Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein At Maineville during CMS and state inspections, most recent first.
A resident with dysphagia and a physician-ordered minced and moist diet was given a regular texture meal by a social worker who did not verify the diet order. Shortly after, the resident was found unresponsive and choking, requiring CPR and hospitalization for cardiac arrest and pneumonitis due to food inhalation. Staff interviews confirmed the failure to check the diet order before serving the meal.
A resident with paraplegia and decreased sensation suffered a severe burn to the leg and foot after being placed too close to a portable space heater, which was used in response to a heating system failure. The use of space heaters in resident rooms was prohibited by facility policy, but several rooms had them during the outage. Staff were unclear about who authorized the heaters, and there was a lack of proper monitoring and documentation of room temperatures, leading to significant injury and subsequent infection.
When the facility's HVAC system malfunctioned, resulting in low temperatures in several rooms, portable space heaters were placed in resident rooms despite facility policy and NFPA Life Safety Code prohibiting their use. The Maintenance Coordinator could not immediately repair the system and was unaware of who provided or removed the heaters. Staff later confirmed the heat outage was due to a faulty gas valve, and the heating system was eventually repaired.
A facility failed to provide proper incontinence care for a resident with Alzheimer's and dementia. The care plan required cleansing the perineum after each episode, but a CNA did not follow the correct procedure, particularly in cleaning the uncircumcised penis. The CNA admitted to being trained differently at the facility, which led to the deficiency.
A resident with dementia and atrial fibrillation was left calling for help for 40 minutes without response from a CNA, who was present and able to hear the calls. The CNA eventually responded by providing a can of soda, which stopped the resident from yelling. This incident violated the facility's policy on treating residents with dignity and respect.
A facility failed to document and notify a physician about a resident's lack of urine output from an indwelling catheter over several days, despite a physician's order to measure output every shift. The resident, with multiple medical conditions, had no recorded urine output for several shifts, and the facility did not follow its policy to notify the physician of significant changes in the resident's condition.
A CNA failed to use gloves in a sanitary manner during catheter care for a resident with an indwelling catheter, leading to non-compliance with the facility's infection control policy. The CNA did not change gloves or perform hand hygiene after touching various items in the room, resulting in the use of contaminated gloves during the procedure.
Resident Provided Incorrect Diet Texture Resulting in Choking and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dysphagia and a history of stroke, was not provided food in the correct texture as ordered by the physician. The resident was on a regular diet with minced and moist texture due to aspiration risk, as documented in the care plan and physician orders. Despite these orders, a social worker, who typically does not prepare or serve meals, provided the resident with a regular texture meal without verifying the diet order. Shortly after receiving the incorrect meal, the resident was found unresponsive and not breathing by a certified nursing assistant (CNA) who was bringing the correct diet plate. The CNA immediately called for assistance, and a nurse assessed the resident, finding evidence of choking on food. The nurse and CNA worked to clear the airway, and when no pulse was found, cardiopulmonary resuscitation (CPR) was initiated until emergency medical services arrived. The resident was subsequently hospitalized, intubated, and diagnosed with cardiac arrest and pneumonitis due to inhalation of food and vomit. Interviews with staff confirmed that the social worker did not check the resident's diet order before serving the meal, and the CNA was unaware the resident had already been served. The facility's policy specified the requirements for a minced and moist diet, which were not followed in this instance. No other residents were reported to have received the wrong diet texture during the same meal event.
Severe Burn Injury Due to Prohibited Space Heater Use During HVAC Failure
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when the HVAC system malfunctioned in one area, causing room temperatures to drop below the required range. In response, portable space heaters, which are prohibited in resident rooms, were placed in four rooms. This action directly led to a serious incident where a resident with lower extremity paralysis and decreased sensation, due to spinal cord compression and other comorbidities such as diabetes, sustained a full thickness burn on the left leg and foot after being positioned too close to a space heater. The burn was severe, resulting in blistering, skin breakdown, and subsequent infection with faecalis and E. faecium, requiring hospitalization and ongoing outpatient burn care. Multiple staff interviews and documentation confirmed that the space heaters were present in several rooms during the period of heating system failure. Staff members reported that the heaters became hot to the touch and could cause burns. There was confusion among staff regarding the origin and authorization of the space heaters, with some stating that maintenance or administration directed their placement, while others denied knowledge of their presence. The affected resident was observed by staff and family to be sitting within inches of the heater, and due to his paraplegia, was unable to sense the danger or move away, resulting in significant injury. The facility's policy explicitly prohibited the use of space heaters in resident areas and required specific interventions and monitoring in the event of HVAC failure. However, there was a lack of documentation of room temperatures and no evidence that alternative, policy-compliant measures were implemented to ensure resident safety during the heating outage. The incident was further compounded by delayed recognition and escalation of the resident's injuries, as well as inconsistent communication among staff regarding the presence and risks of the space heaters.
Use of Prohibited Space Heaters During HVAC Malfunction
Penalty
Summary
The facility failed to ensure that portable space heaters were not used in resident rooms when the HVAC system malfunctioned, resulting in decreased temperatures in a section of the building. The heat malfunction affected five resident rooms, and portable space heaters were placed in four of these rooms. The Maintenance Coordinator was unable to immediately repair the heating system and did not know the origin of the space heaters, who placed them, or their subsequent removal. Room temperatures were monitored, but there was no documentation, and the lowest temperature recalled was 67 degrees Fahrenheit, though the specific room was not identified. Facility policy prohibits the use of portable space heaters in resident rooms due to fire safety concerns and compliance with the National Fire Protection Association (NFPA) Life Safety Code. The policy also requires that environmental temperatures be maintained between 71-81 degrees Fahrenheit, with specific interventions if temperatures fall outside this range. Staff interviews confirmed that the heat outage was due to a faulty gas valve and that the heating system was eventually repaired by a contractor. The use of space heaters in resident rooms was in direct violation of facility policy and regulatory requirements.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident diagnosed with Alzheimer's disease and dementia, who was frequently incontinent with his bladder and always incontinent with his bowel. The care plan for the resident required cleansing of the perineum after each incontinence episode. However, during an observation of incontinence care, a CNA did not follow the proper procedure for cleaning the resident, particularly in handling the uncircumcised penis. The CNA wiped the resident in a downward motion on both sides and brushed down the penis without retracting the foreskin to clean beneath it, as required by the facility's policy. The CNA admitted during an interview that she was trained differently at the facility compared to her aide training, which included cleaning the foreskin and scrotum. The facility's policy for perineal care of a male resident specifies using a washcloth with mild soap, cleaning the urethral meatus if a catheter is present, and washing the penis in a circular motion while retracting the foreskin for uncircumcised residents. The CNA's deviation from this policy contributed to the deficiency in providing proper incontinence care for the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the case of a resident diagnosed with dementia and atrial fibrillation. The resident, who was moderately cognitively impaired, was observed in her room seated in a recliner and yelling out for help for a period of 40 minutes. During this time, a Certified Nursing Assistant (CNA) was present in the common area and was able to hear the resident's calls for help but did not immediately respond. The CNA was observed sitting at the counter by the kitchen and assisting other residents to get up and move to the common area for lunch. It was only after 40 minutes that the CNA went into the resident's room, acknowledged the resident's calls, and provided a can of soda, which stopped the resident from yelling. The facility's policy on Resident Rights emphasizes that residents have the right to be treated with courtesy, respect, and full recognition of their dignity and individuality, which was not upheld in this instance.
Failure to Notify Physician of No Urine Output
Penalty
Summary
The facility failed to ensure proper documentation and notification regarding a resident's urine output from an indwelling catheter. The medical record review revealed that Resident #01, who was admitted with diagnoses including obstructive and reflux uropathy, non-Alzheimer's dementia, malnutrition, and complete uterovaginal prolapse, had no urine output recorded for several shifts over multiple days. Despite the physician's order to measure urine output every shift, there was no documentation of urine output for Resident #01 on several occasions from 08/22/24 to 08/28/24. Additionally, there was no evidence that the physician was notified of the lack of urine output during this period. The facility's policy on Notification of Change of Condition requires immediate notification of the resident, physician, and resident's representative in cases of significant changes in the resident's condition. However, the review of the nurse's progress notes indicated that the physician was not informed about the absence of urine output for Resident #01, as required by the policy. This deficiency was identified during an investigation under Complaint Numbers OH 00158944 and OH00158592, highlighting a lapse in the facility's compliance with its own notification policy.
Improper Glove Use During Catheter Care
Penalty
Summary
The facility failed to ensure that gloves were used in a sanitary manner during catheter care for a resident with an indwelling catheter. The resident, who was severely cognitively impaired and receiving hospice services, was on enhanced barrier precautions. During an observation, a CNA was seen performing catheter care without changing gloves or performing hand hygiene after touching various items in the room, including the bed remote and trash can lid, before and during the procedure. This resulted in the CNA using contaminated gloves to perform catheter care. The facility's policy on indwelling urinary catheter care and management outlines specific steps for maintaining hygiene, including performing hand hygiene and using clean gloves. However, the CNA did not adhere to these guidelines, as she used the same pair of gloves throughout the procedure without changing them or performing hand hygiene. This non-compliance was identified during a complaint investigation, affecting one of the four residents with catheters in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maineville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Health Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Loveland Care Center | 3.4 mi | ★★★★★ | 1 | 0 |
| Lodge Nursing & Rehab Center | 3.6 mi | ★★★★★ | 7 | 0 |
| Majestic Care Of Cedar Village. | 3.7 mi | ★★★★★ | 4 | 0 |
| Mcv Health Care Facilities, Inc | 3.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.