Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, policy review, resident interview, family interview and staff interview,
the facility failed to provide clean and homelike environment. This affected two (#21 and #24) of 10 resident
rooms reviewed for environment. The facility census was 53.
Findings include:
1. Review of Resident #21's medical record revealed an admit date of 02/10/22, with diagnoses including:
multiple sclerosis, gastro esophageal reflux disease, osteoporosis, and bipolar disease. Review of quarterly
Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 with
intact cognition.
Interview on 04/01/25 at 9:36 A.M., with Resident #21's sister revealed concern about housekeeping.
Revealing Resident #21's room had dirty carpet, and dirty bedside table while visiting on 03/31/35 which is
a common occurrence. Sister reported that the room regularly looks unkept, with crumbs on the floor and
stained bedding. Sister revealed that Resident #21's bathroom had dirty sink and toilet during her visit on
03/31/25, which is a common occurrence. Sister reported not being able to figure out what cleaning
schedule staff follow to keep resident's room clean.
Observation of Resident #21's room on 04/01/25 at 1:30 P.M., revealed carpet with crumbs scattered
around bed and television and was dirty. The bedside table was not clean, with sticky residue. The
bathroom floor was dirty as well as the sink that had stained dark residue as well as toothpaste in the bowl
of the sink. Resident #21's toilet had multiple rings that appeared to be dirty. Resident #21's shower also
had a residue and hair lying on the shower floor.
Interview on 04/01/25 at 1:38 P.M., with Certified Nurse Assistant (CNA) #298 revealed sweeping, cleaning
the bathroom, cleaning the room and laundry should be done on scheduled shower days. CNA #298
confirmed housekeeping tasks cannot always be accomplished that often, depending on the other tasks
needing to be accomplished based on priority. CNA #298 confirmed the carpet was dirty and needed to be
deep cleaned as well as having a lot of residual crumbs lying around. CNA #298 confirmed the bathroom
floor, the sink and the toilet were all dirty; the shower had residue and hair lying on the shower floor.
Interview on 04/01/25 at 3:58 P.M., with Resident #21 revealed she regularly showers herself and that room
is not clean on days when she showers herself. Resident #21 confirms CNA's will assist with cleaning tasks
when asked but they do not keep any regular schedule for cleaning as far as she can tell.
(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 10
Event ID:
366393
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 - Few
Interview on 04/01/25 at 2:31 P.M., with CNA # 286 revealed Resident #21 frequently has dirty linens but
will, at times, refuse to allow CNA to change her linens.
2. Review of Resident #24's medical record revealed an admission on [DATE], with diagnoses including:
seizure disorder, diabetes, hypertension, and respiratory failure. Review of MDS assessment dated [DATE]
revealed a Brief Interview for Mental Status (BIMS) test score of 14 indicating intact cognition. MDS also
revealed Resident #24 to be dependent or needing maximum assistance for all activities of daily living and
dependent for all independent activities of daily living.
Observation and interview on 04/01/25 at 2:06 P.M., with Resident #24, revealed Resident #24 was lying in
his bed watching television. Interview with Resident #24, at this time, revealed his room is cleaned if he
requests it to be cleaned. Resident #24 admitted he does not like to be bothered and will forgo getting it
cleaned. Observation of the carpet directly next to Resident #24's bed was sticky and was very dirty.
Resident #24 confirmed he normally eats in his bed and does tend to drop a lot of food due to the tremors
in his hands. Resident #24's bathroom was observed with a pink residue in the sink, the toilet had
numerous dirt rings, as well as dirty floor.
Interview on 04/01/25 at 2:27 P.M., with CNA #286 confirmed Resident #24's room should be cleaned on
shower days or when dirty. Linens are normally changed on shower days, but Resident #24's linens are
changed more frequently as he regularly eats in his bed. Resident #24 has hand tremors which affect his
ability to always keep food on silverware or accurately get food to his mouth resulting in needing bed linens
changed more frequently. CNA #286 confirmed Resident #24's room carpet was dirty, and the bathroom
floor was also dirty. Resident 24s sink had a pink residue and sink top was dirty. The toilet has numerous
dirt rings. CNA #268 confirmed that resident's room should have been cleaned on 04/01/25 when he was
given a bed bath. CNA #268 admits getting to all resident room housekeeping tasks is challenging on most
days.
Review of the policy titled, Elder Room Cleaning Policy and Procedure, created July 2007 and updated May
2013, revealed the facility is to provide a clean, attractive, and safe environment for elders and their
families, visitors, and partners.
This deficiency represents non-compliance investigated under Complaint Number OH00161906.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 2 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and Ombudsman notification list review, the facility failed to notify the
Ombudsman of resident admissions to hospital. This affected two (#37 and #44) of four residents reviewed
for hospitalization. The facility census was 53.
Findings include:
1. Review of Resident #37's medical record revealed an admission date of 10/25/24, with diagnoses
including depression, dementia, encephalopathy, and debility.
Review of the State Optional Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37
had severe cognitive deficits and required extensive assistance with activities of daily living.
Review of nursing note dated 12/30/24, indicated Resident #37 experienced a sudden health condition
change and was transferred and admitted to the hospital.
2. Review of Resident #37's medical record revealed an admission date of 07/17/24, with diagnoses
including hypertensive kidney disease, vascular dementia, mood disorder, and aortic stenosis.
Review of the State Optional MDS dated [DATE] revealed Residents #44 had severe cognitive deficits and
requires extensive assistance with activities of daily living.
Review of nursing note dated 02/27/25 revealed Resident #44's daughter came to take resident to a
doctor's appointment where it was found that she had fluid around her lungs and the doctor had sent
Resident #44 to the hospital for admission.
Review of the form listed as Ombudsman Notification of Discharges dated for February 2025 revealed
Resident #44 was not on the list.
Interview on 04/03/25 at 10:41 A.M., with the Administrator and Director of Nursing (DON) verified that they
were not notifying the Ombudsman of admissions if the resident was coming back to the facility and was
only notifying the ombudsman if the resident was not returning to the facility. There was no notification
made for Resident #37 and #44.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 3 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to provided bed hold notices. This affected three
(#37, #39 and #44) of four residents reviewed for hospitalization. The facility census was 53.
Findings include:
1. Review of Resident #37's medical record revealed an admission date of 10/25/24, with diagnoses
including depression, dementia, encephalopathy, and debility.
Review of the State Optional Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37
had severe cognitive deficits and required extensive assistance with activities of daily living.
Review of nursing note dated 12/30/24, indicated Resident #37 experienced a sudden health condition
change and was transferred and admitted to the hospital.
Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #37.
Interview on 04/03/25 at 10:09 A.M., with the Administrator verified there was no bed hold for Resident #37.
2. Review of Resident #37's medical record revealed an admission date of 07/17/24, with diagnoses
including hypertensive kidney disease, vascular dementia, mood disorder, and aortic stenosis.
Review of the State Optional MDS dated [DATE] revealed Residents #44 had severe cognitive deficits and
requires extensive assistance with activities of daily living.
Review of nursing note dated 02/27/25 revealed Resident #44's daughter came to take resident to a
doctor's appointment where it was found that she had fluid around her lungs and the doctor had sent
Resident #44 to the hospital for admission.
Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #44.
Interview on 04/02/25 at 5:12 P.M., with the Administrator verified Resident #44 had not received a bed hold
notice when they were admitted to the hospital.
3. Review of the closed record for Resident #39 revealed she was admitted on [DATE] and discharged on
02/28/25 to the hospital. Her diagnoses included severe protein-calorie malnutrition, anxiety disorder,
hypomagnesemia, hypothyroidism, neurocognitive disorder with Lewy bodies, hyperparathyroidism,
osteoarthritis, osteoporosis, and hyperlipidemia.
Review of her Minimum Data Set (MDS) admission dated 02/04/25 revealed her Brief Interview of Mental
Status (BIS) score was 2 indicating she was severely cognitively impaired. She required maximal
assistance for eating and was dependent for her activities of daily living (ADLs).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 4 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of a progress notes dated 02/28/25 revealed Resident #39 was sent to the hospital due to her
nephrostomy tube coming out.
Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #39.
Interview on 04/02/25 at 5:12 P.M., with the Administrator verified Residents #39 had not received a bed
hold notice when they were admitted to the hospital.
Event ID:
Facility ID:
366393
If continuation sheet
Page 5 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to accurately assess the resident status in the
facility. This affected one (#17) of four residents reviewed for discharge. The facility census was 53.
Residents Affected - Few
Findings include:
Review of the closed medical record for Resident #17 revealed she was admitted [DATE] and discharged
[DATE]. Her diagnoses included anemia, type 2 diabetes, chronic kidney disease, chronic obstructive
pulmonary disease, malignant neoplasm of lung, hypertension, osteoarthritis, glaucoma, obstructive sleep
apnea, and gout.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview
of Mental Status (BIMS) score was 15 indicating she was cognitively intact. She required supervision for
eating and maximal assistance for activities of daily living (ADLs). There was no evidence of a discharge
MDS for her 10/23/25 discharge.
Interview on 04/03/25 at 11:48 A.M., with the MDS Nurse (#326) confirmed there was no discharge MDS
completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 6 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0777
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to notify the physician of stat (immediate) diagnostic
imaging in a timely fashion. This affected one (#208) of one resident reviewed for radiology services. The
facility census was 53.
Residents Affected - Few
Findings include:
Review of records for Resident #208 revealed an admission date of 03/16/25 with an admitting diagnoses
of chronic obstructive pulmonary disease (COPD), seizures, anxiety, and polyneuropathy. Review of
Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #208 had moderate cognitive
impairment and required extensive assistance of one for toileting.
Review of physician's orders revealed an order dated 03/26/25 for an urgent (stat) Kidney, Ureter, and
Bladder x-ray (KUB) for abdominal pain.
Review of results for KUB revealed examination date of 03/26/25 at 6:05 P.M. and facility reported date of
03/26/25 at 6:21 P.M., results included There was a moderate amount of rectal stool present.
Review of progress notes from 03/26/25 to 03/31/25 revealed the physician, resident, and family were
notified of the stat KUB results on 03/31/25 at 3:19 P.M. by Registered Nurse (RN) #311.
Interview on 04/02/25 at 9:46 A.M., with RN #311 stated she called the physician on 03/31/25 because she
noticed there was no documentation in Resident #208's chart indicating the physician had been notified of
the results of the stat KUB. RN #311 verified five days had passed since the results were received. RN
#311 stated stat diagnostic results should have been called to the physician by which ever nurse received
the notification by the imaging provider on 03/26/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 7 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident interview, family interview, staff interview and policy review, the facility failed
to assure dental services were provided in a timely manner to meet the needs of the resident. This affected
one (#21) of three residents reviewed for dental care. The facility census was 53.
Residents Affected - Few
Findings include:
Review of Resident #21's medical record revealed an admission date of 02/10/22, with diagnoses including:
multiple sclerosis, gastro esophageal reflux disease, osteoporosis, and bipolar disease. Review of quarterly
Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of
14 with intact cognition.
Review of medical record revealed on 09/25/24 Resident #21 was experiencing jaw pain. Resident #21
alerted Licensed Practical Nurse (LPN) #262, she had fallen and hit her face on her snack cabinet.
Resident #21 felt the fall lead to the jaw pain. Resident revealed she had not reported the fall to the staff.
LPN #262 assessed resident's face and no bruising noted. LPN #262 attempted to do neurologic checks
but resident #21 refused. Record indicated that a written note was left for physician in a folder for review.
Medical record review revealed on 11/26/24, Registered Nurse (RN) #306 had spoken to Social Worker
#343 and a referral had been made to dentist for Resident #21's jaw pain
Review of Resident #21's medical record revealed an order written on 11/26/24 for Resident #21: Refer to
Dentist for jaw pain two times a day for jaw pain. Order remains in place as of 04/01/25 and there was no
clarifications on what the order was actually stating.
Medical record review revealed a note that Resident #21 was seen by dentist on 01/29/25. Medical record
revealed she was seen for a periodic oral evaluation that made no mention of jaw pain or assessment for
jaw pain. Dentist noted that dentures fit well and oral tissue was healthy. Dentist unable to get x-rays due to
resident's gag reflex. Oral hygiene instructions provided to resident during visit. Dentist indicated there was
no plan for treatment follow up and that resident would be seen based on payor source requirements.
Review of medical record revealed a social service note dated 03/07/25 that emergency dental care
request sent to 360 Care related to jaw pain.
Interview on 04/01/25 at 9:36 A.M., with Resident #21's sister revealed continued concerned for resident's
jaw pain as Resident #21 continues to complain to sister of jaw pain and ill fitting dentures. Sister stated
she wanted Resident #21 seen by a dentist for evaluation and treatment. Sister was unaware of Resident
#21 being seen previously by dentist.
Interview on 04/02/25 at 3:46 P.M. with LPN #263 revealed Resident #21 is assessed for jaw pain twice
daily and believed Resident #21 had been referred to dentist for follow up. LPN #263 revealed Resident #21
does not complain of jaw pain at every assessment.
Interview on 04/01/25 at 10:14 A.M. and again on 04/02/25 at 3:48 P.M., with Resident #21 stated she
continues to have intermittent jaw pain and ill fitting dentures. Resident #21 confirmed she was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 8 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0791
seen by dentist in the past few months, but did not feel jaw pain was addressed.
Level of Harm - Minimal harm
or potential for actual harm
Review of the undated policy titled , Ancillary Services stated: Upon admission and thereafter, the right to
adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise
necessary and appropriate care consistent with the program for which the resident contracted. This care
shall be provided without regard to considerations such as race, color, religion, national origin, age, or
source of payment for care.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 9 of 10
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
366393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein at Maineville
201 Marge Schott Way
Maineville, OH 45039
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and menu review, the facility failed to have pasteurized eggs
available for residents if requested over easy fried eggs. This had the potential to affect all 53 residents
residing in the facility. The facility census was 53.
Findings include:
Observation on 03/31/25 at 11:39 A.M., with Certified Nursing Assistant (CNA) #345 revealed there was a
18 pack of eggs that were not pasteurized.
Interview on 03/31/25, during observation, with CNA #345 reported that if a resident request over easy fried
eggs then they will make them because it is available all the time item.
Observation on 03/31/25 at 11:46 A.M., with CNA #293 revealed there was a three large trays of eggs that
were not pasteurized.
Interview on 03/31/25, during observation, with CNA #293 reported that if a resident request over easy fried
eggs then they will make them because it is on the always available menu.
Review of the Always Available Menu revealed that eggs of choice (scrambled, fried, or hard boiled) are
available for breakfast.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366393
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
7 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.
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F777 - The facility must—
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
F791 - Dental Services
Provide or obtain dental services for each resident.
FAQ · About this visit
Common questions about this visit
What happened during the April 3, 2025 survey of OTTERBEIN AT MAINEVILLE?
This was a inspection survey of OTTERBEIN AT MAINEVILLE on April 3, 2025. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OTTERBEIN AT MAINEVILLE on April 3, 2025?
Yes, 7 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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.