Inspection·June 20, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview and policy review, the facility failed to ensure expired medications and supplies were discarded appropriately. This had the potential to affect all 107 residents in the facility. Additionally, the facility failed to properly secure medications. This had the potential to affect four independently mobile and confused residents (#101, #23, #91, #57) identified by the facility. The facility census was 107. Findings include: 1. Observation of the medication room on the Westhall medication storage room on 06/19/19 at 9:05 A.M. revealed Brovana inhalation solution 15 microgram (mcg)/2 millimeter (ml) with an expiration date of 02/19. Interview with Unit Manager #266 on 06/19/19 at 9:25 A.M. verified that the above items were expired and being stored in the medication room during the survey. 2. Observation of the medication room located in the East Hall on 06/19/19 at 9:45 A.M. revealed one idosorb 40 gram (g) tube of ointment with an expiration date of 05/2018, and Citracal gummies calcium supplement with an expiration date of 04/19. 3. Observation of the East Hall medication cart on 06/19/19 at 10:00 A.M., revealed one multiple dose bottle of aspirin 325 milligram(mg) with an expiration date of 05/2019. Interview with Unit Manager #241 on 06/19/19 at 10:05 A.M., verified the above items located in the medication storage room and the medication cart were expired and being stored during the survey. 4. Observation of the Rehabilitation Unit Medication room on 06/19/19 at 10:20 A.M., revealed seven Nicotine Transdermal system patches with an expiration date of 12/18 were being stored during the survey. 5. Observation of the Rehabilitation Unit medication cart on 06/19/19 at 10:35 P.M., revealed three opsite flexigrid dressing with an expiration date of 11/2018, one bottle of Systane 10 ml lubricant eye drops with an expiration date of 04/19 and one package of triple antibiotic ointment with an expiration of 04/19 were being stored in the care during the survey. Interview with the Unit Manager #389 immediately following observation verified the above expired items being stored in the medication room and the medication cart should have been removed and were not. The facility confirmed the expired medications at the potential to affect all 107 residents residing in the facility. Review of the policy titled Medication Storage dated 08/16, was silent regarding expired medication. 6. Observation of medication administration on 06/18/19 at 5:45 P.M. revealed a multiple dose bottle of vitamin B 500 micrograms (MCG) and multiple dose bottle of glucosamine/chondroitin 500 milligram (mg)/400 mg was left on top of the medication cart in the [NAME] hall unsecured and unsupervised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365506 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Dorothy Love 3003 West Cisco Road Sidney, OH 45365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 while the nurse administered medication in the Buckeye dining room. Level of Harm - Minimal harm or potential for actual harm Interview on 06/18/19 at 5:52 P.M. with LPN #400 verified that she left the medication unlocked on top of the medication cart. The facility confirmed the unsecured medications had the potential to affect four independently mobile and confused residents (#101, #23, #91, #57) who could potentially access the medications. Residents Affected - Many Review of Policy for Medication Storage dated 08/16 revealed all prescription medications must be stored under proper temperature and secured against unauthorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365506 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Dorothy Love 3003 West Cisco Road Sidney, OH 45365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of quality assessment and assurance (QA&A) sign in sheets, staff interview and policy review, the facility failed to ensure the medical director attended all QA&A meetings. This had the potential to affect all 107 residents residing in the facility. The facility census was 107. Residents Affected - Many Findings include: Review of the sign-in documentation for the Quality Assurance and Performance Improvement meetings dated 07/17/18 revealed the physician signature was absent. Review of the sign-in sheet for the meeting date 10/16/18 revealed the physician signature was absent. Interview on 06/19/19 at 1:21 P.M. with the Director of Nursing provided verification the Medical Director did not participate in the required quarterly meetings. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Policy dated 11/19 revealed he medical director or designee will attend the quarterly QA&A meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365506 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Dorothy Love 3003 West Cisco Road Sidney, OH 45365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review, the facility failed to ensure a nurse appropriately cleansed her hands prior to preparing and handling medications. This affected one (#62) out of seven residents reviewed during medication administration. The facility census was 107. Residents Affected - Few Findings include: Observation of Licensed Practical Nurse (LPN) #400 at 5:25 P.M. on 06/18/19, revealed nurse pushed cart up hallway to area beside nurses' station. LPN #400 did not wash her hands or use hand sanitation prior to popping out medication Propranolol 40 milligram (mg) tablet from bubble pack into her hand then dropping the tablet into a plastic medication cup. LPN #400 was then observed opening a multiple dose Vitality vitamin bottle and multiple dose eye vitamin bottle and pouring the pills into her hand then placing them into the plastic container. LPN #400 then administered the medication to Resident #62. Interview with LPN #400 immediately following the observation verified that she touched Resident #62's medications with her hands. Review of facility policy titled General Dose Preparation and Medication Administration, dated 12/01/07, revealed prior to preparing to administering medication, authorized and competent facility staff should follow facility's infection control policy (e.g. handwashing). According to the policy facility staff should not touch the medication when opening a bottle or unit dose package. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 5 of 5