Otterbein Monclova

In the surveyor’s words

From the most serious findings on record at Otterbein Monclova, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 2, 2023

  Based on review of the medical record, staff interviews and policy review, the facility failed to timely notify the physician of signs and symptoms of a wound infection leading to a delay in treatment. This resulted in actual harm when Resident #23's toe wound began to show signs and symptoms of infection and the facility staff had not notified the physician. Resident #23 required care from the emergency room for treatment of osteomyelitis (severe wound infection). Additionally, the facility failed to correctly implement wound treatments per physician orders and timely administer antibiotics per physician orders. This affected one (Resident #23) of three residents reviewed for wound care. The facility census was 48. […]

• Actual harm, isolatedF686Nov 2, 2023

  Based on medical record review, staff interview, resident interview, policy review, and review of manufacturer guidelines, the facility failed to monitor the position and inflation of a wheelchair back support cushion, resulting in avoidable skin breakdown. Additionally, the facility failed to effectively monitor and assess skin breakdown. This resulted in Actual Harm when Resident #08 developed a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum. This affected one (Resident #08) of three residents reviewed for wound care. The facility census was 48. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE]. […]

• Actual harm, isolatedF692Nov 21, 2022

  Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure weights were obtained per physician order, and ongoing monitoring was provided for residents identified at nutritional risk and sustaining weight loss. This resulted in Actual Harm when Resident #39 experienced a severe weight loss of 9.33 percent from 08/18/22 to 11/15/22 and a severe weight loss of 12.76 percent from 06/06/22 to 11/15/22. There was no evidence weekly weights were obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#39) out of six residents reviewed for nutrition. The facility census was 53. Findings include: Review of Resident #39's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF867Mar 27, 2025

  Based on observation, staff interview, resident interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective quality assurance and performance improvement (QAPI) program to address repeated deficiencies identified during four consecutive comprehensive surveys. This had the potential to affected all 54 residents in the facility. The census was 54. Findings include: Review of the CMS Provider History Profile document, with Certification and Survey Provider Enhanced Reporting (CASPER) system data, last updated 03/06/25, revealed the facility was issued a deficiency for not providing services/treatments to prevent/heal pressure ulcers on the three previous comprehensive surveys… […]

• No harm, potential for more than minimal, widespreadF812Dec 24, 2024

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 57 residents in the facility. The census was 57. Findings include: 1. Observation on [DATE] at 8:15 A.M. in House #4 revealed a refrigerator with an opened and undated carton of broccoli soup, an opened and undated carton of potato soup, and a plastic reusable bag of food without a label or date. Further observation of a second refrigerator revealed what appeared to be several paper towels lying flat underneath the bottom drawer with a pinkish/red tint to them. Interview and observation on [DATE] at approximately 8:20 A.M. […]