Inspection·December 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, medical record review, staff interview, manufacturer representative interview, and review of a manufacturer's handbook, the facility failed to ensure a MaxiSky Lift (a ceiling mounted lift that was utilized to transfer and reposition residents) was maintained in safe working condition prior to completing a resident transfer. This affected one (#21) of five residents identified by the facility to use a MaxiSky Lift. The facility census was 54. Findings Include:Review of the medical record for Resident #21 revealed an admission date of 09/25/25 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dysphagia following a cerebral infarction, dysarthria following a cerebral infarction, urinary tract infection, type two diabetes mellitus, chronic bronchitis, left bundle branch block, syncope and collapse, class three obesity, hypertensive heart disease with heart failure, congestive heart failure, atherosclerotic heart disease, lumbar radiculopathy, diarrhea, angina pectoris, vitamin D deficiency, anxiety, chronic pain, dry eye syndrome, osteoarthritis, dorsalgia, palpitations, shortness of breath, heartburn, transient ischemic attack, hypercholesterolemia, weakness, and insomnia.Review of Resident #21's admission Minimum Data Set (MDS) assessment, dated 10/06/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #21's cognition was intact. Further review of the MDS assessment indicated Resident #21 required substantial/maximum assistance or was dependent in all functional abilities including, but not limited to, eating, hygiene, dressing, and toileting. Observation on 12/09/25 at 1:38 P.M. of Certified Nurse Aide (CNA) #110 and CNA #203 providing incontinence care to Resident #21 revealed the safety latch on the MaxiSky Lift being used to transfer Resident #21 was broken on one side. Interview on 12/09/25 at 1:38 P.M. with CNA #110 and CNA #203 verified the safety latch on the MaxiSky Lift used to transfer Resident #21 was broken. CNA #110 and CNA #203 were unsure exactly how long the safety latch on the MaxiSky Lift had been broken, but they were both aware of it being broken. Review of the MaxiSky instructions for use, dated 03/2022, revealed all rails must be closed with end stoppers or connected to other closed rail components. Before use, make sure all end stoppers are in place and secured. A wrong installation of these items might lead to a patient fall and to injuries. Do not attempt to transfer a patient if the safety latches are not blocking the support's opening for the strap. Further review revealed the lift must be inspected for missing hardware or broken enclosure initially, before every use, and every year. Inspect the lift for any damage, and if there is any damage on the lift, or there are parts missing, DO NOT USE IT. Interview on 12/10/25 at 11:27 A.M. with Sales Representative #201 revealed the safety latch was a secondary safety feature put in place to ensure a patient does not fall when being transferred utilizing the MaxiSky Lift. This deficiency represents and incidental finding discovered during the complaint investigations. 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 2 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 12/11/2025 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)