N if no side effects were noted. Resident #35 was currently taking Xarelto (anticoagulant) 20 mg by mouth daily. Further review of Resident #35's MAR for 09/2018 revealed there was no documentation of anticoagulation medication side effect being monitored on the following dates and times. 09/01/18 at 2:00 P.M., 09/02/18 at 2:00 P.M., 09/04/18 at 2:00 P.M. and 11:00 P.M., 09/05/18 at 2:00 P.M. and 11:00 P.M., 09/06/18 at 2:00 P.M. and 11:00 P.M., 09/07/18 at 2:00 P.M. and 11:00 P.M., 09/11/18 at 11:00 P.M., 09/13/18 at 11:00 P.M., 09/14/18 at 11:00 P.M., 09/15/18 at 11:00 P.M., 09/16/18 at 2:00 P.M. and 11:00 P.M. , 09/18/18 at 11:00 P.M., 09/19/18 at 11:00 P.M., 09/20/18 at 11:00 P.M., 09/21/18 at 2:00 P.M., 09/23/18 at 11:00 P.M. Review of progress notes for 09/2018 revealed no explanation for the missing documentation. During an interview on 09/27/18 at 11:45 A.M., the Director of Nursing (DON) confirmed there was missing documentation for the administration of Percocet and for anticoagulation side effects during 09/2018. 2. Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of quarterly Minimum Data Set (MDS)dated 07/25/18 revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of care plan dated 01/25/18 revealed the focus of diabetes and interventions were to check blood sugars and provide medication for diabetes as ordered by the physician. Review of PO dated 06/05/18 revealed Novolog Sliding Scale to inject as per sliding scale subcutaneously before meals and at bedtime, PO dated 08/03/18 revealed Novolog, inject eight units subcutaneously before meals PO dated 08/08/18 revealed Lantus to inject 36 units subcutaneously one time a day at 9:00 P.M. Review of MAR from 09/01/18 through 09/27/18 revealed there was missing documentation for Lantus on 09/08/18, 09/12/18, 09/14/18, and 09/16/18. There was missing documentation for Novolog eight units on 09/08/18 and 09/12/18 for the 5:00 P.M. dose. Further review of the MAR for Novolog sliding scale revealed missing documentation on 09/08/18 and 09/12/18 for the blood sugar and administration of the insulin for the 5:00 P.M. and 9:00 P.M. dose and on 09/16/18 there was missing blood sugar and insulin administration. Review of progress notes from 09/01/18 through 09/27/18 revealed they were absent for an explanation as to why there was missing documentation for the Lantus and Novolog. Interview with the DON on 09/27/18 at 2:44 P.M. revealed she did not know why the Lantus and Novolog were not given and why the blood sugars weren't taken. 3. Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly MDS dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Review of care plan for Resident #20 revealed hypertension and the intervention was to administer medications as ordered and obtain the blood pressure as directed. Review of PO dated 04/13/18 for Resident #20 revealed Lisinopril 40 mg take one tablet daily. Review of blood pressures for Resident #20 revealed there was one on 04/13/18 on admission which was 197/114. Review of progress notes for 04/13/18 for Resident #20 revealed no followup for the high blood pressure. There wasn't another blood pressure recorded until 09/12/18. Interview with the DON on 09/27/18 at 2:40 P.M. verified the high blood pressure should been monitored.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview the facility failed to monitor psychoactive medication side effects and monitor behaviors. This affected three Residents (#20, #22 and #35) of five reviewed for unnecessary medications. The facility census was 43. Findings include: 1. Review of Resident #35's medical records revealed an admission date of 02/27/10 with diagnoses that included dementia, psychosis, atrial fibrillation, hypertension, anorexia nervosa and major depressive disorder. Resident #35's brief interview for mental status (BIMS) score on 08/29/18 was 9, moderate cognitive impairment. Review of physician orders (PO) revealed Resident #35 was ordered Olanzepine (antipsychotic) 2.5 milligrams (mg) two times daily and Remeron (antidepressant) 15 mg daily. Further review of PO revealed orders dated 02/28/18 to monitor for side effects of antidepressant and antipsychotic medication every shift. An order dated 02/28/18 was to monitor for behaviors such as itching, hitting, increase in complaints, biting, etc. every shift. Review of Resident #35's medication administration record (MAR) from 09/01/18 through 09/26/18 revealed that antidepressant medication side effects were not monitored 19 out of 78 opportunities and that antipsychotic medication side effects were not monitored 19 out of 78 opportunities. Behaviors were not monitored 19 out of 79 opportunities. During an interview on 09/27/18 at 11:45 A.M., the Director of Nursing (DON) confirmed there was missing documentation of antidepressant and antipsychotic side effects and behavior monitoring for Resident #35. 2. Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly MDS dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Review of care plan dated 04/18/18 for Resident #20 revealed potential for drug complications for Seroquel with interventions to monitor/document/report as needed any adverse reactions to antipsychotic medications. Review of PO dated 05/08/18 for Resident #20 revealed Ativan 0.5 mg give 1 tablet every six hours as needed for anxiety. This Ativan was discontinued on 07/30/18. Further review of PO revealed the resident was prescribed Seroquel (antipsychotic) 25 mg every morning, 40 mg every evening and 100 mg at bed time for mood stabilization and psychosis. Review of MAR from 05/01/18 through 05/31/18 revealed Resident #20 received the Ativan on 05/16/18, 05/19/18, 05/20/18, 05/21/18, 05/22/18, and 05/28 18. Further review of MAR from 09/01/18 through 09/27/18 revealed there wasn't any behavioral monitoring. Review of physician notes for Resident #20 from 05/25/18 through 07/19/18 revealed they were silent to a rationale why the physician kept the Ativan on the order. Interview with the DON on 09/27/18 at 2:40 P.M. verified the physician did not show a rationale as to why the as needed Ativan was continued. She also verified there should have been behavioral monitoring for use of Seroquel. 3. Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of quarterly MDS dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of PO for Resident #22 dated 01/16/18 revealed Zoloft 50 mg, give one every day related to major depressive disorder. Review of care plan for Resident #20 dated 01/25/18 revealed for potential for drug related complications related to antidepressant medication. Interventions were to monitor/report as needed adverse reactions to antidepressant. Review of MAR for Resident #20 from 09/01/18 through 09/27/18 revealed behaviors were not monitored on 23 out of 79 opportunities. Interview with the DON on 09/27/18 at 2:40 P.M. verified there was missing documentation for monitoring behaviors for Resident #22.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on review of the facility's Quality Assessment and Assurance (QAA) meeting sign-in logs and staff interview the facility failed to have the required QAA committee meetings and have the required QAA members. This had the ability to affect all the residents of the facility. The facility census was 43. Findings include: Review of QAA committee sign-in logs revealed on 01/25/18 four staff members where in attendance (Administrator, Medical Director and the Director of Nursing (DON)). On a QAA committee sign-in log dated 04/27/18 three staff members (Administrator, Medical Director and DON) and two outside service providers had signed in. On a QAA committee sign-in log dated 07/25/18 three staff members (Administrator, Medical Director and DON) had signed in. The facility was unable to provide a QAA committee sign-in log for the third quarter of 2017. The Director of Nursing (DON) stated in an interview on 09/26/18 at 9:52 A.M. the QAA committee had three members, the Administrator, herself (DON) and the medical director. The DON stated they would invite other providers to attend. The Administrator confirmed in an interview on 09/27/18 at 3:10 P.M., the QAA committee did not comprise of five total staff members. The Administrator confirmed there was no documentation of sign-in logs for a QAA committee meeting held the third quarter of 2017.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on review of the facility's Water Management Program for Legionella Risk Reduction, review of water temperature logs and staff interview the facility failed to have a Legionella plan in place. This had the ability to effect all of the residents of the facility. The facility census was 43. Findings include: Review of the facility's Water Management Program for Legionella Risk Reduction dated 06/28/18 revealed that control measures for hot water was to set hot water tank to 122 degrees Fahrenheit (F) and circulate water at 120 F. Hot water system temperatures were to be monitored and recorded weekly. Cold water was be monitored at set locations weekly. Temperatures for cold water should be below 70 F. All water exit points are to be flushed for three minutes on a monthly basis. Review of water temperature logs dated 06/15/18 through 09/19/18 revealed that there was no documentation of hot water tank monitoring and that cold water temperatures recorded exceeded 70 F. There was no documentation of water exit points being flushed. Maintenance Director (MD) #149 stated in an interview on 09/26/18 at 1:40 P.M. that he did not have any documentation of any water temperature monitoring for Legionella before he started working at the facility. MD #149 stated he started at the facility in May 2018. MD #149 started he started checking water temperatures and flushing exit points in June 2018. MD #149 stated the facility had recently requested quotes from water management companies for facility water assessments. MD #149 confirmed there was no documentation of hot water tank temperatures, water exit flushing and that cold water temperatures were recorded above 70 F. During an interview the Administrator on 09/27/18 at 12:45 P.M. confirmed the Water Management Program for Legionella Risk Reduction was dated 06/28/18. The Administrator was unable to provide a policy in place before 06/28/18 and stated she though it was put in place after the last annual survey. The Administrator stated that quotes for a facility water assessment had been requested from water management companies.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Grade B+ (80/100). Above average facility, better than most options in Ohio.
• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Ohio facilities.
• 42% turnover. Below Ohio's 48% average. Good staff retention means consistent care.

Concerns

• 31 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

Email me this report

About This Facility

What is Otterbein Springboro's CMS Rating?

CMS assigns OTTERBEIN SPRINGBORO an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Otterbein Springboro Staffed?

CMS rates OTTERBEIN SPRINGBORO's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 42%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Otterbein Springboro?

State health inspectors documented 31 deficiencies at OTTERBEIN SPRINGBORO during 2018 to 2022. These included: 31 with potential for harm.

Who Owns and Operates Otterbein Springboro?

OTTERBEIN SPRINGBORO is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by OTTERBEIN SENIORLIFE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 55 residents (about 92% occupancy), it is a smaller facility located in CENTERVILLE, Ohio.

How Does Otterbein Springboro Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, OTTERBEIN SPRINGBORO's overall rating (5 stars) is above the state average of 3.2, staff turnover (42%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Otterbein Springboro?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Otterbein Springboro Safe?

Based on CMS inspection data, OTTERBEIN SPRINGBORO has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Otterbein Springboro Stick Around?

OTTERBEIN SPRINGBORO has a staff turnover rate of 42%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Otterbein Springboro Ever Fined?

OTTERBEIN SPRINGBORO has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Otterbein Springboro on Any Federal Watch List?

OTTERBEIN SPRINGBORO is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 60
Avg. Residents: 55
Occupancy: 92.7%
Ownership: Non profit - Other
Chain: OTTERBEIN SENIORLIFE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
5-Star Rating: +40
31 Deficiencies: -10
Final Score: 80/100

Nearby Alternatives

MCV HEALTH CARE FACILITIES, IN... 5-star OHIO LIVING QUAKER HEIGHTS 5-star OTTERBEIN MIDDLETOWN 5-star

View all in CENTERVILLE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 366368