Otterbein Loveland

Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/30/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Review of nurse progress note for Resident #70 dated 10/01/25 revealed the resident left the facility against medical advice (AMA) on 09/30/25 per the request of the resident's representative.

Upon discharge Licensed Practical Nurse (LPN) #142 accidentally provided Resident #70's representative with Resident #71's medications and discharge paperwork by mistake. LPN #142 did not identify the error until shift change when the night shift nurse was unable to find Resident #71's medications in the cart.

Review of the medical record for Resident #71 revealed an admission date of 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis with a discharge date of 10/07/25.

Review of the physician's orders for Resident #71 dated 09/30/25 revealed the resident had orders for the following medications: Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol polyethylene glycol, prednisolone eye drops, sennoside, Synthroid.

Review of a police report dated 10/01/25 at 4:05 P.M. revealed on 10/01/25 Resident #70's representative made an in-person report at the police station regarding concerns with the resident's care at the facility.

Review of the report revealed the resident's representative reported the resident discharged from the facility on 09/30/25 and discovered the facility had given her medications and written discharge instructions for a different resident. Resident #70's representative stated she had called the facility to notify them, and the staff acknowledged the error.

The facility asked the representative to bring the medications and discharge instructions back so the facility could then provide the resident's representative with the correct information and medications. Resident #70's representative requested the police officer accompany her to the facility to make the exchange as she felt uneasy doing so.

The officer followed Resident #70's representative to the facility where the medications and discharge instructions were exchanged without issue.

Review of the report revealed Resident #70's representative confirmed the resident had not taken any of the medications the facility had provided in error.

Interview on 03/24/26 at 3:03 P.M. with the Administrator and the Director of Nursing (DON) reported the nursing staff realized Resident #70 was given the wrong medications and wrong discharge instructions about two to three hours after the resident left the facility.

The Administrator confirmed the facility staff called Resident #70's representative regarding the error and the representative said she would bring the medications and discharge instructions back the next day to exchange them for the correct ones.

Interview on 03/25/26 at 11:17 A.M. with Resident #70's representative confirmed upon discharge on [DATE] the facility sent another resident's discharge instructions and medications with the resident. Resident #70's representative reported the facility did call her about the error and she told the facility she would bring the medications and discharge instructions back the following day.

Review of the facility policy titled Discharge/Transfer dated 03/07/25 revealed the facility would develop and implement a discharge planning process involving the resident and/or representative and the interdisciplinary care team to ensure the needs of the resident were identified and there would be a safe transition to a location that met the resident's needs.

This deficiency represents noncompliance investigated under Complaint Number 2671945.

366445 03/26/2026

Otterbein Loveland 6405 Small House Circle Loveland, OH 45140

at 9:20 P.M. without success, because the drawer to the emergency supply machine would not open.

Licensed Practical Nurse (LPN) #502 tried to open the medication dispensing machine seven times

non-pharmaceutical interventions while waiting for the oxycodone to arrive, and Resident #100's pain level was a seven out of ten on 09/19/25 at 11:24 P.M.

The Administrator stated on 09/20/25 at 12:45 A.M. Resident #100 told staff she was leaving the facility, and her family was coming to pick her up.

The Administrator confirmed the nurses had not notified Resident #100's physician that the facility did not have the resident's oxycodone available for administration.

Review of the facility policy titled Controlled Substances Prescriptions dated May 2022 revealed the prescriber would be contacted for directions when the delivery of the medication will be delayed or the medication was not or would not be available.

This deficiency represents noncompliance investigated under Complaint Number 2625197 and Complaint Number 2626925.

366445 03/26/2026

Otterbein Loveland 6405 Small House Circle Loveland, OH 45140

Observation of the House Five kitchen freezer revealed it contained the following items: two undated medical ice packs, two undated gallon bags full of ice with ice crystals on them, an undated loaf of gluten free bread which was open to air.

Further observation of the House Five kitchen pantry revealed there was a bucket full of dirty wash cloths next to a shelf where potatoes were being stored.

The pantry freezer had a brown substance in it.

The following cabinets in the pantry had a brown substance on them: the cabinet containing the crock pot and skillet, the cabinet containing the mixing bowl, the cabinet containing the cutting board, the cabinet drawer containing the measuring cups.

Interview on 03/24/26 at 7:54 A.M with DT #506 confirmed the observations in the House Five kitchen. 2.Observation on 03/24/26 at 8:49 A.M. of the House Five kitchen dishwasher revealed the dishwasher wash temperature was 148 degrees Fahrenheit (F) and the dishwasher rinse temperature was 175 degrees F.Interview on 03/24/26 at 8:49 A.M. with DT #506 verified the dishwasher wash temperature was 148 degrees F and should have been above 160 degrees F, and the dishwasher rinse temperature was 175 degrees F and should have been 180 degrees F. 3.Observation of on 03/24/26 at 9:01 A.M. of food temperatures per Certified Nursing Assistant (CNA) #157 revealed the sausage was being held at 127.6 degrees F during meal service.Interview on 03/24/26 at 9:01 A.M with CNA #157 verified the sausage was being held at 127.6 degrees F during meal service.

Review of the facility policy titled Food Temperatures dated May 2013 revealed hot foods must be kept at a temperature of 135 degrees F or higher. 4.

Observation on 03/26/26 at 7:43 A.M. of meal preparation in the House Five kitchen revealed CNA #507 was cooking eggs and bacon on an electric skillet. CNA #507 had her hair in a ponytail but was not wearing a hair net.Interview on 03/26/26 at 7:43 A.M. with CNA #507 confirmed she was cooking eggs and bacon on an electric skillet and was not wearing a hair net.

This deficiency represents noncompliance investigated under Complaint Number 2673774.

366445 03/26/2026

Otterbein Loveland 6405 Small House Circle Loveland, OH 45140

Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 01/15/26 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.)

Review of the care plan for Resident #31 dated 01/13/26 revealed the resident had an indwelling catheter related to skin breakdown and urinary retention.

Interventions included staff to maintain EBP for the resident due to the presence of the indwelling catheter.

Review of the physician's orders for Resident #31 dated March 2026 revealed there was an order for the resident to be in EBP due to the indwelling catheter.

Observation on 03/24/26 at 8:35 A.M. revealed there was an EBP cart stocked with personal protective equipment (PPE) outside Resident #31's room Observation of catheter care for Resident #31 on 03/24/26 at 8:45 A.M. per Certified Nursing Assistant (CNA) #75 revealed the aide did not don a gown prior to providing care.

Interview on 03/24/26 at 8:56 A.M. with CNA #75 verified that Resident #31 was supposed to be on EBP and the aide had not donned a gown while providing care.

Review of the facility policy titled Isolation Precautions Process dated 03/26/25 revealed EBP will be utilized for residents with urinary catheters during their entire stay at the facility.