Otterbein North Shore
OTTERBEIN NORTH SHORE in LAKESIDE, OH — inspection on March 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility policy
and resident representative of a change in the resident's condition.
Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications would administered per physician orders and the physician would be notified of medications withheld.
This deficiency represents non-compliance investigated under Master Complaint Number 2780772.
366358 03/27/2026
Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440
Review of the medical record for Resident #11 revealed an admission on [DATE].
Diagnoses included unspecified dementia, major depressive disorder, and dysphagia.
Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severe cognitive impairment.
Further review of the MDS revealed Resident #11 was dependent on staff for feeding assistance.
Review of the care plan dated 09/27/24 revealed Resident #11 was at risk for malnutrition related to inability to feed self.
Interventions included providing feeding assistance, and staff were to feed the resident all meals and snacks.
Further review of the care plan dated 07/16/20 revealed Resident #11 had an activity of daily living (ADL) self-care performance deficit related to dementia, and weakness.
Interventions included feeding Resident #11 by staff or family. Resident #11 required one staff assistant to eat.
Review of the physician's orders dated 04/03/25 revealed an order for a regular diet, pureed texture, mildly thick consistency.
Further review of the care plan revealed an order on 08/13/25 for a health shake with meals for weight gain.
Additional review of the physician's orders revealed an order on 10/23/25 for a magic cup with meals per speech therapy, alternating with bites of food.
Observation on 03/27/26 at 8:20 A.M. revealed Certified Nursing Assistant (CNA) #218 feeding Resident #11 breakfast. Resident #11 had oatmeal, eggs, fruit, and thickened juice.Interview on 03/27/26 at 8:29 A.M. with CNA #218 revealed Resident #11 was given oatmeal, eggs, fruit and thickened juice for breakfast. CNA #218 confirmed that Resident #11 was to receive a magic cup but was unaware that the magic cup was to be given in between bites of food.
CNA #218 was not aware that Resident #11 received a health shake with meals.
Further interview with CNA #218 revealed in the kitchen there were resident diet orders and confirmed that Resident #11 was to receive a magic cup with meals, offering in between bites, and a health shake with every meal.2.
Review of the medical record for Resident #14 revealed an admission on [DATE].
Diagnoses included hyperkalemia, chronic fatigue, and weakness.
Review of the admission MDS dated [DATE] revealed Resident #14 had moderate cognitive impairment.
Further review of the MDS revealed Resident #14 required supervision during mealtimes.
Review of the care plan dated 03/08/26 revealed Resident #14 was at risk for changes to nutritional and hydration status related to hyperkalemia, acute kidney injury, and chronic kidney disease.
Interventions included offer a substitute for meal intakes less than 50 percent.
Further review of the care plan revealed Resident #14 received a mechanically altered diet and often refused.
Diet was changed to regular diet, regular texture, with thin liquids on 03/21/26.
Staff was to monitor weights weekly for one month, then monthly reporting any negative findings.
Staff were to provide supplements as ordered.
Additional review of the care plan revealed Resident #14 was at risk for altered nutrition status related to significant weight loss from hospital, and medical diagnoses.
Interventions included nutritional supplements.
Review of the physician's orders for Resident #14 revealed an order on 03/18/26 for magic cup supplement with meals.
Observation on 03/27/26 at 8:15 A.M. revealed Resident #14 sitting at the dining room table eating two eggs, bacon, and toast.Interview on 03/27/26 at 8:29 A.M. with CNA #218 revealed Resident #14's diet card stated Resident #14 was to receive a magic cup with each meal. CNA #218 further confirmed Resident #14 was not offered a magic cup and that CNA #18 was not aware that Resident #14 had an order for a magic cup.Interview on 03/27/29 at 10:30 A.M. with the Administrator revealed there was not a policy on supplemental orders.This deficiency represents non-compliance investigated under Complaint Number 2780772
366358 03/27/2026
Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440
Review of the MAR dated 03/18/26 revealed the resident had not been
03/19/26.
Review of the Medication Inventory on Hand report revealed the carbidopa-levodopa was
documentation the resident had refused the medication.Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #27's medication was not administered per physician orders, and the medication was available in the facility. 3.
Review of the medical record for Resident #13 revealed an admission date of 03/10/26.
Diagnoses included acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension.
Review of the admission MDS assessment dated [DATE] revealed Resident #13 had intact cognition.
Review of the hospital discharge medication orders revealed an order for carvedilol 6.25 mg, one tablet two times per day.
Review of the physician order dated 03/10/26 revealed an order for carvedilol 6.25 mg two times a day for hypertension.
Hold for systolic blood pressure less than 100 and hold if pulse was less than 60 beats per minute.
Review of a nursing note dated 03/10/26 at 2:48 P.M. revealed the resident had arrived at the facility.
Review of the vital sign record dated 03/10/26 at 8:20 P.M. revealed the residents' blood pressure was 116/59 with a heart rate of 84 beats per minute.
Review of the MAR dated 03/10/26 revealed the evening dose of the carvedilol was not administered.
Review of the nursing notes dated 03/10/26 revealed no documentation the resident had refused the medication.
Review of the Medication Inventory on Hand report revealed the facility had carvedilol available for administration.
Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #13's medication was not administered per physician orders, and the medications were available in the facility.
Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications were administered in accordance with written orders of the attending physician or physician extender.
Review of the facility policy MedBank System Policies and Procedures, dated 10/23/25 revealed the on hand medication supply would be used for the first dose use and other situation where medication was not readily available from the pharmacy until the next scheduled delivery.
This deficiency represents non-compliance investigated under Master Complaint Number 2780772 and Complaint Number 2720892.
366358 03/27/2026
Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440
Review of the hospital discharge medication orders revealed an order for carvedilol 6.25 mg, one tablet two times per day.
Review of the physician order dated 03/10/26 revealed an order for carvedilol 6.25 mg two times a day for hypertension.
Hold for systolic blood pressure less than 100 and hold if pulse was less than 60 beats per minute.
Review of a nursing note dated 03/10/26 at 2:48 P.M. revealed the resident had arrived at the facility.
Review of the vital sign record dated 03/10/26 at 8:20 P.M. revealed the residents' blood pressure was 116/59 with a heart rate of 84 beats per minute.
Review of the MAR dated 03/10/26 revealed the evening dose of the carvedilol was not administered.
Review of the nursing notes dated 03/10/26 revealed no documentation the resident had refused the medication.
Review of the Medication Inventory on Hand report revealed the facility had carvedilol available for administration.
Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #13's medication was not administered per physician orders, and the medications were available in the facility.
Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications were administered in accordance with written orders of the attending physician or physician extender.
Review of the facility policy MedBank System Policies and Procedures, dated 10/23/25 revealed the on hand medication supply would be used for the first dose use and other situation where medication was not readily available from the pharmacy until the next scheduled delivery.
This deficiency represents non-compliance investigated under Master Complaint Number 2780772 and Complaint Number 2720892.