Inspection·June 15, 2022

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure bed hold notices were provided in writing to residents and their representatives when residents were transferred to the hospital. This affected two residents (#53 and #61) of two reviewed for hospitalization. The facility census was 81. Findings Include: 1. Review of Resident #53's medical record revealed an admission date of 05/03/22. Diagnoses included type II diabetes. Review of Resident #53's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #53 was cognitively intact. Resident #53 required extensive assistance with bed mobility, dressing and personal hygiene. Resident #53 was totally dependent on staff for transfers and toilet use. Review of the facility's Hospital Transfer Log revealed Resident #53 was transferred to the hospital on [DATE]. Review of Resident #53's Census information revealed Resident #53 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #53's progress notes revealed on 05/28/22 Resident #53 was transferred to the hospital for evaluation and treatment. On 05/28/22 at 9:24 P.M. it was noted Resident #53 was admitted to the hospital. On 05/30/22 it was noted Resident #53 returned to the facility from the hospital. Review of Resident #53's Written Transfer Notification dated 05/28/22, revealed Resident #53 nor her representative were notified of Resident #53's transfer to the hospital. There was no evidence a bed hold notification was completed. Interview on 06/12/22 at 2:02 P.M. with Resident #53 revealed she was transferred to the hospital for blood sugar issues. Resident #53 reported she was not provided a bed hold notice. Interview on 06/14/22 at 10:15 A.M. with the Administrator verified neither Resident #53 nor her representative were provided a notification of bed hold with the number of bed hold days remaining and the cost per day. Review of the facility policy titled, Discharge/Transfer of the Resident, revised 06/01/20 revealed at the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specified the duration of the bed hold. 2. Review of Resident #61's medical record revealed an admission date of 06/10/21 with a diagnosis of obstructive and reflux uropathy, unspecified dementia without behavioral disturbance, urinary tract infection (UTI), unspecified Escherichia coli [E. coli] as the cause of diseases classified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 2 of 11 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 06/15/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few elsewhere, extended spectrum beta lactamase (ESBL) resistance, difficulty walking, weakness, and neuromuscular dysfunction of bladder. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #61 had mild cognitive impairment. His functional status is listed as extensive one to two person assist for all activities of daily living. The MDS also revealed Resident #61 has an indwelling catheter for his bladder and is always incontinent of bowel. The MDS also listed the Resident has not having skin impairment. Review of the progress note dated 05/29/22 at 10:00 A.M. revealed the resident sitting up in bed. Dark circles noted, diaphoretic though common. Skin pale pink/afebrile. Breath sounds easy/quiet on room air and saturations are within normal limits. Occasional congested cough/nonproductive. Lungs with rhonchi bilaterally noting inspiration/expiration on room air. Urine mostly clear yellow. Antibiotic complete for last UTI with ESBL/E.coli. Will notify physician. Physician order dated 05/29/22 revealed 10:49 AM revealed a new order to send to emergency room for evaluation/treatment. Review of the letter of transfer to the family dated 05/29/22 revealed the facility was not incompliance with this tag. The facility did not send a bed hold notice with number of days remaining and the reserve per day bed payment. Interview on 06/14/22 at 10:15 A.M. with the Administrator verified neither Resident #61 nor his representative were provided a notification of bed hold with the number of bed hold days remaining and the cost per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 3 of 11 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 06/15/2022 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #38's medical record revealed an admission date of 05/14/20. Diagnoses included dementia, macular degeneration, major depression, and heart failure. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed the resident scored a three on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive impairment. The resident was assessed to have moderate vision impairment and wore glasses. Resident #38 required extensive assistance of two staff for all mobility activities of daily living. The resident was assessed to be independent with eating following set up. Review of the plan of care implemented on 06/03/20 revealed Resident #38 had macular degeneration with impaired vision. The resident was unable to read any size print but was able to recognize colors and a pen light. Interventions included to keep her glasses clean and her glasses in good repair. Observation on 06/12/22 at 11:48 A.M. revealed Resident #38 was in the dining room and was served lunch. Her lunch tray included a frozen magic cup (supplement) and a chicken strip. State Tested Nursing Assistant (STNA) #688 removed the resident's silverware from the napkin and cut the chicken. Resident #38 ate her chicken with her fingers. She picked up her fork and the magic cup. Resident #38 had a difficult time finding the opening to the magic cup with her fork. After several attempts she found the opening to the cup and ate the magic cup with her fork. The resident did not have glasses on. Observation on 06/13/22 at 5:05 P.M. revealed Resident #38 was sitting in her wheelchair in the dining room crying stating, I can't see. The resident did not have glasses on. Observation on 06/15/22 at 8:45 A.M. revealed Resident #38 was in the dining room and she did not have glasses on. Interview on 06/15/22 at 8:45 A.M. Resident #38 reported she wore glasses and could see better with her glasses on. She stated her vision comes and goes at times. Resident #38 reported she would have liked to have her glasses on, but she did not know where they were. Interview on 6/15/22 at 8:50 A.M. STNA #697 stated she was caring for Resident #38. STNA #697 verified the resident used to wear glasses although she had not seen the resident wear them in awhile. STNA #697 was unsure if the resident's glasses were in the facility or if the resident's family took them home. STNA #697 verified the resident did not have glasses on during breakfast. Interview on 06/15/22 at 8:55 A.M. Licensed Practical Nurse (LPN) #625 stated Resident #38 wore glasses and was unsure of where the resident's glasses were located. Interview on 06/15/22 at 9:00 A.M. Registered Nurse (RN) #611 verified Resident #38 wore glasses and verified the resident was not wearing them. Observation during the interview, revealed Resident #38's glasses were located on top of the resident's nightstand. RN #611 reported night shift staff got the resident up and ready for the day and she would educate the staff. RN #611 cleaned the glasses lens and took them to the resident in the dining room. Resident #38 allowed RN #611 to apply the glasses to her face. Resident #38 responded by saying, Now I can see you. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 4 of 11 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 06/15/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm Interview on 06/15/22 at 9:05 A.M. with the Director of Nursing verified the plan of care stated Resident #38 had macular degeneration and the resident wore glasses. The DON reported STNAs use, Care Cards, to let them know the needs of each resident. Review of the current, Care Card, for Resident #38 stated the resident was to wear glasses daily. Residents Affected - Few Based on observation, medical record review, resident interview, staff interview, and review of care card, the facility failed to ensure a resident identified with communication limitations, had devices and/or communication tools or techniques implemented to ensure effective resident to staff communication. Additionally, the facility failed to ensure a resident had access to her glasses. This affected two residents (#17 and #38) of three residents reviewed for communication devices. The census was 81. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 04/11/19. Diagnoses included Alzheimer's disease, history of larynx cancer, tracheostomy, presence of artificial larynx, and aphonia (loss of ability to speak). Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #17 was severely cognitively impaired. Resident #17 required extensive assistance with dressing, toilet use, and personal hygiene. Resident #17 was absent of spoken words and was sometimes able to make himself understood. Resident #17 was sometimes able to understand others. Resident #17 received suctioning and tracheostomy care and hospice care at the time of the review. Resident #17's speech therapy ended 11/23/21. Review of Resident #17's care plan revised 05/17/22 revealed supports and interventions for impaired gas exchange related to laryngeal cancer and tracheostomy, self-care deficit, and difficulty making self understood related to tracheostomy/laryngectomy. Approaches for difficulty being understood included trach care as ordered, encourage speaking, finger plug with pressure over stoma to create voice as much as possible, allow Resident #17 time to speak avoid interrupting, encourage verbalization, observe for signs of non-verbal signs of distress, repeat what the resident said to validate the resident, speech therapy as ordered, and when Resident #17 became frustrated provide word/phrase and reassure. Review of Resident #17's Speech Therapy (ST) Discharge summary dated [DATE] revealed Resident #17 had the goal to demonstrate functional ability to communicate in social settings given assistance from trained staff/caregivers. Resident #17 had reached a 70% present level on this goal at the time of discharge. Recommended interventions included continued functional communication skills. Resident #17 was discharged due to reaching maximum potential. Observation on 06/13/22 at 2:15 P.M. of Resident #17 found him on the secured unit moving his lips and hands attempting to communicate with State Tested Nursing Assistant (STNA) #702. STNA #702 directed Resident #17 to the bathroom. Resident #17 complied with the direction but returned to STNA #702 and continued to try to mouth words and move his hands. STNA #702 walked away from Resident #17 when he was trying to communicate with her. Interview on 06/13/22 at 2:18 P.M. with STNA #702 revealed Resident #17 had a tracheostomy and was not able to speak any more. STNA #702 reported he was able to understand and was cooperative with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 5 of 11 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 06/15/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care at times. STNA #702 stated Resident #17 had no communication board or anything she was aware of to assist him with making his needs known. STNA #702 stated she was not able to understand what Resident #17 was trying to communicate. Observation on 06/13/22 at 2:22 P.M. of Resident #17 found he re-approached STNA #702 and was trying to communicate by mouthing words and using his hands. STNA #702 turned away from Resident #17 and stated to him she was not able to understand anything he was trying to say to her. Resident #17 appeared frustrated and followed STNA #702 into another resident's room trying to communicate. STNA #702 directed Resident #17 out of the resident room and closed the door. Interview on 06/13/22 at 2:43 P.M. with Resident #17 revealed he was moving his lips and whispering words. Resident #17 was asked if he had a communication board or any type of communication tools. Resident #17 shook his head indicating no he didn't have any device available while he mouthed the word no. Resident #17 was asked if staff were able to understand what he needed or wanted and Resident #17 shook his head and mouthed the word no. Observation on 06/13/22 at 2:46 P.M. with Resident #17 found Resident #17 again trying to communicate with STNA #702. STNA #702 turned away from Resident #17 and Resident #17 was observed throwing his hands up in the air and walking away from STNA #702. Interview on 06/14/22 at 7:23 A.M. with Licensed Practical Nurse (LPN) #635 revealed she had known Resident #17 since his admission and she was able to understand his type of communication. LPN #635 reported staff needed to give Resident #17 direct eye contact, pay close attention to his body language, give him time to mouth what he was trying to say and he was able to make some of his needs known. LPN #635 verified Resident #17 had no communication device or tools for helping him communicate with staff who were not familiar with him. Interview on 06/14/22 at 3:17 P.M. with LPN #630 verified it was difficult to understand what Resident #17 was trying to say and he had no communication tools available. LPN #630 reported he was supposed to be encouraged to plug his tracheostomy with his finger so he could vocalize better but he would often refuse so she would ask him yes or no questions to determine what his needs were. LPN #630 reported Resident #17 was able to understand and would follow instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 6 of 11 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 06/15/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, observations, resident interview, family interview, staff interview and review of the facility bowel protocol, the facility failed to ensure wound/skin dressings were properly applied for two (#8 and #25) of two residents reviewed for skin conditions requiring dressing changes. In addition, the facility failed to implement their bowel protocol after a resident had no bowel movement for over three days. This affected one resident (#429) of one reviewed for constipation. The facility census was 81. Residents Affected - Few Findings include: 1. Medical record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses including generalized osteoarthritis, dementia without behaviors, overactive bladder, major depression, and edema (swelling). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a nine on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits. She required extensive assistance of two staff for transfers. She was non-ambulatory, had occasional incontinence of urine, and was always continent of bowel. She did not have skin breakdown. Review of the plan of care dated 04/01/22 revealed the resident was at risk for skin breakdown and currently had skin tears on her lower legs. Interventions included to provide treatments and provide treatments as ordered by the physician. Review of the June 2022 physician orders revealed an order to cleanse the skin tears on the left lower leg, apply xeroform (petroleum based for skin tears) dressing, cover with ABD (extra thick secondary protective dressing), and wrap with gauze daily. Observation on 06/14/22 at 8:50 A.M. revealed Resident #8 seated in a wheelchair in the dining room with a large amount of light red drainage on her left sock. Interview on 06/14/22 at 8:55 A.M. Licensed Practical Nurse (LPN) #635 stated Resident #8 had dressing changes completed in the evenings. LPN #635 verified she was unaware of the fact the resident had a large amount of what appeared to be moist light red drainage on her sock. LPN #625 stated she would change the dressing after she was done with medication administration. Observation on 06/14/22 at 10:30 A.M. revealed Resident 8 was in the beauty shop getting her hair done. There was still a large amount of light red drainage noted on her sock. Observation on 06/14/22 at 11:05 A.M. of wound care for Resident #8 revealed LPN #625 moistened several washcloths with water. LPN #625 donned gloves and removed the resident's white mid-calf sock. The sock had a large amount of light red drainage on it. There was no dressing observed on the resident's open wounds. The resident complaint the procedure was very painful. When asked where the old dressing was, LPN #625 reported the wound nurse saw the resident's that morning and had not changed the treatment to the open areas. The resident was observed to have edema in her left lower leg and foot. The leg appeared red. LPN #625 reported the resident's lower leg was more swollen than normal and was warm to the touch. LPN #625 reported the physician saw the resident on 06/13/22 and ordered an antibiotic, which would be started 06/14/22. LPN #625 continued providing wound care to Resident #8. LPN #625 cleansed a C-shaped skin tear, a triangular shaped open area, and an open area of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 7 of 11 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 06/15/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few posterior portion of the leg. Xeroform dressing was applied and covered with an ABD (extra thick secondary dressing) and wrapped with gauze. LPN #625 applied clean socks to the resident. LPN #625 verified there were no dressings on open areas to the residents left lower leg since approximately 9:00 A.M. when she was seen by the wound nurse. Interview on 06/14/22 at 1:20 P.M. the Director of Nursing (DON) verified a dressing should always be applied to an open wound. It was not the facility's policy to leave a dressing off a wound for another nurse to address is later. The DON reported Advanced Practice RN #807 was a wound consultant who visited weekly. The DON was unaware Advanced Practice RN #807 was leaving wounds without a dressing until a staff nurse were available to apply the dressing. 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder, mild intellectual disabilities, unspecified psychosis, depressive and anxiety disorders, weakness, and repeated falls. Review of the MDS assessment dated [DATE] revealed Resident #25 had moderate cognitive impairment. Resident #25 required extensive assistance for activities of daily living (ADLs). The MDS also listed the resident as having a stage III pressure area. Resident #25 utilized an indwelling catheter and was frequently incontinent of bowel. Review of Resident #25's care plan dated 06/06/22 revealed the resident was at risk for pressure ulcers. Interventions included to provide wound treatments as ordered. Review of the physician order dated 06/11/22 revealed orders to cleanse coccyx wound with normal saline, apply zinc barrier to peri-wound, apply Medi honey and calcium alginate to wound bed, cover with 4 x 4 gauze and the ABD. Secure with paper tape, change every other day until 07/03/22 and as needed. Observation on 06/14/22 at 11:30 A.M. revealed Resident #25's wound dressing to the coccyx was not in place. Measurements of the wound were 4.5 centimeters (cm) by 1.2 cm by 0.2 cm. There was moderate serous drainage with 80 percent granulation tissue and 20 percent epithelial. Interview on 06/14/22 at 11:30 A.M. revealed Registered Nurse (RN) #200 was finishing up the dressing change for Resident #25 and verified there was no dressing applied to the residents coccyx wound. RN #200 verified Advanced Practice RN #807 saw Resident #25 between 8:30 A.M. and 11:30 A.M. and left the resident's wound exposed without a dressing. RN #200 was unaware the wound was left exposed and was unsure of the exact time the wound was left exposed. Interview on 06/14/22 at 1:20 P.M. the Director of Nursing (DON) verified a dressing should always be applied to an open wound. It was not the facility's policy to leave a dressing off a wound for another nurse to address is later. The DON reported Advanced Practice RN #807 was a wound consultant who visited weekly. The DON was unaware Advanced Practice RN #807 was leaving wounds without a dressing until a staff nurse were available to apply the dressing. The DON verified Resident #25 was incontinent of bowel and could have had a bowel movement while her wound was left exposed. 3. Review of Resident #429's medical record revealed an admission date of 05/22/22. Diagnoses included fracture of left pubis subsequent encounter, weakness, cognitive communication deficit, and urinary tract infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 8 of 11 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 06/15/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #429's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #429 was cognitively intact. Resident #429 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #429 displayed no behaviors during the review period. Resident #426 was always continent of bowel. Review of Resident #429's bowel movement tracking revealed Resident #429 went from 06/06/22 to 06/13/22 (six days) with no bowel movements. Review of Resident #429's physician orders for June 2022 revealed no standing orders to treat constipation. Orders to treat constipation had been discontinued: Polyethylene glycol 3350 powder 17-gram dose once daily, ordered 05/23/22 and discontinued on 05/31/22. Senna 8.6 milligrams (mg) two tablets one daily, ordered 05/31/22 and discontinued 06/03/22. Senna 8.6 mg two tablets once daily, ordered 06/03/22 and discontinued on 06/12/22. Dulcolax suppository 10 mg insert rectally, ordered, and discontinued 06/06/22. Further review of physician orders revealed no additional medications/interventions added from 06/06/22 to 06/12/22. Review of the Medication Administration Record (MAR) for June 2022 revealed the Senna ordered 06/03/22 and discontinued 06/12/22 was administered as ordered, however the resident still had not produced a bowel movement and no additional interventions were added until 06/12/22, when Bisacodyl tablet delayed release 10 mg once daily was ordered. Interview on 06/12/22 at 11:58 A.M. with Resident #429 and her niece found Resident #429 to be somewhat confused. Resident #429 reported she had not pooped in over a week. Resident #429's niece verified Resident #429 had not had a bowel movement but reported it had been about five days and not a full week. Resident #429's niece reported it was still concerning Resident #429 had not had a bowel movement and it appeared the facility had not done anything about it. Interview on 06/15/22 at 9:08 A.M. with the Director of Nursing (DON) verified Resident #429 had no bowel movements between 06/06/22 and 06/13/22 and no additional interventions were added until 06/12/22. Review of the facility policy titled, Bowel Management Protocol, revised 10/10/20 revealed the facility was to monitor and identify constipation. An oral laxative was to be administered to every resident who had not had a bowel movement in three consecutive days. If the resident had not had results from the laxative administered earlier in the day the nurse was to administer a suppository after the last medication pass. If the resident still did not experienced results from the suppository administered in the evening, the resident would be given a phosphate enema in the early morning by 6:00 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 9 of 11 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 06/15/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on medical record review, staff interview, and review of facility policy, the facility failed ensure an appropriate diagnosis was obtained to justify the use of an antipsychotic medication. This affected one resident (#6) of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Review of Resident #6's medical record revealed an admission date of 05/13/21. Diagnoses included Alzheimer's disease, cognitive communication deficit, major depressive disorder, and cerebral atherosclerosis (hardening of the of the walls in the arteries of the brain). Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #6 was rarely or never understood. A Staff Assessment for Mental Status was completed and revealed Resident #6 had short and long term memory problems and was severely cognitively impaired. Resident #6 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 05/23/22 revealed Resident #6 received antipsychotic medication. Review of Resident #6's physician orders revealed an order dated 03/29/22 and discontinued 04/12/22 for haloperidol lactate concentrate (antipsychotic medication) 2 milligrams (mg)/ milliliters (ml) every six hours as needed (PRN) for restlessness agitation. An order dated 05/23/22 and discontinued 05/24/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml twice a day. No diagnosis was documented to support the use of the antipsychotic medication. An order dated 05/24/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml twice a day. No diagnosis was documented to support the use of the antipsychotic medication. An order dated 05/18/22 and discontinued 05/18/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the antipsychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 05/18/22 for hallucinations and agitation as documented by the nurse who administered the medication. An order dated 05/18/22 and discontinued 05/31/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the antipsychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 05/19/22, 05/20/22, 05/28/22, and 05/30/22 for restlessness and agitation as documented by the nurse who administered the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 10 of 11 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 06/15/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm An order dated 06/06/22 and discontinued 06/14/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the anti-psychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 06/06/22, 06/09/22, and 06/14/22 for restlessness, anxiety, agitation and combativeness as documented by the nurse who administered the medication. Residents Affected - Few An order dated 06/14/22 at 4:11 P.M. and discontinued 06/20/22 for haloperidol lactate concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the anti-psychotic medication. Review of Resident #6's physician progress note dated 06/06/22 revealed Resident #6's PRN Haldol (haloperidol lactate) was restarted for episodic agitation and restlessness. Interview on 06/14/22 at 4:16 P.M. with the Director of Nursing (DON) revealed the physician reviewed Resident #6 on 06/06/22 and restarted Haldol for episodic agitation and restlessness which contributed to a fall risk. The DON verified agitation and restlessness was not an approved diagnosis for the use of antipsychotic medication, Haldol. The DON stated she would contact the physician. Review of Resident #6's physician progress notes revealed on 06/14/22 at 4:27 P.M. a diagnosis of dementia with psychosis was added for Resident #6. Review of the facility policy titled, Psychotropic Medications, revised 03/01/21 revealed a resident would only receive psychotropic drugs PRN if that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365506 If continuation sheet Page 11 of 11