Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Loveland during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to maintain sanitary food storage and preparation conditions and did not ensure proper equipment and food temperatures for residents served from one house kitchen. Inspectors observed uncovered and undated food items in the refrigerator and freezer, dirty wash cloths stored next to food, and brown residue on the pantry freezer and cabinets holding cooking equipment and utensils. The dishwasher was operating below required wash and rinse temperatures, hot food (sausage) was held below the facility’s policy standard of 135°F, and a CNA cooked eggs and bacon on an electric skillet without wearing a hair net.
A resident who was cognitively intact and required supervision with ADLs was discharged, and an LPN mistakenly sent that resident’s representative home with another resident’s medications and written discharge instructions, which included detailed information on multiple prescribed drugs for serious conditions such as cerebral infarction, seizures, and sepsis. The error was discovered at shift change when the night nurse could not locate the second resident’s medications in the cart. The administrator and DON confirmed that the wrong medications and paperwork had been provided, and the discharging resident’s representative later reported to police that they had received another resident’s private health information, although none of the incorrect medications were taken.
A resident who was cognitively intact and required supervision with ADLs was discharged AMA at the request of a representative, and an LPN mistakenly sent home another resident’s medications and discharge instructions. The error was discovered at shift change when staff could not locate the other resident’s medications, and the discharged resident’s representative later reported the issue to police and returned the incorrect medications and paperwork. The Administrator and DON stated staff realized the error a few hours after discharge, and facility policy required a discharge planning process to ensure a safe transition that met the resident’s needs.
A resident admitted with a lumbar compression fracture and significant back pain had a PRN oxycodone order, but staff were unable to obtain the medication from the emergency supply machine due to repeated malfunctions. The nurse verified orders with the on-call provider, faxed prescriptions to the pharmacy, and administered Tylenol while the resident continued to report moderate to severe pain. Despite multiple attempts to access the emergency supply and arranging for pharmacy delivery, no oxycodone was administered, and the physician was not notified that the ordered pain medication was unavailable, contrary to facility policy requiring prescriber contact when controlled substances are delayed or not available.
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident had severe cognitive impairment, required total assistance with ADLs, and had a care plan and MD orders specifying EBP due to the catheter. An EBP cart with PPE was available outside the room, but during observed catheter care a CNA did not don a gown, despite acknowledging that the resident was supposed to be on EBP. Facility policy required EBP for residents with urinary catheters for the duration of their stay.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not provide documentation that the Medical Director attended or participated in required quarterly QA committee meetings, as sign-in sheets lacked the Medical Director's signature and no alternative evidence was available. This failure to document participation affected all residents, as the QA committee did not meet the required membership per facility policy.
Multiple residents experienced unsanitary and uncomfortable living conditions, including stained carpets, soiled bathrooms, torn window blinds, and inadequate lighting. Several residents received cold showers due to water temperatures consistently below facility requirements, with maintenance delays in addressing the issue. Residents with significant care needs were affected, and cleaning was inconsistent, sometimes requiring family intervention.
Two residents were affected by lapses in infection control: a CNA handled soiled linens without gloves or a bag, allowing them to touch her body while transporting them, and an LPN failed to change gloves or sanitize hands between treating multiple wound sites on a resident's legs. Both actions were contrary to facility policy and were confirmed by staff interviews and policy review.
The facility did not provide scheduled activity programs or encourage participation for several residents with cognitive and physical impairments, despite documented care plans and preferences for engagement. Staff reported being too busy with other duties to conduct activities, and observations confirmed that residents were not invited or assisted to participate, resulting in a lack of meaningful engagement as required by facility policy.
The facility did not ensure that the Medical Director conducted required face-to-face visits with several residents, all of whom had complex medical conditions such as dementia, diabetes, and Alzheimer's disease, within the mandated 60-day interval. The Medical Director was unaware of this requirement, resulting in missed visits for these individuals.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
A resident with multiple health conditions who was dependent on staff for toileting experienced a significant delay in receiving assistance after activating the call light, resulting in an incontinence episode. Staff interviews and observations confirmed that only one RN and one CNA were on duty at the time, and both acknowledged the facility was short staffed, leading to delayed care and resident distress.
A resident with multiple medical conditions was admitted with conflicting documentation regarding code status, including both full code and DNRCC orders. Neither the electronic health record nor the paper chart contained a signed advance directive, despite facility policy requiring such documentation. Staff interviews confirmed the absence of the required advance directive in the medical record.
A resident with multiple medical conditions reported to two CNAs that a staff member intentionally turned cold water on him during a shower. The CNAs attempted to inform their supervisor, but the allegation was not escalated to the Administrator as required by policy. The incident was only reported after being discovered by a surveyor, indicating a failure by staff and management to follow immediate reporting procedures for abuse allegations.
Two residents dependent on staff for toileting and hygiene did not receive timely or adequate incontinence care. One resident was not properly cleaned according to facility policy, with key steps omitted during perineal care. Another resident waited over an hour for assistance after an incontinence episode, despite staff being aware of the situation, resulting in prolonged exposure to soiled clothing and resident distress.
Failure to Maintain Sanitary Food Storage, Preparation, and Safe Temperatures in House Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage, preparation, and sanitation practices in House Five’s kitchen affecting 21 residents who received food from that kitchen. Observation of the refrigerator showed an undated and uncovered pitcher of pink liquid and a piece of cardboard from a drink box used to hold the water dispenser shut. The freezer contained two undated medical ice packs, two undated gallon bags of ice with ice crystals, and an undated, open loaf of gluten-free bread exposed to air. In the pantry, a bucket full of dirty wash cloths was stored next to a shelf holding potatoes, and the pantry freezer and multiple cabinets and drawers (including those containing a crock pot, skillet, mixing bowl, cutting board, and measuring cups) had a brown substance on them. The dietary technician present confirmed these observations. Further observations showed the House Five kitchen dishwasher was operating below required sanitizing temperatures, with a wash temperature of 148°F and a rinse temperature of 175°F, which the dietary technician acknowledged were below the expected 160°F wash and 180°F rinse. During meal service, a CNA measured sausage being held at 127.6°F, below the facility’s policy requirement that hot foods be maintained at 135°F or higher, and confirmed this temperature. On another observation of meal preparation, a CNA was cooking eggs and bacon on an electric skillet without wearing a hair net, despite having her hair in a ponytail, and confirmed she was not wearing a hair net. These conditions collectively demonstrated failure to store and prepare food in a sanitary manner, to ensure proper dishwasher temperatures, and to maintain hot foods at safe holding temperatures for residents served from House Five’s kitchen.
Privacy Breach When Wrong Discharge Medications and Instructions Given to Another Resident
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's health information when discharge medications and paperwork for one resident were mistakenly given to another resident's representative. Resident #70, who was cognitively intact and required supervision with ADLs, was discharged on 09/30/25. At discharge, LPN #142 accidentally provided Resident #70's representative with Resident #71's medications and written discharge instructions instead of Resident #70's. Resident #71 had been admitted with diagnoses including cerebral infarction, seizures, and sepsis and had active physician orders for multiple medications, including Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol, polyethylene glycol, prednisolone eye drops, sennoside, and Synthroid. The error was not identified by facility staff until shift change, when the night shift nurse was unable to locate Resident #71's medications in the medication cart. The Administrator and DON reported that nursing staff realized the wrong medications and discharge instructions had been given to Resident #70 approximately two to three hours after the resident left the facility. Resident #70's representative later reported the incident to the police and confirmed that the facility had sent home another resident's medications and discharge instructions, and that none of those medications had been taken. Both the Administrator and Resident #70's representative confirmed that private health information for Resident #71 had been disclosed to Resident #70 and her representative, contrary to the facility's HIPAA policy, which states that the facility will protect the privacy and confidentiality of residents' individually identifiable health information.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a cognitively intact resident who required supervision with ADLs and had diagnoses including COVID-19, depression, and macular degeneration. The resident was admitted on 09/10/25 and discharged on 09/30/25, leaving against medical advice at the request of the resident’s representative. At discharge, an LPN mistakenly provided the resident’s representative with another resident’s medications and written discharge instructions. The error was not identified until shift change when the night shift nurse could not locate the other resident’s medications in the medication cart. The other resident, admitted on 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis and with multiple active medication orders, remained in the facility. The resident’s representative discovered that the medications and discharge instructions belonged to a different resident and reported concerns about the resident’s care to the police the following day. The representative informed the police that the facility had acknowledged the error when she called and had asked her to return the medications and discharge instructions so they could be exchanged for the correct ones. A police officer accompanied the representative back to the facility, where the exchange occurred without issue, and the representative confirmed that none of the incorrect medications had been administered to the resident. The Administrator and DON reported that nursing staff realized the error approximately two to three hours after the resident left the facility. Review of the facility’s Discharge/Transfer policy showed that the facility was required to develop and implement a discharge planning process involving the resident or representative and the interdisciplinary team to ensure the resident’s needs were identified and there was a safe transition to a location that met the resident’s needs.
Failure to Ensure Availability of Prescribed Pain Medication and Notify Prescriber of Delay
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed pain medication was available for administration to a resident with significant back pain. The resident was admitted with osteoporosis and a wedge compression fracture of the first lumbar vertebra and reported lower back pain rated as six out of ten shortly after admission. A baseline care plan documented that the resident was alert and oriented with short-term memory problems, required supervision for mobility and toileting, and was independent with eating. A physician’s order was in place for oxycodone 5 mg by mouth every four hours as needed for moderate pain, and one to two 5 mg tablets every four hours as needed for moderate to severe pain, for up to twenty doses in total. On the evening of admission, the nurse verified admission medication orders with the on-call provider and faxed the medication list and prescriptions, including oxycodone, to the pharmacy. The Medication Administration Record showed that the resident received Tylenol 600 mg for a pain level of six out of ten, but no oxycodone or other pain medications were documented as administered. Pain assessments documented pain levels of six out of ten at 8:30 p.m. and 9:55 p.m., and seven out of ten at 11:24 p.m. The nurse contacted the pharmacy at 9:20 p.m. to verify receipt of the oxycodone prescription and was given a code to obtain two 5 mg oxycodone tablets from the facility’s emergency supply machine. When the nurse attempted to retrieve the oxycodone from the emergency supply machine with a second nurse, the drawer malfunctioned and would not open despite multiple attempts. The nurse called the pharmacy again to report the problem and was advised to contact the DON or the machine’s support number. The nurse notified the ADON and DON and continued unsuccessful attempts to access the medication, then requested immediate delivery of oxycodone, which the pharmacy indicated would arrive in the early morning hours. The resident was informed of the situation and offered Tylenol while continuing to report pain at a level of seven out of ten. The Administrator and DON later confirmed that the nurses did not notify the resident’s physician that the oxycodone was not available, despite a facility policy stating the prescriber would be contacted when delivery of a controlled substance would be delayed or the medication would not be available.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder, had a Minimum Data Set assessment indicating severe cognitive impairment and dependence on staff for ADLs. The resident’s care plan documented the presence of an indwelling catheter for skin breakdown and urinary retention, with an intervention specifying that staff were to maintain EBP due to the catheter, and physician orders also directed that the resident be on EBP. During observation, an EBP cart stocked with PPE was present outside the resident’s room, but when a CNA provided catheter care, the CNA did not don a gown as required. In a subsequent interview, the CNA confirmed awareness that the resident was supposed to be on EBP and acknowledged not wearing a gown while providing care. Review of the facility’s Isolation Precautions Process policy showed that EBP was to be used for residents with urinary catheters during their entire stay, which was not followed in this instance.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Lack of Documented Medical Director Participation in QA Committee Meetings
Penalty
Summary
The facility failed to provide evidence that the Medical Director attended and participated in the required quarterly Quality Assurance (QA) committee meetings. Review of the QA meeting sign-in sheets for four consecutive quarters showed that the Medical Director did not sign the attendance paperwork. During staff interview, the Administrator confirmed that the Medical Director was required to attend and participate in each quarterly QA meeting, and acknowledged that there was no documentation, aside from a statement that the Medical Director attended by telephone, to verify participation. The facility's policy specifies that the QA committee must include the Medical Director, Administrator, Infection Preventionist, Director of Nursing, and at least two other care partners. This deficiency had the potential to affect all 58 residents in the facility, as the required committee composition and participation were not documented as required.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found with heavily stained carpets, soiled toilets, dirty bathroom floors, torn window blinds, and black substances around window frames and walls. In one instance, a resident's pillow had a dried substance that appeared to be blood, and food debris was scattered throughout the carpet. Residents and staff confirmed that cleaning was inconsistent, with some families resorting to cleaning the bathrooms themselves due to ongoing issues such as toilets not flushing properly and persistent soiling. Additionally, lighting issues were identified, with bathroom lights so dim they were nearly out, as confirmed by the maintenance supervisor. Water temperature logs revealed that hot water in several residents' rooms consistently failed to meet the facility's minimum requirement of 108 degrees Fahrenheit, with recorded temperatures ranging from 77 to 104 degrees Fahrenheit over several months. Residents reported receiving cold showers despite staff efforts to let the water run, and the maintenance director acknowledged delays in obtaining repairs and not implementing immediate interventions when water temperatures were below the required threshold. Medical records reviewed for affected residents indicated significant care needs, including cognitive impairment, dependence on staff for medication administration, assistance with activities of daily living, and various medical diagnoses such as congestive heart failure, pressure ulcers, hemiplegia, and seizure disorders. The facility's own policy states that residents have the right to a clean and safe environment, which was not upheld in these instances.
Infection Control Deficiencies in Linen Handling and Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate instances involving two residents. In the first case, a certified nurse aide was observed exiting a resident's room carrying uncovered soiled linens with ungloved hands, allowing the linens to touch her body as she transported them through the hallway to the laundry room. The aide confirmed she did not use gloves or a bag for the linens, stating there were no bags available. Facility policy requires staff to wear gloves, minimize handling, and keep soiled linens covered and away from the body when transporting them. In the second instance, a licensed practical nurse performed wound care on a resident with multiple skin tears on both legs but did not change gloves or sanitize hands between treating the different wound sites. The nurse acknowledged this lapse and stated she should have changed gloves and sanitized hands between each wound treatment. The facility's hand hygiene policy specifies that hand hygiene should occur after contact with wound dressings. Both incidents were verified through staff interviews and policy review.
Failure to Provide Scheduled Activities and Resident Engagement
Penalty
Summary
The facility failed to provide activity programs that support the physical, mental, and psychosocial well-being of residents, as required. Observations, medical record reviews, and interviews revealed that scheduled activities such as morning reminiscing, pottery, morning stretches, and one-on-one visits were not conducted as listed on the activity calendars across multiple houses. Staff interviews confirmed that activities were not held because CNAs were occupied with other duties, such as working in the kitchen, and residents were not encouraged or invited to participate in activities. Several residents with severe cognitive impairments and multiple medical diagnoses, including dementia, diabetes, Parkinson's disease, and depression, were affected. Their care plans indicated a need for encouragement, reminders, and motivation to participate in activities, with preferences for group and individual engagement such as watching television, crafts, BINGO, and socializing. Despite these documented needs and preferences, observations showed that residents were often left in their rooms or sitting idle, with no staff engagement or activity facilitation. Staff interviews further confirmed that activities were inconsistently provided, and residents were not routinely invited or encouraged to join. The facility's policy emphasized the importance of meaningful engagement and staff accountability for activity documentation, but this was not reflected in practice. As a result, the facility did not meet the requirement to provide activities that promote independence and community interaction for all residents reviewed.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Medical Director conducted face-to-face visits with residents at least once every 60 days, as required. Medical record reviews and staff interviews revealed that four residents, each with significant medical diagnoses such as pneumonia meningitis, ulcerative colitis, viral hepatitis, non-traumatic brain dysfunction, dementia, diabetes, cancer, coronary artery disease, Alzheimer's disease, renal insufficiency, and psychotic disorder, had not been seen by the Medical Director within the mandated timeframe. The last documented visit for these residents was on the same date, and subsequent review confirmed that no follow-up visits occurred within 60 days. During an interview, the Administrator acknowledged that the Medical Director was unaware of the requirement to see residents every 60 days.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in delayed care for a resident who was dependent on staff for toileting and transfers. The resident, who had multiple diagnoses including type 2 diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation, was frequently incontinent of bladder and bowel and required substantial assistance with daily activities. On the day in question, the resident activated the call light and waited over an hour for assistance. Although a nurse and a nurse aide entered the room after approximately 30 minutes, the resident had already experienced an incontinence episode and expressed frustration and embarrassment about the situation, noting concerns about her sensitive skin. Staff interviews confirmed that only one RN and one CNA were on duty at the time, and both acknowledged the facility was short staffed. The CNA reported being aware of the resident's accident but stated she needed to prioritize preparing breakfast for other residents before providing assistance. Another CNA confirmed being called in later due to staffing shortages. These observations and interviews demonstrate that the facility did not have sufficient nursing staff on duty to provide timely care and services, directly impacting the resident's dignity and comfort.
Failure to Document Resident Advance Directive and Code Status
Penalty
Summary
The facility failed to obtain and maintain written documentation of a resident's code status and advance directive in the medical record. Upon admission, the resident was noted to have multiple diagnoses, including type two diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation. The admission summary indicated the resident was alert and listed as a full code, while a physician order documented a Do Not Resuscitate Comfort Care (DNRCC) status. However, a subsequent physician progress note again listed the resident as a full code. Review of both the electronic health record (EHR) and the hard copy medical record revealed no copy of an advance directive, although the hard chart was labeled with DNRCC on the outside and the EHR banner also indicated DNRCC. Interviews with facility staff confirmed that there was no signed advance directive in either the paper chart or the EHR for the DNRCC code status. The Quality of Life Coordinator stated that code status was discussed during care conferences, but could not provide documentation of a signed directive. The Administrator confirmed that the resident was admitted with a DNRCC code status according to received records, but later discussions with the resident and family revealed a preference for full code status. The facility's policy required obtaining and placing copies of all advance directives in the medical record, but this was not done for the resident in question.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to timely report an allegation of abuse involving a resident with diagnoses including hemiplegia, cerebral infarction, right hip fracture history, seizure disorder, and hypertension. The resident, who had intact cognition and required moderate staff assistance, reported to two CNAs that a staff member had intentionally turned cold water on him during a shower as a form of mistreatment. The CNAs, after being informed of the allegation, attempted to communicate the incident to their supervisor, the Coach Manager (CM), but the CM did not follow up or report the allegation to the Administrator as required by facility policy. The incident was not reported to the Administrator until it was brought to attention by a surveyor during the annual survey, despite multiple opportunities for staff and the CM to escalate the allegation. Interviews confirmed that neither the CNAs nor the CM reported the abuse allegation to the Administrator or other management in a timely manner, contrary to the facility's policy that mandates immediate reporting of all abuse allegations. The Administrator verified that she was unaware of the incident until the surveyor's inquiry and emphasized that immediate reporting to her or a supervisor is required.
Failure to Provide Timely and Adequate Incontinence Care
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for two residents who were dependent on staff for toileting and personal hygiene. For one resident with a history of impaired mobility, pneumonia meningitis, ulcerative colitis, and viral hepatitis, observation revealed that a CNA did not follow proper perineal care procedures. The CNA did not retract the foreskin or adequately clean and dry the scrotal area during incontinence care, despite the resident being saturated with urine and having feces present. The CNA admitted to rushing the care due to being late, and this was inconsistent with the facility's policy, which outlines specific steps for thorough cleaning and drying to prevent infection. Another resident, who was frequently incontinent of bowel and bladder and dependent on staff for toileting, reported waiting over an hour for assistance after activating the call light. Staff interviews confirmed that both a nurse and a CNA were aware of the resident's need for toileting assistance but prioritized other tasks, resulting in the resident remaining in soiled clothing for an extended period. The resident expressed frustration and embarrassment about the incident, noting concerns about sensitive skin. These findings demonstrate that the facility did not ensure prompt and adequate incontinence care as required.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Loveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Florentine Gardens | 1.9 mi | ★★★★★ | 0 | 0 |
| Arbors At Milford | 2.2 mi | ★★★★★ | 11 | 0 |
| The Laurels Of Milford | 2.7 mi | ★★★★★ | 11 | 0 |
| Loveland Care Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Venetian Gardens | 4.1 mi | ★★★★★ | 1 | 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.