Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Portage Valley during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and identified fall risk experienced a fall in the room during nighttime hours, reported hitting the head, and was found to have repeatedly elevated BP readings on a neurological assessment. Although an assessment and vital signs were obtained, the provider was not notified until many hours later, and there was no documentation that the elevated BP values were communicated. The record also lacked any documentation that the resident’s family or representative was informed of the fall or change in condition, despite staff interviews and facility policy confirming that both the physician and family should be notified after such events.
Surveyors found that opened food items in a walk-in freezer, including pizzas, dough, potato wedges, rolls, bread, and diced onions, were left undated and improperly stored, despite facility policy requiring all opened and prepared foods to be covered, labeled, and dated for proper stock rotation and prevention of foodborne illness. The Dietary Manager confirmed that opened items should be dated and acknowledged the discrepancy between practice and policy, and the facility verified that all residents received food from this kitchen, meaning the issue had the potential to affect the entire resident census.
A resident with severe chronic pain was admitted with orders for multiple pain medications, including narcotics and adjuncts, all of which were available in the facility's medication dispensing system. Despite this, only Tylenol was administered for severe pain, as nursing staff did not follow procedures to access or authorize the prescribed medications. The resident continued to experience uncontrolled pain, ultimately requiring emergency transfer to the hospital for pain management.
Two residents did not receive medications as ordered due to staff failing to verify medication dosages and not administering available medications from the Cubex machine. In one case, an RN gave a depression medication without confirming the dosage, and in another, a resident with severe pain was not given prescribed narcotics or gabapentin despite their availability, resulting in unmanaged pain.
A facility failed to assess a new bruise and conduct neurological assessments for a resident with dementia and a history of a subdural hematoma. The resident's bruise was noted without detailed assessment, and no neurological checks were performed despite facility policy. Staff interviews revealed inconsistent assessment practices and lack of protocol adherence.
The facility failed to prevent falls and adequately monitor injuries for two residents. One resident, at risk for falls, did not receive a timely wheelchair evaluation, leading to a fall. Another resident experienced an unwitnessed fall, and the facility did not conduct neurological checks or monitor injuries as required. These deficiencies highlight inadequate response to fall risks and injuries.
A resident with dementia and muscle wasting experienced a fall that was not documented in their medical record, despite being noted in the MDS assessment. The fall, which resulted in an abrasion and bruising, was recorded in the facility's confidential risk management system but omitted from the resident's progress notes. The DON confirmed the lack of documentation in the medical record, and the incident was identified during a complaint survey.
A facility failed to address a legal guardian's request to keep a resident's wheelchair next to the bed, despite the resident's cognitive impairment and risk of falls. Observations showed the wheelchair was in the bathroom, not by the bed, and staff interviews confirmed the oversight. The facility did not review or implement the guardian's request, leading to non-compliance with resident rights.
A resident with dementia and incontinence issues was treated without dignity by an STNA, who loudly questioned the resident about urinating on himself. The incident was captured on video and reviewed by the resident's family, leading to a complaint. The facility's DON and Administrator acknowledged the lack of respect and dignity in the interaction, which violated the Ohio Nursing Home Residents' Rights.
The facility did not complete reference checks for a newly hired STNA, as required by their policy. This deficiency was confirmed through personnel record reviews and an Administrator interview, potentially affecting all 48 residents.
A resident with paralysis and dysphagia was not assisted with eating, despite being care planned for extensive assistance. The resident's lunch tray was left untouched, and staff interviews revealed a lack of communication and follow-through. The facility lacked specific policies for feeding dependent residents.
The facility failed to administer medications as ordered by the physician and in accordance with manufacturer instructions, resulting in a medication error rate of 10.26%. Errors included improper timing of insulin administration, failure to prime the insulin pen, and unavailability of prescribed eye drops for a resident with COPD and Type II Diabetes Mellitus.
A facility failed to ensure a resident with type II diabetes mellitus was free from significant medication errors when an LPN administered insulin after the resident had consumed 75% of their meal and did not prime the insulin pen as required. The LPN was unaware of the need to prime the pen, leading to potential incorrect dosage delivery.
Failure to Notify Physician and Family After Resident Fall With Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a physician and the resident’s representative of a change in condition following a fall. A resident admitted with multiple significant diagnoses, including an intracapsular fracture of the left femur, COPD, protein calorie malnutrition, Alzheimer’s disease, a stage three sacral pressure ulcer, and anemia, had severely impaired cognition with a BIMS score of three and required assistance with transfers and toileting. The resident was care planned as being at risk for falls due to cognitive impairment, gait and balance problems, poor communication/comprehension, and unawareness of safety needs. The incident/accident log and progress notes showed that the resident was found on the floor of her room at 1:55 A.M., reported hitting her head, and had an initial blood pressure of 197/106 and oxygen saturation of 90%. A neurological assessment documented continued elevated blood pressures (191/103, 198/95, 191/97, and 203/108) over the next several hours. Despite these findings, the physician was not notified of the fall until 11:12 A.M., and there was no documentation that the elevated blood pressures were reported. The medical record also contained no documentation that the resident’s family or representative was notified of the fall or the elevated blood pressure readings. Staff interviews confirmed that such elevated blood pressures should be re-evaluated and reported to the physician, that family should always be notified of a fall or change in condition, and that based on the assessment and continued elevated blood pressure, the provider should have been notified. The ADON verified that the physician should have been contacted after the assessment and that family should have been notified when the fall occurred. The facility’s Falls Management policy required notifying the resident representative and physician of the fall and findings following the immediate assessment, which was not followed in this case.
Improper Storage and Labeling of Opened Food Items in Freezer
Penalty
Summary
Surveyors identified a deficiency in food storage practices when, during an observation of walk-in freezer #1, they found multiple opened and undated food items, including cheese pizzas, a bag of pizza dough, a bag of potato wedges, dinner rolls, brown bread, and a bag of diced onions. The Dietary Manager confirmed that these items were open and undated and acknowledged that facility practice requires any food item that is opened to be marked with an open date. Review of the facility’s Food Storage Policy and Procedure, revised May 2013, showed that its purpose is to assure all food is stored, labeled, and dated properly to ensure stock rotation and prevent foodborne illnesses, and that prepared food is to be covered, dated, and labeled with the preparation date and a use-by date four to seven days after preparation. The facility verified that all residents received food from the kitchen, so the improperly stored and unlabeled food in the freezer had the potential to affect the entire census of 44 residents. This deficiency represents non-compliance investigated under Complaint Number 2701756.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of chronic and severe back pain, including diagnoses such as chronic pain syndrome, intervertebral disc degeneration, radiculopathy, spinal stenosis, and spondylosis, was admitted to the facility. Upon admission, the resident was alert and oriented, and had physician orders for multiple pain management medications, including gabapentin, Percocet (a narcotic), quetiapine fumarate, and Tylenol. The baseline care plan specified the need for pain medication as prescribed and administration prior to treatments. Despite these orders, only Tylenol was administered when the resident reported severe pain rated at 10 out of 10, and the Tylenol was not effective in managing the pain. The facility's medication administration records and interviews confirmed that the prescribed pain medications, including narcotics and other adjuncts, were available in the facility's Cubex machine at the time of the resident's admission. The process for accessing these medications required nursing staff to call the pharmacy for authorization, which was not done. The pharmacist confirmed that no calls were received for authorization to access the resident's pain medications, and the nurse on duty did not recall attempting to access the Cubex or contacting the pharmacy. As a result, the resident did not receive the prescribed pain management regimen and continued to experience uncontrolled pain. Later that evening, the resident was found on the floor after calling a family member for help due to ongoing pain. Emergency services were called by the family, and the resident was transported to the emergency room, where she reported not receiving her prescribed narcotic medications and only receiving Tylenol. In the ER, the resident was administered morphine, which resulted in improved pain control. Facility policy required assessment and timely administration of pain medication as prescribed, but this was not followed, resulting in a failure to provide safe and appropriate pain management for the resident.
Failure to Verify and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medication doses were properly verified prior to administration and did not administer available medications as ordered by physicians for two residents. In the first instance, a resident with a diagnosis of depression and mild cognitive impairment was prescribed Wellbutrin XL 150 mg to be taken in the morning. During a medication pass, an RN administered a pill labeled as bupropion ER XL without a dosage indicated on the packaging. The RN did not verify the dosage before administration, relying solely on pill recognition, and did not contact the pharmacy to confirm the correct dosage or report the labeling issue. In the second case, a resident admitted with multiple pain-related diagnoses was prescribed Percocet, Tylenol, and gabapentin for pain management. Although both Percocet and gabapentin were available in the facility's Cubex machine, the resident was only given Tylenol for severe pain, as the nurse did not access the Cubex for the other medications or contact the pharmacy for authorization. The resident's pain was not effectively managed, and the prescribed medications were not administered as ordered, despite being available on-site. Interviews with pharmacy staff, nursing staff, and facility leadership confirmed that the required medications were present in the Cubex machine and that staff were aware of the procedures to access them. Facility policies required medications to be administered as prescribed and for staff to verify medication details prior to administration, but these procedures were not followed in the cases reviewed.
Failure to Assess Bruise and Conduct Neurological Assessments
Penalty
Summary
The facility failed to properly assess a newly identified bruise and did not conduct necessary neurological assessments following a head injury for a resident. The resident, who had diagnoses of dementia, anxiety, and osteoporosis, was admitted after a fall that resulted in a small subacute subdural hematoma. Despite the hospital's recommendation for follow-up, the facility did not document any neurological assessments after a new bruise was observed on the resident's forehead. The bruise was noted in a progress note and a Weekly Skin Observation Tool, but lacked detailed assessment including size, color, or other characteristics. Interviews with facility staff revealed inconsistencies in the assessment of the bruise. The Director of Nursing (DON) admitted there was no specific protocol for assessing new bruises, leading to varied practices among nurses. A Licensed Practical Nurse (LPN) did not document the bruise's characteristics, assuming it had been done by a previous shift. The DON confirmed that no neurological assessments were conducted because the bruise was not considered a hematoma, despite the facility's policy requiring such assessments following head trauma. The facility's policies on skin care management and neurological assessment were not adhered to, contributing to the deficiency.
Failure to Implement Fall Prevention and Monitoring Protocols
Penalty
Summary
The facility failed to implement timely interventions to prevent a fall for a resident with dementia and epilepsy, who was at risk for falls. Despite being identified as needing a wheelchair evaluation on 12/16/24, the therapy department was not notified until 01/08/25, after the resident slid from the wheelchair on 01/03/25. The resident's care plan was not updated with necessary interventions until 03/03/25, and no modifications were made to the wheelchair to reduce fall risk, leaving the resident vulnerable to further incidents. Another resident with dementia and muscle wasting experienced an unwitnessed fall on 12/14/24, resulting in a non-major injury. The facility failed to conduct neurological checks in accordance with their policy, with the first assessment occurring approximately six hours after the fall. Additionally, the facility did not consistently monitor the resident's injuries, as required by physician orders, with several shifts lacking documentation of the necessary assessments. The facility's deficiencies in both cases highlight a lack of timely and adequate response to fall risks and injuries. The failure to promptly evaluate and modify equipment, update care plans, and conduct required assessments and monitoring contributed to the non-compliance identified in the report.
Failure to Document Fall Incident in Resident's Medical Record
Penalty
Summary
The facility failed to document a fall incident in the medical record of a resident diagnosed with dementia and muscle wasting. The resident, who was dependent on transfers and used a wheelchair, experienced a fall with a non-major injury. Despite the fall being noted in the quarterly Minimum Data Set (MDS) assessment, there was no documentation of the fall in the resident's progress notes from 12/14/24 to 12/16/24. The neurological assessments were completed on 12/14/25 and 12/15/24, and a 72 Hour QShift Follow Up Assessment was conducted on 12/15/24, but these did not include details of the fall. The Director of Nursing (DON) confirmed that the fall was documented in the facility's confidential risk management system but not in the resident's medical record. The incident report, which was marked as privileged and confidential, detailed the circumstances of the fall and the injuries sustained, including an abrasion and bruising to the resident's left eyebrow. The interdisciplinary treatment team met to develop a fall intervention plan following the incident. This deficiency was identified during a complaint survey.
Failure to Address Guardian's Request for Resident's Safety
Penalty
Summary
The facility failed to adequately address requests made by a resident's legal guardian, affecting a resident with cognitive impairment and multiple health issues, including dementia and severe protein-calorie malnutrition. The resident's daughter, appointed as the legal guardian, requested that the resident's wheelchair be placed next to the bed to prevent falls, as the resident sometimes attempted to get up independently to use the bathroom. Despite the guardian's request and a sign posted in the resident's room as a reminder, the wheelchair was observed in the bathroom, not next to the bed, during multiple observations. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed the guardian's request and the resident's tendency to attempt getting out of bed without assistance. However, the Administrator was uncertain about the necessity of the request and whether the facility had implemented it. The facility's documentation showed no evidence of reviewing the guardian's request, conducting assessments related to the request, or implementing the specific interventions identified on the signs in the resident's room. This deficiency was investigated under a specific complaint number and highlighted non-compliance with the facility's responsibilities to uphold resident rights.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by an incident involving a nursing assistant and a resident with impaired cognition and incontinence issues. The resident, who had diagnoses including dementia, pulmonary fibrosis, and chronic obstructive pulmonary disease, was observed in a video recording being treated without dignity by a State Tested Nursing Assistant (STNA). The STNA entered the resident's room, raised her hands, and loudly questioned the resident about urinating on himself, which was perceived as aggressive behavior by the resident's daughters who reviewed the video. The STNA admitted to speaking loudly because the resident was hard of hearing, but the Director of Nursing and the Administrator, upon reviewing the video, acknowledged that the interaction lacked respect and dignity. The STNA's actions were not aligned with the Ohio Nursing Home Residents' Rights, which emphasize the right to be treated with courtesy and respect. The incident was reported as a deficiency under a Master Complaint Number, indicating non-compliance with regulatory standards.
Failure to Complete Employee Reference Checks
Penalty
Summary
The facility failed to ensure that employee reference checks were completed for a State tested Nursing Assistant (STNA) hired on 04/11/23. This oversight was identified during a review of personnel records, which revealed that reference checks for the STNA had not been conducted. An interview with the Administrator confirmed the absence of documentation for completed reference checks. The facility's policy, last revised on 10/25/22, mandates that attempts be made to obtain information from previous or current employers before hiring new employees. This deficiency had the potential to affect all 48 residents in the facility.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for eating received the necessary assistance during meals. Resident #16, who was admitted with diagnoses of intracerebral hemorrhage with left-sided paralysis and dysphagia, was care planned to receive extensive assistance from one staff member for eating. Despite this, observations and documentation revealed that the resident's lunch tray was left untouched in her room, with the food appearing unoffered and uneaten. Interviews with staff indicated a lack of communication and follow-through, as the STNA responsible for feeding the resident did not return to assist after initially leaving the tray. The incident was further compounded by a lack of facility policies specifically addressing the feeding of residents dependent on staff assistance. Interviews with the facility's administrator and staff confirmed that interventions were based solely on the care plan, without additional guidelines or protocols. This deficiency was identified during a complaint investigation and highlighted the potential impact on other residents requiring similar assistance.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions, resulting in a medication error rate above five percent. Specifically, four medication errors were observed out of 39 opportunities, leading to a medication administration error rate of 10.26%. This affected one resident who had multiple medications prescribed for chronic obstructive pulmonary disease (COPD) and Type II Diabetes Mellitus. The errors included administering insulin Lispro after the resident had already consumed 75% of their meal, not priming the insulin pen before administration, and administering aerosol treatments outside the prescribed time frames. Additionally, the prescribed Polyvinyl Alcohol eye drops were not administered because they were unavailable in the facility. Observation and interviews with the involved LPN confirmed the discrepancies in medication administration. The LPN was unaware of the requirement to prime the insulin pen before use and acknowledged the unavailability of the eye drops. The facility's medication administration procedure mandates that medications be administered within one hour before or after the scheduled time, except for before or after meal orders, which should be based on meal times. The failure to adhere to these guidelines and manufacturer instructions contributed to the observed medication errors.
Failure to Administer Insulin as Ordered and Improper Use of Insulin Pen
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when medications were not administered as ordered by the physician. Specifically, a Licensed Practical Nurse (LPN) administered insulin to a resident after the resident had already consumed 75% of their meal, contrary to the physician's order to administer the insulin before meals. Additionally, the LPN did not prime the insulin pen before administration, which is required to ensure the correct dosage is delivered. The LPN was unaware of the need to prime the pen, as confirmed during an interview. The resident involved had type II diabetes mellitus and was prescribed Humalog KwikPen insulin to be administered according to a sliding scale before meals and at bedtime. The failure to administer the insulin as ordered and the lack of priming the pen were observed during a medication administration round. The facility's policy on medication administration requires medications to be administered within one hour before or after the scheduled time, except for before or after meal orders, which should be based on meal times. This deficiency was identified during a complaint investigation and affected one of three residents observed during medication administration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 676 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pemberville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Genoa Retirement Village | 6.5 mi | ★★★★★ | 14 | 0 |
| Windsor Lane Healthcare Center | 8.4 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Perrysburg | 9.2 mi | ★★★★★ | 39 | 0 |
| Willows At Bowling Green The | 9.4 mi | ★★★★★ | 1 | 0 |
| Three Meadows Post Acute | 10 mi | ★★★★★ | 13 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Otterbein Portage Valley.
100% money-back within 48 hours.
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.