Inspection visit

Health inspectionJuly 26, 2023

OTTERBEIN MONCLOVACMS #3663616 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the State Tested Nurse Aide job description, and observation, the facility failed to ensure residents were dressed in a dignified manner. This affected one resident (#2) of three residents observed for dignified care and provision of clean clothing. The facility census was 55. Findings include: Review of the medical record for Resident #2 revealed Resident #2 admitted to the facility on [DATE] with the diagnoses including but not limited to cerebral infarction with hemiplegia and hemiparesis affecting right side, type two diabetes mellitus, dysphagia, and major depression. Review of Resident #2's Minimum Data Set assessment, dated 06/30/23, revealed Resident #2 had intact cognition, was dependent on staff for completion of activities of daily living, and required extensive physical assistance of two or more staff with bed mobility, transfer, toileting and dressing. Resident #2 was incontinent of bladder and continent of bowel. Review of Resident #2's Care Plan, dated 06/23/23 and revised on 07/21/23, revealed a nursing plan of care was developed to address Resident #2's cerebral infarction and related right sided hemiplegia. Interventions included assist with care as needed and dress weak side first. The care plan further revealed on 06/23/23 and revised on 07/07/23, a nursing plan of care was revised addressing Resident #2's history of urinary tract infection. Interventions included provide Resident #2 with peri-care as needed. No frequency of incontinence monitoring was documented. In addition a second plan of care was developed on the same dates addressing the residents urinary incontinence. Interventions included change disposable brief frequently and as needed, and clean peri-area with each incontinence episode. Interview with State Tested Nurse Aide #305 on 07/25/23 at 6:32 A.M., revealed she was unable to wash Resident #2's clothes due to there being no detergent available. STNA #305 further stated she worked in the 12 bed home alone during the night and was unable to obtain detergent from another home on the campus. STNA #305 indicated due to additional job duties including resident care, housekeeping, and laundry. The laundry does not get completed at times. Review of the STNA job description, revised November 2016, revealed principle duties and responsibilities included the administration of personal care, activities, and environment including cooking, housekeeping and laundry. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 366361 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Observation on 07/25/23 at 6:35 A.M. revealed Resident #2 up in a wheelchair with brown/yellow stained shorts. The brown/yellow stains were located in the perineal area. STNA #305 stated she dressed the resident in clothing he picked out and saw the stain on the shorts. However, she did not offer to change Resident #2's shorts when she discovered the stain. STNA #305 indicated the stain appeared to be from urinary or bowel incontinence. STNA #305 also stated there was no stain remover available in home. Residents Affected - Few Observation on 07/25/23 at 6:40 A.M. in laundry room revealed Resident #2's laundry hamper was full and sitting in front of the washer. There was no detergent or stain remover identified. Interview on 07/25/23 at 7:11 A.M. with the Director of Nursing verified Resident #2 was dressed in soiled and stained clothing. This deficiency represents non-compliance investigated under Master Complaint Number OH00144903 and Complaint Number OH00144402. This is an example of continued non-compliance from the survey dated 06/01/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview, and review of the State Tested Nurse Aide job description, the facility failed to maintain the facility carpeting in rooms and common areas in a clean and sanitary manner. This affected all 24 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24) who resided in House 5060 and House 5085. The facility census was 55. Findings include: Observation on 07/24/23 at 3:18 P.M. and on 07/25/23 at 6:45 A.M. of Resident #2's room revealed the carpet next to the bed was covered with multiple dark/black stains. The stains covered an area which was approximately six feet by six feet on the carpet. Interview on 07/26/23 at 6:30 A.M. with State Tested Nurse Aide (STNA) #306 and STNA #307 verified the stains to Resident #2's carpets and stated they did not have time to spot clean carpets and stains. The STNA's stated job duties include resident care, cooking meals, washing laundry, and housekeeping six days a week. A housekeeper cleaned all resident rooms and common areas once weekly. Observation on 07/26/23 between 8:15 A.M. and 9:05 A.M. with the Administrator revealed the following; 1. Resident #6's room had multiple black stains next to the bed and dresser. 2. Resident #8's room had scattered debris and stains on the floor next to the bed. Additionally, there was a used surgical glove on the floor in the bathroom. 3. The common area of home 5060 had black stains on the floor in the common area near the television and behind the recliners 4. Resident #16's room had paper debris on the floor next to the bed and recliner. 5. Resident #10's room had large black stains next to the bed as well as debris on the floor. Interview on 07/26/23 at 8:35 A.M. with Resident #10 confirmed the stains on the floor. Resident #10 stated STNA's were supposed to complete housekeeping of the resident rooms. Resident #10 stated STNA's do not clean the rooms daily or clean the carpets. 6. Resident #18's room was noted with small scattered stains on the floor and a six inch by six inch stain next to the bed. 7. The common corridor floor near the cross corridor door outside of Resident #5's room had two large black stains and additional carpet stains near the television area. 8. Resident #3's room had multiple stains on the floor next to the bed and near the chair. 9. Resident #24's room had brown stains on the carpet at the entry to the room as well as multiple dark stains next to the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/26/23 at 8:33 A.M. with Housekeeper #1 revealed the facility had five homes on the campus. Each home is cleaned by a housekeeper once weekly and STNA's are supposed to maintain resident rooms and common areas the other six days a week. Housekeeper #1 stated when she cleans the homes they are noted to have an extreme (large) amount of debris on the floors including carpet stains. Interview on 07/26/23 at 9:10 A.M. with the Administrator confirmed the stained and soiled flooring. The Administrator verified each of the five homes were cleaned by a housekeeper once weekly and the remaining six days, the STNA's were to complete housekeeping services. Review of the STNA job description, revised November 2016, revealed STNA's are responsible for the administration of personal care, activities, and environment including cooking, housekeeping and laundry. This deficiency represents non-compliance investigated under Complaint Number OH00144402. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure off loading boots were applied as ordered to promote healing of a diabetic foot ulcer. This affected one resident (#1) of three residents reviewed for foot care. The facility identified five current residents with wounds. The facility census was 55. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 01/21/22 with diagnoses including but not limited to end stage renal disease, type two diabetes mellitus, cerebral infarction, coronary artery disease, and muscle weakness. Review of Resident #1's Minimum Data Set assessment, dated 05/05/23, revealed Resident #1 had intact cognition, was dependent on staff for activities of daily living, and was at risk for pressure ulcer development with no skin breakdown. Review of Resident #1's nurses notes on 06/06/23 at 11:57 A.M., revealed Resident #1 returned from an outpatient appointment and reported foot pain. An assessment noted Resident #1's right big toe had dried blood near the nail and very dry skin layers on the big toe. A dressing was applied and Resident #1 was encouraged to offload heels when in bed. Review of the physician wound specialist note on 06/07/23 revealed Resident #1's right big toe was assessed and was a diabetic ulcer. The right big toe wound measured one centimeter (cm) long by 1.5 cm wide by 0.1 cm deep. Physician orders included the application of off loading boots. Review of the physician wound specialist assessment and associated orders, dated 07/19/23, revealed the diabetic toe wound measured 0.7 cm long by 1.0 cm wide by 0.1 cm deep. Off-loading boots were continued and surgical excisional debridement was performed with the addition of antibiotic therapy, Cipro 500 milligrams (mg) twice daily for six weeks. Review of the physician order dated 07/21/23 revealed Resident #1 was ordered for off-loading boots to be worn at all times except on dialysis days on Tuesday, Thursday and Saturday, and could wear own footwear. Observation on 07/24/23 (Monday) at 1:04 P.M., 2:05 P.M., 5:50 P.M., 8:15 P.M. revealed Resident #1 was seated at the bedside with shoes applied to both feet and Resident #1's feet were resting on the floor. Heel protectors (off-loading boots) were observed to be sitting in a chair in the corner of the room. Interview on 07/24/23 at 8:15 A.M. with Resident #1 revealed a State Tested Nurse Aide (STNA) put shoes on Resident #1 in order to transfer the resident from the bed to the chair in the morning and did not remove or place off-loading boots on at any time during the day. Interview on 07/24/23 at 8:25 P.M. with STNA #301 revealed there was no information indicating Resident #1 was not to be wearing shoes available to STNA #301. STNA #301 indicated the nurses are to instruct STNA's on resident interventions. Interview on 07/24/23 at 8:42 P.M. with the Director of Nursing verified STNA's were unaware of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure relief interventions for Resident #1 and confirmed Resident #1 wore shoes during the entire day on 07/24/23. Review of Skin Care Management policy, revised 11/17/22, revealed nursing staff were to implement, monitor and modify if needed appropriate strategies to attain or maintain intact skin; prevent complications; promptly identify and manage complications; and involve resident and caregiver in skin care management. This deficiency represents non-compliance investigated under Complaint Number OH00144472. This is an example of continued non-compliance from the survey dated 06/01/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and facility policy review, the facility failed to timely reposition one resident who was at risk for pressure ulcers. This affected one resident (#2) of three residents reviewed for the provision of repositioning assistance and pressure ulcer prevention interventions. The facility identified five current residents with pressure ulcers. The facility census was 55. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/22/23 with diagnoses including but not limited to cerebral infarction with hemiplegia and hemiparesis affecting right side, type two diabetes mellitus, and hypertension Review of Resident #2's Minimum Data Set assessment, dated 06/30/23, revealed Resident #2 had intact cognition, was dependent on staff for completion of activities of daily living, and required extensive physical assistance of two or more staff with bed mobility, transfer, toileting and dressing. Resident #2 utilized a wheelchair for mobility with supervision and was at risk for pressure ulcer development with no skin breakdown. Review of Resident #2's nursing plan of care revealed on 06/23/23, the nursing plan of care was initiated to address Resident #2's actual/potential for skin breakdown related to decreased mobility and moisture associated skin damage to scrotum. Interventions included enhanced barrier precautions, pressure reduction mattress to bed, and turn and reposition frequently and as needed. There was no time frequency indicated for turning and repositioning Resident #2. Review of Resident #2's pressure sore risk assessment, completed on 07/15/23, revealed Resident #2 was at risk for pressure sores. Further review of the scale revealed Resident #2's risk factors included slightly limited sensory perception, skin occasionally moist, chairfast, and friction/shear problem. Observations on 07/24/23 at 4:17 P.M., 5:16 P.M., 5:30 P.M., and 7:05 P.M., revealed Resident #2 was seated in the same position in the wheelchair. Interview on 07/24/23 at 4:43 P.M., with State Tested Nurse Aide (STNA) #300 revealed Resident #2 was provided with incontinence care and repositioning at 11:00 A.M. STNA #300 indicated there had been no attempts made to check on or reposition Resident #2 since 11:00 A.M. Observation on 07/24/23 at 7:05 P.M. revealed STNA #303 assisted Resident #2 with activities of daily living. At 7:12 P.M. Resident #2's skin was observed to be intact. Interview on 07/24/23 at 7:26 P.M. with STNA #303 revealed she reported to the facility and assumed Resident #2's care at 4:30 P.M. STNA #303 indicated no report was provided regarding Resident #2 including when he was last repositioned in the wheelchair. STNA #303 was unable to provide information regarding Resident #2's repositioning schedule or habits. STNA #303 indicated all residents should be checked and repositioned at least every two hours. Review of the Skin Care Management policy, revised 11/17/22, revealed nursing staff were to implement, monitor and modify if needed appropriate strategies to attain or maintain intact skin; prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm complications; promptly identify and manage complications; and involve the resident and caregiver in skin care management. This deficiency represents non-compliance investigated under Complaint Number OH00144472. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on medical record review, staff interview, and observation, the facility failed to ensure incontinence care was provided in a timely manner. This affected one resident (#2) of three residents reviewed for incontinence care. The facility census was 55. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/22/23 with diagnoses including but not limited to cerebral infarction with hemiplegia and hemiparesis affecting right side, type two diabetes mellitus, and benign prostatic hyperplasia. Review of Resident #2's Minimum Data Set assessment, dated 06/30/23, revealed Resident #2 had intact cognition, was dependent on staff for completion of activities of daily living, and required extensive physical assistance of two or more staff with bed mobility, transfer, toileting and dressing. Resident #2 was incontinent of bladder and continent of bowel. Review of Resident #2's nursing plan of care, revealed on 07/07/23 the nursing plan of care was revised to address Resident #2's history of urinary tract infection. Interventions included provide with peri-care as needed. No frequency of incontinence monitoring was documented. In addition, a second plan of care was developed on the same date and addressed Resident #2's urinary incontinence. Interventions included change disposable brief frequently and as needed, and clean peri-area with each incontinence episode. Interview on 07/24/23 at 4:43 P.M. with State Tested Nurse Aide (STNA) #300 revealed Resident #2 was provided incontinence care at 11:00 A.M. however no attempts had been made to check on Resident #2 to see if Resident #2 required incontinence care since 11:00 A.M. Observation on 07/24/23 at 7:05 P.M. revealed STNA #303 went to assist Resident #2 with activities of daily living. At 7:12 P.M., STNA #303 placed Resident #2 in a stand up lift and stood the resident and removed his pants. The observation revealed Resident #2's brief and pants were soaked with urine. The wheelchair cushion was observed to be wet and a strong urine odor was detected. STNA #303 proceeded to place Resident #2 in bed, obtained one wet wash cloth with soap, one wet wash cloth with water and a dry towel. STNA #303 removed the front of Resident #2's brief and cleansed Resident #2's perineal area in a circular motion STNA #303 used the same portion of the wash cloth to cleanse the entire peri area which cross contaminated Resident #2's anterior perineal area with the posterior perineum. Interview on 07/24/23 at 7:26 P.M. with STNA #303 revealed she reported to the facility and assumed care of Resident #2 at 4:30 P.M. STNA #303 revealed no report was provided regarding Resident #2 including when he was last checked for incontinence. STNA #303 was unable to provide information regarding Resident #2's incontinence schedule or habits. STNA #303 confirmed cross contamination of Resident #2's perineal area occurred during incontinence care. STNA #303 revealed residents should be checked at least every two hours. Interview on 07/25/23 at 8:25 P.M. with the Director of Nursing revealed the facility did not have a policy or procedure directing staff on how to perform incontinence care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 This deficiency represents non-compliance investigated under Complaint Number OH00144402. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the menu, observation, and staff interview, the facility failed to ensure meals were served according to the menu. This affected all twelve residents (#2, #6, #7, #8, #10, #12, #13, #14, #15, #16, #17, and #18) who resided in House 5060. The facility census was 55. Findings include: Review of the facility dietitian approved menu revealed the evening meal on 07/24/23 was baked fish, butter noodles, sliced carrots, and a tossed salad. Observation on 07/24/23 at 4:55 P.M. revealed State Tested Nurse Aide (STNA) #300 was preparing and plating the evening meal. The meals included fish, butter noodles, and sliced carrots. At 5:08 P.M., STNA #300 began serving the meal to the residents. The meal did not include a tossed salad. Interview on 07/24/23 at 5:34 P.M. with STNA #300 verified all 12 residents (#2, #6, #7, #8, #10, #12, #13, #14, #15, #16, #17, and #18) in the home had been provided the evening meal and all residents received food by mouth. STNA #300 stated she did not provide any of the residents with a tossed salad due to not having enough salad for all of the residents in the home. Interview on 07/24/23 at 5:37 P.M. with Diet Technician (DT) #1 confirmed the evening meal on 07/24/23 was supposed to include a tossed salad which was not provided. DT #1 also verified no additional food item was provided to replace the nutritional value of the tossed salad. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 11 of 11

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0557GeneralS&S Dpotential for harm
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

FAQ · About this visit

Common questions about this visit

What happened during the July 26, 2023 survey of OTTERBEIN MONCLOVA?

This was a inspection survey of OTTERBEIN MONCLOVA on July 26, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OTTERBEIN MONCLOVA on July 26, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·July 26, 2023