Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein St Marys Retirement Community during CMS and state inspections, most recent first.
Failure to Complete Ordered Heel Wound Treatment: A resident with a heel pressure injury had ordered betadine treatment discontinued when a combined coccyx/heel order was changed, and the heel treatment was not restarted as ordered by the wound NP. MAR review showed no documentation of the heel treatment for several days, and the DON confirmed the omission and that the wound physician had improperly documented a left heel wound on an earlier note.
A resident with Parkinson's disease, dementia, and other diagnoses was found on the floor face down, but nursing did not assess him promptly because an LPN believed he was care planned to be on the floor. The CNA reported the event, the DON later confirmed an unwitnessed time on the floor should be treated as a fall, and the charting did not reflect that the resident had been found face down.
The facility failed to complete ordered catheter tubing and bag changes for one resident with an indwelling urinary catheter, with no documentation that the scheduled changes were done and the DON confirming the omissions. The facility also failed to provide timely incontinence care for another resident who was dependent on staff and always incontinent of stool; a CNA left the soiled brief in place during pericare and said he would return later with the nurse for zinc ointment, despite acknowledging the resident had not been checked for incontinence until then.
Failure to follow a resident’s BiPAP order occurred when staff documented the order as not given on multiple shifts and the chart lacked supporting progress notes. The resident, who had COPD, acute on chronic respiratory failure, CHF, and edema, stated the BiPAP had not been applied since admission because staff said they needed a connector to hook oxygen into the device; an RN confirmed the connector was not available until later.
Medication parameters were not followed for a resident with COPD, CHF, acute on chronic respiratory failure, and localized edema. The resident had orders for Metoprolol Succinate ER and Torsemide with hold parameters for low BP, but MAR review showed both medications were given when BP readings were below the ordered limits. The DON verified the medications were administered outside of parameters, and the facility policy required medications to be given according to the physician's written orders.
Soiled Gloves Used During Incontinence Care: A resident who was dependent for toileting hygiene and always incontinent of stool received incontinence care from two CNAs, during which one CNA continued cleansing after her gloves became soiled with stool, wiped the stool off with toilet paper instead of changing gloves, handled the clean incontinence product, and later used the same soiled gloves to readjust catheter tubing. CDC guidance reviewed by the surveyor stated gloves should be changed and hands cleaned if gloves become soiled.
The facility failed to provide wound care as ordered for a resident with multiple diagnoses, including a displaced bimalleolar fracture and type one diabetes. The care plan required changing the wound vac on specific days, but the facility did not enter the updated orders, resulting in missed wound vac changes. This deficiency was confirmed through a review of records and an interview with the DON.
Failure to Complete Ordered Heel Wound Treatment
Penalty
Summary
Pressure ulcer treatment was not completed as ordered for one resident with skin alterations. The resident was admitted with diagnoses including vitamin D deficiency, atherosclerotic heart disease, neuromuscular dysfunction of the bladder, and spinal stenosis, and was cognitively intact with no pressure ulcers noted on the quarterly MDS. A nursing note documented a physician visit with new orders for betadine to the right heel and Medihoney with bordered gauze to the coccyx. Physician orders later showed the coccyx treatment and right heel betadine order, but the order was discontinued two days later. Wound documentation showed the resident had an unstageable deep-tissue injury with intact skin to the heel, with measurements recorded as 3 cm x 2.5 cm and later 2.8 cm x 2.5 cm with dry, brown/black hard eschar. The wound NP noted the heel was stable and ordered betadine daily, leave open to air. However, the MAR showed betadine was not documented as applied to the right heel for several days, and there was no current order in place. The DON confirmed the right heel treatment was stopped when the coccyx order was changed because it was a combined order, and the right heel treatment was not restarted as ordered. The DON also confirmed the wound physician had improperly documented a left heel wound on the earlier note. Observation later showed the resident's right heel wound with eschar in place.
Delayed assessment after unwitnessed fall
Penalty
Summary
The facility failed to assess a resident timely after an unwitnessed fall. Resident #34 had diagnoses including Parkinson's disease with dyskinesia, primary osteoarthritis, psychotic disorder with delusions, dementia with agitation, and major depressive disorder. The resident's care plan identified a fall risk related to decreased mobility, a deep brain stimulator, Parkinson's disease, and a history of placing himself on the floor to find belongings. Interventions included a mat beside the bed, Dycem on the recliner, keeping the lift chair remote secured, anticipating needs, safety education, proper footwear, and ensuring the call light was within reach. On 06/22/26, a housekeeper observed Resident #34 on the floor face down and reported it to a CNA, who assisted the resident into a bedside chair. The CNA told the LPN the resident had been on the floor, but the LPN did not assess him at that time because the resident was care planned to be on the floor. The DON later confirmed that if Resident #34 was on the floor unwitnessed, it was to be treated as a fall. The resident was not assessed by nursing until later, and the charting did not reflect that he had been found face down. The Falls Management policy stated that after a fall, the nurse will complete a physical assessment for injury and provide immediate care as needed.
Missed catheter maintenance and delayed incontinence care
Penalty
Summary
The facility failed to ensure a resident's urinary catheter tubing and collection bag were changed as ordered. Resident #4 was admitted with diagnoses including neuromuscular dysfunction of the bladder and spinal stenosis, and the quarterly MDS indicated the resident was cognitively intact and had an indwelling urinary catheter. Physician orders directed that the catheter bag and tubing be changed as needed, when visibly soiled or damaged, and every seven days on the night shift. Review of the TAR showed no documentation that the catheter bag or tubing was changed on 06/09/26 or 06/17/26, with the TAR blank on those dates. The last documented change was 06/02/26, and the next documented change was 06/23/26. The DON confirmed there was no documentation that the scheduled changes had been completed. The facility also failed to provide timely incontinence care to a resident who was dependent on staff for toileting hygiene and documented as always incontinent of stool. Resident #5 had diagnoses including acute transverse myelitis, neuromuscular dysfunction of the bladder, type 2 diabetes, and depression. The care plan directed staff to change and assist with toileting as needed and provide pericare after each incontinence episode. During observation, CNA #173 performed pericare but left the soiled incontinence product in place beneath the resident, stating he would return with the nurse after medication pass so zinc ointment could be applied. The CNA acknowledged he had not checked the resident for incontinence until the observation and stated he did not provide incontinence care because the nurse would need to apply medication to the coccyx. The DON stated the expectation was that incontinence care would be provided in a timely manner.
Failure to Follow BiPAP Orders
Penalty
Summary
The facility failed to follow a physician’s BiPAP order for Resident #16, who was admitted with COPD, acute on chronic respiratory failure, CHF, and localized edema. The resident’s admission MDS indicated he was cognitively intact and required supervision with transfers and bed mobility, set up with eating, and moderate assistance with toileting hygiene. The physician ordered BiPAP use every night shift and as needed between meals with specified IPAP, EPAP, respirations, FiO2, and 3 LPM oxygen bleed-in. Review of the June MAR showed a code of 9 documented on multiple dates for the BiPAP order, with chart codes indicating other/see progress notes, but the progress notes did not contain documentation supporting those entries. During interview, the resident stated staff had not applied the BiPAP machine since admission and told him they needed a piece to hook the oxygen into it. Observation at the time of interview did not show oxygen tubing present. An RN who worked the listed night shifts confirmed she entered the code 9 because the connector needed to hook oxygen to the BiPAP was not available until 06/23/26.
Medication Parameters Not Followed During Administration
Penalty
Summary
Resident #16, who was admitted with diagnoses including COPD, acute on chronic respiratory failure, CHF, and localized edema, had intact cognition and required supervision with transfers and bed mobility, set up with eating, and moderate assistance with toileting hygiene. The care plan included monitoring for adverse effects of diuretic therapy, and physician orders were in place for Metoprolol Succinate ER 25 mg, half a tablet daily, and Torsemide 20 mg every other day, both with parameters to hold if SBP was less than 110 mmHg or DBP was less than 60 mmHg. Review of the blood pressure record showed multiple readings below the ordered parameters, including 105/58, 92/46, 104/50, 94/50, 100/52, 101/70, and 98/50. Despite these readings, the June MAR documented administration of Metoprolol Succinate on those dates and Torsemide on several of those dates. During interview, the DON verified that both blood pressure medications were administered outside of parameters, and the facility policy stated medications are to be administered in accordance with the attending physician's written orders.
Soiled Gloves Used During Incontinence Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when infection procedures were not followed during incontinence care for one resident. Resident #5 was admitted with diagnoses including acute transverse myelitis in demyelinating disease of the central nervous system, bacteremia, neuromuscular dysfunction of the bladder, type 2 DM, local infection of the skin and subcutaneous tissue, psoriasis, and depression. The quarterly MDS showed a BIMS score of 14, indicating intact cognition, and the resident was dependent on staff for toileting hygiene and always incontinent of stool. The care plan included interventions to change and assist with toileting as needed and to provide pericare after each incontinence episode. During observation of incontinence care, two CNAs assisted the resident after a stool episode. One CNA cleansed stool from the groin area while both staff used toilet paper for cleansing. CNA #183 was observed with excrement on both gloves, looked at her gloves, used toilet paper to remove stool from them, and continued assisting with cleansing without changing gloves. She then pulled the clean incontinence product out from under the resident and later used the same soiled gloves to readjust the catheter tubing over the resident's leg. In interview, CNA #183 confirmed she wiped stool from both gloves with toilet paper and did not change them until after incontinence care was completed and the catheter tubing had been repositioned. CDC guidance reviewed by the surveyor stated gloves should be changed and hands cleaned if gloves become soiled.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple diagnoses, including a displaced bimalleolar fracture, type one diabetes, and major depressive disorder. The resident required extensive assistance for ADLs and had surgical wounds. The care plan included specific interventions for skin integrity, such as changing the wound vac on specified days. However, the facility did not enter the updated orders to change the wound vac on Thursday and Saturday, resulting in the wound vac not being changed on those days. The deficiency was confirmed through a review of the Treatment Administration Record (TAR) and an interview with the Director of Nursing (DON), who verified that the order was not put in for the wound vac change on the specified days. This oversight led to the wound vac not being changed as required, affecting the resident's wound care management. The deficiency was investigated under Complaint Number OH00152598.
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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 St Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grande Lake Healthcare Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Vancrest Of St Mary's | 3.5 mi | ★★★★★ | 5 | 0 |
| Transitional Care Unit | 3.6 mi | ★★★★★ | 4 | 0 |
| Gardens At Celina | 7.4 mi | ★★★★★ | 3 | 0 |
| Celina Manor | 7.7 mi | ★★★★★ | 13 | 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 October 2026) and official state health department websites.