Health 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. Page 1 of 2 366361 366361 12/11/2025 Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications as ordered by the physician, resulting in a significant medication error. This affected one (#7) of three residents reviewed for medication administration. The facility census was 54.Findings Include: Review of the medical record for Resident #7 revealed an admission date of 11/13/25 with diagnoses including end stage renal disease (ESRD), presence of a left artificial knee joint, hyperlipidemia, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis, anemia, renal dialysis, atherosclerotic heart disease, obesity, lumbar spinal stenosis, weakness, chronic kidney disease (CKD), and type two diabetes mellitus.Review of Resident #7's medical record revealed a physician order, dated 11/14/25, for Xphozah, generic name tenapanor (a medication used to treat CKD), 30 milligrams (mg) to be given by mouth one time per day for ESRD. Review of the November 2025 medication administrator record (MAR) for Resident #7 revealed the physician ordered 30 mg dose of Xphozah was not administered on 11/15/25, 11/16/25, 11/18/25, 11/20/25, and 11/22/25.Review of the December 2025 MAR for Resident #7 revealed the physician ordered 30 mg dose of Xphozah was not administered on 12/02/25 and 12/09/29. Interview on 12/11/25 at 12:30 P.M. with the Administrator verified the physician ordered 30 mg dose of Xphozah was not administered to Resident #7 on 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/22/25, 12/02/25, and 12/09. Further interview with the Administrator revealed the medication was not administered on these dates as it was not available in the facility to administer to Resident #7.Review of the facility policy titled, Medication Administration Procedure, dated 11/17/25, revealed medications are administered in accordance with written orders of the attending physician or physician extender. This deficiency represents non-compliance investigated under Complaint Number 2650945. Residents Affected - Few 366361 Page 2 of 2