Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Springboro during CMS and state inspections, most recent first.
Unlocked Medication Cart: A medication cart in the 300 cottage was observed unlocked with no nurse present nearby, while medications for 11 residents were stored inside. The Administrator verified the cart was unsecured, and the facility policy required medications and biologicals to be stored safely and securely and accessible only to authorized personnel.
Menu portion sizes were not followed for residents on regular and bite-sized diets. A CNA was observed serving broccoli, rice, chicken, and a breadstick in portions that did not match the posted menu, and she stated she did not know the required portion sizes. The RD confirmed the menu listed portion sizes but said the kitchen did not follow exact portions.
Cross-Contamination During Food Prep and Dishwashing Deficiency: A CNA prepared resident meal trays with the same gloved hands after touching multiple surfaces and food items, and another CNA used the same gloves to scrub dirty dishes and then plate food without washing hands or changing gloves. Surveyors also found expired buns in one kitchen and a dishwasher wash temperature below the manufacturer’s recommended range.
Failure to convey resident funds after discharge. A resident with cerebral infarction, adult failure to thrive, OA, HTN, CKD, dementia with agitation, and anxiety disorder was severely cognitively impaired and had a POA-authorized resident funds account. The account remained open after discharge and was not closed until months later, when the remaining balance was issued to the Treasurer of the State; the BOM confirmed the funds were not conveyed within 30 days.
Missing Activities Care Plan and Preferences Not Documented: A resident with Alzheimer’s disease, dementia, anxiety, and depression was assessed as moderately cognitively impaired and needed set-up help with eating, oral hygiene, and personal hygiene. The MDS showed the resident valued reading books, newspapers, and magazines and liked listening to music, but the care plan did not include an activities care plan or the resident’s activity preferences, which was confirmed by the Administrator.
Care plan did not accurately reflect a resident's tube feeding needs. A resident with Parkinson's disease, Lewy Body neurocognitive disorder, severe cognitive impairment, and dysphagia was dependent for ADLs and receiving Jevity 1.5 via G-tube, but the care plan stated the resident did not want tube feed or IV while also documenting ongoing tube feeding. The MDS nurse and DON verified the inconsistency, and the resident's daughter wanted tube feeding administered.
Insulin Pen Not Primed Before Use: An RN administered a resident’s Admelog SoloStar without priming the new pen needle first. The resident had type 2 DM, CKD, anxiety, and dementia, and was receiving scheduled insulin injections. The RN confirmed the needle was not primed and stated it did not need to be. The manufacturer’s instructions and the facility’s insulin pen policy both required priming before dialing the prescribed dose.
Failure to Use EBP for Residents With Wounds and Breaks in Hand Hygiene During Wound Care: The facility did not ensure EBP was used for two residents with wounds, including one resident with a surgical back wound and another with pressure injuries, despite wound-related care plans and available PPE. In addition, an RN performed wound care for a resident with a left heel wound without changing gloves or washing hands after touching the bed remote, leaving the room, or removing the soiled dressing, and later confirmed the hand hygiene lapses.
Pneumococcal Vaccine Not Offered: A resident with multiple chronic conditions and moderate cognitive impairment had a pneumococcal vaccine consent that showed the POA neither consented nor declined vaccination. The record showed prior PPSV23 receipt, but there was no documentation that PCV20, PCV21, or PCV15 was offered or declined, and no additional pneumococcal vaccine was given.
Staff left a pot of eggs cooking on a boiling gas stove in an unattended kitchen with the entry gates open, potentially affecting several cognitively impaired and independently mobile residents. Interviews confirmed that staff are required to keep the kitchen gates closed and never leave the stove unattended, as outlined in facility orientation materials.
Unlocked Medication Cart
Penalty
Summary
Medication carts were not kept locked as required. During observation on 04/30/26 at 8:10 A.M., the 300 cottage medication cart was found unlocked, and no nurse was visible near the unsecured cart. At 8:12 A.M., the Administrator verified that the cart was unlocked and that a nurse was not present in the cottage. The Administrator also verified that the medications for Residents #5, #7, #14, #15, #18, #33, #34, #52, #54, #55, and #57 were stored in that cart. Review of the facility policy titled Medication Storage in the Facility, dated May 2022, stated that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Menu Portion Sizes Not Followed
Penalty
Summary
The facility failed to ensure menu portion sizes were followed for residents on regular and bite sized diets. The week-at-a-glance menu for house 9349 dated 04/27/26 specified that residents on regular and bite sized diets were to receive five ounces of grilled chicken, four ounces of broccoli, one-half cup of rice pilaf, and one breadstick for lunch. During observation in the kitchen at 12:36 P.M., CNA #166 was seen serving residents on regular diets two scoops of broccoli with an unlabeled spoon, a scoop of rice with an unlabeled spoon, a piece of chicken that she cut in half, and a breadstick. The CNA was also observed serving residents on bite size diets two scoops of broccoli with an unlabeled spoon, a scoop of rice with an unlabeled spoon, a piece of chicken that she cut in half and then into bite size pieces with kitchen scissors, and a breadstick. During interview, CNA #166 stated she did not know the portion sizes for regular or bite size diets and confirmed she was not following the menu portion sizes. The RD also verified that portion sizes were listed on the menu but stated the facility had an open concept kitchen and did not follow exact portion sizes.
Cross-Contamination During Food Preparation and Dishwashing Temperature Deficiency
Penalty
Summary
Food was not served in a manner that protected against cross-contamination during meal preparation in multiple kitchen areas. In the rehab unit, CNA #124 prepared trays for 10 residents by handling hamburger buns, sauced ground beef, canned fruit, and plate covers with the same gloved hands while moving between tasks, including reaching into a bag for buns, placing fruit into serving dishes, and covering plates without changing gloves or sanitizing hands. During interview, CNA #124 confirmed she touched buns with gloves after touching other surfaces and utensils without changing gloves or sanitizing hands. In the 300 cottage kitchen, CNA #149 was observed scrubbing dirty dishes while wearing gloves and then using the same gloves to plate spaghetti, salad, and breadsticks without removing the gloves or washing hands. CNA #149 verified she had used the same gloves to wash dirty dishes, plate food items, and touch the breadsticks. The facility also had a pack of expired buns dated 04/25/26 in House 9336, and the dishwasher in House 9320 was observed with a wash temperature of 134 degrees Fahrenheit and a rinse temperature of 185 degrees Fahrenheit, below the manufacturer’s recommended wash temperature of 155 to 160 degrees Fahrenheit.
Failure to Convey Resident Funds After Discharge
Penalty
Summary
The facility failed to ensure resident funds were conveyed within 30 days of discharge from the facility. This affected one resident, who had diagnoses including cerebral infarction, adult failure to thrive, osteoarthritis, hypertension, chronic kidney disease, dementia with agitation, and anxiety disorder. The resident was severely cognitively impaired on the quarterly MDS assessment, and the resident’s POA had authorized a resident funds account at the facility. Review of the resident funds account showed a beginning balance of $69.14 and an ending balance of $49.14 on the quarterly statement covering 07/01/25 to 09/30/25. The resident discharged from the facility on 10/13/25, but the account was not closed until 01/14/26, when a debit of $49.14 was posted to close the account and a check for $49.14 was issued to the Treasurer of the State. The BOM verified in interview that the resident’s funds account was not conveyed within 30 days of discharge. The facility policy stated resident trust accounts would be closed and refunded per regulatory guidelines.
Missing Activities Care Plan and Preferences Not Documented
Penalty
Summary
The facility failed to ensure that Resident #23 had an activities care plan. Resident #23 was admitted with diagnoses including Alzheimer's disease with late onset, paroxysmal atrial fibrillation, incisional hernia with obstruction without gangrene, hypertension, pure hypercholesterolemia, sleep apnea, atherosclerotic heart disease of native coronary artery without angina pectoris, generalized anxiety disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance, acute kidney failure, restlessness and agitation, other vitamin B12 deficiency, iron deficiency anemia, anxiety disorder, and major depressive disorder. The annual MDS assessment showed the resident was moderately cognitively impaired and required set up assistance with eating, oral hygiene, and personal hygiene. The MDS interview for daily and activity preferences documented that it was very important to the resident to have books, newspapers, and magazines to read and to keep up with the news, and that it was somewhat important to listen to music he liked. Review of the care plan dated 04/28/26 showed the resident did not have an activities care plan and the resident's activities preferences were not listed in the care plan. The Administrator confirmed on 04/29/26 that the resident did not have an activities care plan and that the resident's activities preferences were not listed in the care plan. The facility policy titled Comprehensive Care Planning stated the interdisciplinary team was responsible for developing, implementing, and evaluating a comprehensive person centered plan of care.
Care Plan Did Not Reflect Tube Feeding Needs
Penalty
Summary
The facility failed to ensure the comprehensive care plan was developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by an interdisciplinary team for a resident with tube feeding needs. Resident #3 was admitted with Parkinson's disease, neurocognitive disorder with Lewy Bodies, and oropharyngeal dysphagia. The MDS assessment showed severe cognitive impairment with a BIMS score of 00, and the resident was dependent for ADLs and required a Hoyer lift for transfers. Physician orders and the MAR showed the resident was receiving Jevity 1.5 at 30 ml per hour via gastrostomy tube. The care plan dated 02/07/26 stated the resident was on hospice/comfort care, did not eat enough to prevent decline, and did not want tube feed or IV. However, the same care plan also documented that the resident was receiving Jevity 1.5 at 30 ml per hour for 24 hours with 150 ml water flush every four hours. During interview, the MDS Nurse and DON verified that the care plan documented both that the resident did not want tube feeding and that the resident was receiving tube feeding, and they stated the resident's daughter wanted tube feeding administered. The facility policy stated the interdisciplinary team is responsible for developing, implementing, and evaluating the comprehensive, person-centered plan of care, and that the care plan is updated quarterly and with any significant change in resident status.
Insulin Pen Not Primed Before Administration
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when an insulin pen administration device was not primed before use. During observation of medication administration, RN #312 prepared Resident #37’s Admelog SoloStar by attaching a new needle and dialing the ordered dose of six units, but did not prime the new needle before giving the insulin. The insulin was then administered subcutaneously to the resident’s right arm. When interviewed immediately afterward, RN #312 confirmed that the pen needle had not been primed and stated that the needle did not need to be primed. Resident #37 was admitted on 05/14/25 and had diagnoses including type two diabetes mellitus, anxiety disorder, chronic kidney disease, and dementia. The annual MDS indicated moderately impaired cognition and that the resident received insulin injections. The physician order was for Admelog SoloStar 100 units/ml, six units subcutaneously before meals for type two diabetes mellitus with hyperglycemia. The manufacturer’s instructions required a safety check by dialing up two units and pressing the injection button until insulin appeared before selecting the prescribed dose, and the facility’s insulin pen policy also required priming the pen needle before dialing the patient’s dose.
Failure to Use EBP for Residents With Wounds and Breaks in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to provide Enhanced Barrier Precautions (EBP) for residents with wounds. Resident #67 was admitted with diagnoses including an unspecified lumbar vertebra fracture, rheumatoid arthritis, and obstructive sleep apnea, and had impaired skin integrity related to a surgical wound to the back. The care plan addressed the wound with treatments, weekly skin checks, a pressure-reducing mattress, and frequent turning and repositioning, but the medical record showed no order for EBP. During observation, there was no EBP sign outside the room, and the RN confirmed the resident had a surgical wound with daily dressing changes and no EBP order or sign on the door. Resident #68 was admitted with diagnoses including adult failure to thrive, anxiety disorders, trigeminal neuralgia, recurrent major depressive disorder, moderate protein calorie malnutrition, and chronic kidney disease stage II. The care plan identified impaired skin integrity related to pressure injuries to the right lateral hip, coccyx, and right ankle, with interventions including ordered treatments, weekly skin screens, a pressure-reducing mattress, and frequent turning and repositioning. The medical record showed no order for EBP, although an EBP sign was attached to the door frame and PPE was available in the room. A CNA entered and provided morning care without donning PPE, and later stated the resident was not on precautions and that she had assisted with transferring, dressing, and toileting without wearing PPE other than procedure gloves. The facility also failed to ensure appropriate hand sanitization during wound treatment for Resident #51, who had diagnoses including senile degeneration of the brain, anxiety disorder, mild protein calorie malnutrition, constipation, atherosclerosis of the aorta, weakness, osteoarthritis of the left knee, and urinary retention. The resident was moderately cognitively impaired, required extensive assistance with activities of daily living, and had a left heel wound ordered for daily cleansing and dressing. During wound care, the RN touched the bed remote, left the room to get a biohazard bag, returned without changing gloves, removed the soiled dressing, cleansed the wound, applied skin prep, and placed a new dressing without washing hands or changing gloves. The RN later verified she had not washed her hands or donned new gloves after touching the bed remote, leaving the room, or removing the soiled dressing, and stated she only needed to wash her hands and don new gloves at the beginning of wound care because it was not sterile.
Pneumococcal Vaccine Not Offered
Penalty
Summary
The facility failed to ensure a pneumococcal vaccine was offered to one resident reviewed for vaccinations. Resident #43 was admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, dysphagia, hyperlipidemia, spinal stenosis, heart failure, constipation, dementia, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, epilepsy, generalized anxiety disorder, and insomnia. The resident’s annual MDS showed moderate cognitive impairment and the need for assistance with eating, oral hygiene, personal hygiene, toileting, showering, and lower body dressing. Review of the resident’s pneumococcal vaccine consent showed the POA neither consented nor declined the vaccine, and the record documented prior receipt of PPSV23. The MAR showed no additional pneumococcal vaccines were given during the reviewed period. The Administrator verified that the POA neither consented nor declined the pneumococcal vaccine and that there was no information showing the resident was offered or declined PCV20, PCV21, or PCV15. CDC guidance reviewed by surveyors stated that adults over age 50 who previously received PPSV23 should have the option to receive PCV20 or PCV21 in more than one year, or PCV15 in more than one year.
Unattended Kitchen and Open Gates Create Accident Hazard
Penalty
Summary
Staff failed to ensure a safe environment in the facility kitchen, as observed when a pot of eggs was left cooking on a boiling gas stove in an unattended kitchen with the entry gates open. This situation had the potential to affect four cognitively impaired and independently mobile residents out of twelve residing in the house. Interviews with the Administrator and a CNA confirmed that the stove should never be left unattended while in use and that kitchen gates are supposed to be closed when the kitchen is unattended or the stove is on. Review of the facility's orientation education document also indicated that staff are required to lock the kitchen gates when cooking or not present in the common area and to ensure the stove is off when not in use.
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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 Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Austin Trace Health And Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Hillspring Health Care & Rehab | 2.3 mi | ★★★★★ | 0 | 0 |
| Centerville Health And Rehab | 4.5 mi | ★★★★★ | 5 | 0 |
| St Leonard Hcc | 4.6 mi | ★★★★★ | 2 | 0 |
| Sycamore Trails Post Acute | 5.1 mi | ★★★★★ | 0 | 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.