Otterbein St Marys Retirement Community

In the surveyor’s words

From the most serious findings on record at Otterbein St Marys Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 14, 2023

  Based on medical record review, staff interview, review of facility investigations, review of a Sheriff's Office incident report, review of the weather forecast, review of hospital discharge documents, and review of facility policy, the facility failed to prevent the elopement of confused residents from the secured memory care unit. This resulted in actual harm when one resident (#20) eloped from the facility without staff knowledge, was outside for approximately three hours in cool weather temperatures and light rain, was subsequently admitted to the hospital for evaluation and stabilization and was diagnosed with hypothermia (a significant and potentially dangerous drop in body temperature most commonly caused by prolonged exposure to cold) and a hypothermic blanket was applied. […]

• No harm, potential for more than minimal, widespreadF880Jan 26, 2021

  Based on observation, review of Center for Disease Control (CDC) guidelines, review of facility in-services, review of facility policies and staff interviews, the facility failed to implement infection control and prevention measures to prevent the spread of the Coronavirus Disease 2019 (COVID-19) related to the reuse of N95 masks. This had the potential to affect 38 of 38 residents residing in the facility. Findings include: Observation on 01/21/21 at 9:50 A.M., revealed State tested Nurse Aid (STNA) #30 was wearing an N95 mask while working in the quarantine unit. STNA #30 verified it was an N95 mask and verified the facility staff reuse N95 up to five days. STNA #30 verified wearing of the N95 mask for an entire day or shift constituted a use of the N95 mask. […]

• No harm, potential for more than minimal, patternF883Sep 14, 2023

  Based on record review, staff interview and policy review, the facility failed to provide each resident or representatives with education regarding the risk and benefits of influenza immunization yearly when influenza vaccines were offered. This affected four (#2, #27, #31 and #36) out of five residents reviewed for immunizations. The facility census was 47. Findings include 1. Medical record review for Resident #2 revealed an admitted major depressive disorder, syncope and collapse, cerebral infarction, poly osteoarthritis, vitamin D, hyperlipidemia, seasonal allergic rhinitis, chronic obstructive pulmonary disease (COPD), anemia, hypertension, chronic bronchitis, dementia without behaviors, chronic kidney disease stage three. […]

• No harm, potential for more than minimal, isolatedF686Jun 25, 2026

  Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (#4) of three residents reviewed for skin alterations. The census was 49. Findings include: Review of Resident #4's medical record revealed an admission date of 08/18/25. Diagnoses listed included vitamin D deficiency, atherosclerotic heart disease, neuromuscular dysfunction of bladder, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and had no pressure ulcers. Review of a nursing note dated 06/17/26 at 3:50 P.M. revealed the physician was in to see Resident #4. […]

• No harm, potential for more than minimal, isolatedF689Jun 25, 2026

  Based on record review, observation, staff interview, and policy review, the facility failed to assess a resident timely after a fall. The affected one (Resident #34) out of five residents reviewed for accidents. The facility census was 49.Review of Resident #34's medical record revealed an admission date of 10/03/25 with diagnoses of Parkinson's disease with dyskinesia, with fluctuations, primary osteoarthritis, psychotic disorder with delusions, dementia with agitation, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #34 had moderate cognitive impairment, required partial assistance with ambulation, and resident did not have any falls prior to assessment.Review of the Care Plan, dated 10/04/25 revealed Resident #34 was at risk… […]