Health inspection·November 28, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, staff interview, and review of the facility's admission packet, the facility failed to allow a resident to have medications provided by a pharmacy of choice. This affected one (Resident #5) of three residents reviewed for pharmacy preferences. The facility's census was 44. Findings include: Review of Resident #5's medical record revealed an admission date of 04/27/21. Diagnoses included chronic kidney disease, diabetes mellitus, sedative dependence, obstructive sleep apnea, fibromyalgia, and a history of breast cancer. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required assistance with personal hygiene, toilet use, and dressing. Review of the social service note dated 02/15/22 revealed the facility's pharmacy contacted the facility regarding the Resident #5's outstanding bill. The social worker encouraged Resident #5 to reach out to the pharmacy if she had questions. Family interview on 11/20/22 at 4:10 P.M. revealed the facility stated the family could supply Resident #5 with their own medication from their preferred pharmacy, but the medications must be pre-packaged in chronological packets by a pharmacy and not in individual bottles. The family wanted to use an outside pharmacy because the resident was self-pay and the facility's pharmacy was expensive. Interview on 11/22/22 at 1:53 P.M. the Administrator verified there had been multiple discussions with Resident #5's family stating they could bring in their own medications as long as they were prepackaged in packets. The Administrator verified Resident #5 was receiving medications from the facility's pharmacy. Review of the facility admission Packet revealed residents had the right to the pharmacist of the resident's choice and the right to receive pharmaceutical supplies and services at reasonable prices not exceeding applicable and normally accepted prices for comparably packaged pharmaceutical supplies and services within the community. This deficiency represents non-compliance investigated under Complaint Number OH00137172. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 2 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Notice of Medicare Non-Coverage (NOMNC), review of the Advanced Beneficiary Notice of Non-Coverage (ABN), review of the admission agreement, review of Medicare Part A Skilled Nursing Acknowledgement of Benefits and Co-Payments and staff interview, the facility failed to ensure a timely refund to a resident's representative following discharge. This affected one (#249) of three residents reviewed for conveyance of funds. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #249's medical record revealed an admission date of [DATE]. Diagnoses included atherosclerotic heart disease, hypertension, peripheral vascular disease, aphasia, Alzheimer's disease with late onset and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 was moderately impaired for decision making, required extensive assistance with Activities of Daily Living (ADLs), received speech therapy (ST) and physical therapy (PT), and was expected to be discharged to community. Review of physician orders revealed Resident #249 was discharged from therapy services effective [DATE] and was admitted to hospice on [DATE]. Review of the Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice of Non-Coverage (ABN) dated [DATE] confirmed Resident #249's representative was informed of the end of Medicare services effective [DATE]. Review of a facility billing statement for the Medicare Part A covered period of [DATE] through [DATE] confirmed Medicare was billed for Resident #249's services during those dates. Review of the consent to treat and admission agreement, signed by Resident #249's representative on [DATE], revealed deposits for private pay residents were due at the time of the admission. The deposit amount would include the number of days in the current month as well as the number of days for the following month. If the facility determined an overpayment occurred, the facility shall refund the overpaid amount within 30 days following the discharge or death of the resident. Review of the Medicare A Skilled Nursing admission Acknowledgment of Benefits and Co-Payments, signed by Resident #249's representative on [DATE], revealed Medicare A would pay for the post-hospital skilled nursing services furnished in the center. Additionally, during the Medicare A skilled stay, Medicare would pay for the skilled room and board, meals, nursing services, therapy services, pharmacy, and other covered services and supplies. Eligibility requirements included a qualifying hospital stay, placement in a Medicare Certified Bed within 30 days of discharge from the hospital or other skilled nursing care and available Medicare skilled nursing facility benefit period days. Further review confirmed Resident #249 was eligible for Medicare A skilled services due to the Resident being in the hospital, nursing facility or an extended care wing of a hospital. Finally, for days one through 20, Resident #249 had no co-payment for his skilled admission to the facility. Review of the facility statement for Resident #249 revealed a balance due for $9,360.00 for [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 3 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0582 through [DATE] and [DATE] through [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of facility document Resident #269's Timeline revealed on [DATE], Resident #269 made payment to the facility of $9,360.00, Residents Affected - Few Review of Resident #249's medical record revealed the resident had a discharge date of [DATE]. Review of the facility issued check revealed a check dated [DATE] for the amount of $8,320.00. The description for the check was to refund Resident #249 Interview on [DATE] at 1:42 P.M. with Business Office Manager (BOM) #308 confirmed Resident #249 was admitted on the facility on [DATE] under a qualifying Medicare Part A stay. Due to insufficient progress, BOM #308 stated the resident was cut from Medicare services effective [DATE]. On [DATE], Resident #249 transitioned to private pay and elected hospice benefits on [DATE]. BOM #308 confirmed Resident #249's representative pre-paid in the amount of $9,360.00 for [DATE] through [DATE] and [DATE] through [DATE]. BOM #308 confirmed Resident #249 expired on [DATE] and Resident #249's representative was not refunded any monies until [DATE], as the facility was waiting for Medicare Part A billing to come back. BOM #308 stated in the event Medicare Part A did not cover Resident #249's stay from [DATE] through [DATE], or the resident had co-payments, the facility would deduct those funds before issuing a refund. BOM #308 stated the first Medicare Part A billing was submitted on [DATE]. Due to some billing coding issue, Medicare Part A billing had to be resubmitted, which was done on [DATE]. The facility received payment in full from Medicare on [DATE] and BOM #308 stated the facility issued a refund within 30 days of determining Resident #249 had overpaid for his stay at the facility. Follow up interview on [DATE] at 8:05 A.M. with BOM #308 confirmed Resident #249 had a qualifying Medicare Part A admission for his skilled service days of [DATE] through [DATE], was not assessed any co-payments, and the Resident #249's representative was not issued a refund, in the amount of $8,320.00, until [DATE], nearly four months following Resident #249's discharge from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00136847. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 4 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to ensure residents who required assistance from staff with Activities of Daily Living (ADL) received adequate and timely assistance with grooming. This affected three (Residents #17, #10, and #40) of five residents reviewed for ADL care. The facility's census was 44. Residents Affected - Few Finding include: 1. Review of Resident #17's medical record revealed an admission date or 1/21/16. Diagnoses included unspecified dementia, epilepsy, unilateral primary osteoarthritis left hip, hypertensive heart disease without heart failure, muscle weakness, and polyosteoarthritis. Resident #17 was a female resident. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the cognitive assessment of the interview. Resident #17 required extensive one person assistance with eating, dressing, and personal hygiene. Observations on 11/20/22 at 4:23 P.M., 11/21/22 at 8:13 A.M., and 11/22/22 at 9:13 A.M. revealed Resident #17 was observed in the common area with thick medium length stubble on her chin. Interview on 11/22/22 at 9:15 A.M. with the Administrator verified Resident #17 had thick chin hair and was in need of assistance with personal grooming. 2. Review of Resident #10's medical record revealed an admission date of 11/20/18 and a readmission date of 01/04/21. Diagnoses included Parkinson's disease, type II diabetes, asthma, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, chronic atrial fibrillation, hypertension, morbid obesity, stage IV chronic kidney disease, peripheral vascular disease and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the care plan revised 10/19/22 revealed Resident #10 had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and Parkinson's. Interventions included check nail length and trim and clean on bath day and as necessary. Observation on 11/20/22 at 10:57 A.M. of Resident #10 revealed the resident's fingernails were long and jagged. Interview of Resident #10 at the time of the observation revealed she preferred her fingernails to be shorter. Resident #10 stated when her fingernails were longer, they grew into her skin. In addition, Resident #10 stated she had Parkinson's disease and she was concerned if she developed contracture's her fingernails would dig into the palms of her hands. Observation on 11/21/22 at 1:22 P.M. with State Tested Nurse Aide (STNA) #211, verified Resident #10's fingernails were long and jagged. STNA #211 stated fingernails should be checked and trimmed on each shower day. STNA #211 stated she would take care of Resident #10's fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 5 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #40's medical record revealed an admission date of 10/07/22. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, major depressive disorder, hypertension, unspecified injury at unspecified level of cervical spinal cord, and unspecified injury at T1 level of thoracic spinal cord. Review of the admission MDS dated [DATE] revealed Resident #40 was moderately cognitively impaired and required extensive assistance with bed mobility and personal hygiene and total dependence with transfers. Review of the care plan initiated 10/08/22 revealed Resident #40 had an ADL self-care performance deficit related to limited mobility, weakness and paraplegia. Interventions included extensive one person physical assistance with personal hygiene. Interview on 11/20/22 at 1:10 P.M. with Resident #40's family member revealed she trimmed the resident's fingernails but she did not have the strength to trim his toenails. The family member stated Resident #40's toenails were in bad shape and needed to be taken care of. Observation on 11/21/22 at 1:16 P.M. of Resident #40's toenails, with STNA #204 and the resident's family member, verified the resident's toenails were long, extending over the tips of his toes. STNA #204 confirmed Resident #40's toenails needed trimmed and the resident's family member stated they really needed to be cut. STNA #204 stated the podiatrist typically trimmed toenails but nursing staff could do it as long as the resident was not diabetic. STNA #204 confirmed Resident #40 did not have diabetes. STNA #204 stated she would talk with the nurse to have Resident #40's toenails trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 6 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 record review, observation, and staff interview, the facility failed to provide physician ordered ted hose for Resident #26. This affected one (Resident #26) of one resident reviewed for ted hose orders. Additionally, the failed to complete a timely urinalysis for Resident #28. This affected one (Resident #28) of one resident reviewed for urinalysis timeliness. The facility census was 44. Residents Affected - Few Findings include: 1. Review of Resident #26's medical record revealed an admission date of 04/08/22. Diagnosis included cerebral infarction with hemiplegia affecting the dominant side, chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function. Review of Resident #26's most recent care plan revealed due to immobility, diabetes mellitus, hemiplegia, anemia, morbid obesity the resident was care planned for ted hose. Review of Resident #26's physician's order dated 08/20/22 revealed an order for ted hose 30-40 pressure, which were to be put on in morning and removed at bedtime due to congestive heart failure. Interview with Resident #26 and daughter on 11/20/22 at 10:08 A.M. revealed the resident was to have compression stockings on daily, but the staff did not apply the hose. Observations on 11/20/22 at 10:08 A.M., 11/21/22 at 7:02 A.M., 11:41 A.M. and 1:58 P.M. revealed Resident #26 did not have the compression stockings applied. Interview with State Tested Nursing Aide (STNA) #202 on 11/20/22 at 10:32 A.M. verified Resident #26 had a physician's order for ted hose but the staff failed to apply the ted hose. STNA #202 stated she could only find one compression stocking in the resident's room and the nurse would order another pair. 2. Review of Resident #28's medical record revealed an admission date of 09/04/22. Diagnoses included chronic kidney disease and urinary tract infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the nurse's note dated 11/07/22 revealed Resident #28's family member requested a urinalysis be completed due to Resident #28's increased confusion. Review of Resident #28's physician orders revealed no orders for a urinalysis. Review of the urinalysis results collected on 11/14/22 and reported on 11/17/22 verified the urinalysis was not collected until 11/14/22 (seven days after the family's request). The results of the urinalysis were abnormal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 7 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 Review of the physician order dated 11/17/22 revealed an order for Cipro Tablet 500 milligram (mg), give 500 mg by mouth two times a day related to urinary tract infection for seven days. Interview on 11/22/22 at 2:14 P.M. the Administrator verified a nurse's progress note stating a urinalysis was requested on 11/07/22 and was not completed until 11/14/22. Residents Affected - Few Interview on 11/22/22 at 2:53 P.M. with Assistant [NAME] President #314 verified there was no documentation of a physician order for the urinalysis to be completed in Resident #28's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 8 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital documentation, observation, staff interview, review of facility policy, and review of the National Pressure Injury Advisory Panel (NPIAP) guidance, the facility failed to complete accurate skin assessments, provide ongoing monitoring of pressure ulcers, failed to obtain treatment orders for pressure ulcers, and failed to provide a treatment to pressure ulcers for one resident (#39). This resulted in actual harm when Resident #39's left heel unstageable pressure ulcer had an increase in the amount of necrotic tissue present from 25% to 100% within eleven days. This affected one (#39) of one resident reviewed for pressure sores. The facility identified three residents with pressure sores. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #39's medical record revealed an admission date of 09/22/22 and a readmission date of 11/10/22. Diagnoses included difficulty in walking, dysphagia, asthma, multiple sclerosis, cognitive communication deficit, muscle wasting and atrophy, seizures and herpes viral meningitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required extensive assistance with transfers, dressing, and toilet use, and required limited assistance with personal hygiene. Resident #39 had no pressure ulcers. Review of the care plan revised 09/28/22 revealed Resident #39 had the potential to develop pressure ulcers due to impaired mobility. Interventions included float heels, Pro-Stat (supplement), and report redness, open areas, skin tears and rashes. Review of the wound care note dated 11/01/22 revealed Resident #39 had a left heel, friction wound measuring 1.5 centimeters (cm) by (x) 5.0 cm x 0.1 cm, with scant serous exudate (indicating there was moisture). Treatment orders included: cleanse with wound cleanser and apply foam two times weekly with shower days and as needed. No additional wounds were documented in the wound care note. Further review of the medical record revealed no additional wound assessments completed. Review of the physician order dated 11/03/22 revealed an order to cleanse the left heel with soap and water, pat dry, and apply foam dressing. Change every shower day, Monday, and Thursday, and as needed. Further review of current physician orders for Resident #39 revealed no additional wound care treatment orders. Further review of the medical record revealed Resident #39 went to the hospital on [DATE] for treatment of a urinary tract infection. Review of the hospital documentation, encounter date 11/08/22, revealed the resident was seen for a wound consultation for pressure injuries to the resident's bilateral heels. Resident #39 had erythema (reddening to the skin) to the right great toe tip, blistering to the right lateral foot measuring 12.0 cm x 2.0 cm, a dry scab to the right second toe tip (near the nail) measuring 0.2 cm x 0.2 cm, and erythema to the left medial ankle measuring 3.0 cm x 1.5 cm. All areas were noted to be blanchable, with no drainage, no tunneling, and no odor. Debridement of the right heel blister was completed, and the wound was described as a stage III pressure ulcer measuring 3.0 cm x 2.0 cm x 0.1 cm. Debridement of the left heel blister was completed, and the wound was described as an unstageable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 9 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0686 Level of Harm - Actual harm pressure ulcer measuring 3.5 cm x 4.0 cm x 0.1 cm with wound bed slough, necrotic (death of tissue), and granulation tissue. Further review revealed orders to cleanse bilateral heels with mild soap and water, apply Vaseline then Adaptic (dressing), cover with foam and change daily, bilateral waffle boots, and elevate bilateral lower extremities and float heels. Residents Affected - Few Review of the re-admission screen, dated 11/10/22, revealed Resident #39 re-admitted to the facility from the hospital. The assessment identified Resident #39 had right heel, left heel, and right toe blisters. There were no measurements or assessments completed of the resident's pressure ulcers upon re-admission. The hospital discharge orders contained no orders for treatments to the areas. Review of the wound care note by the Certified Nurse Practitioner (CNP), dated 11/15/22, revealed Resident #39 had four wounds. Wound #1 was located on the left posterior heel and was identified as a resolved area. Wound #2 was located on the left medial heel, identified as an unstageable pressure ulcer measuring 3.5 cm x 5.0 cm x 0.1 cm, and further described as having 25% eschar (dry, dark scab), 25% necrotic tissue, and a small amount of serous exudate (clean, thin, watery substance). The note revealed the CNP documented wound care orders for the left medial heel included: clean with wound cleanser, apply silver alginate and foam, change every other day, and as needed. Wound #3 was identified as a stage III pressure ulcer to the right medial heel measuring 4.9 cm x 2.0 x 0.1 cm and described as having 10% slough with a small amount of serosanguinous exudate (wound drainage). Wound care orders for the right medial heel included: clean with wound cleanser, apply silver alginate and foam cover dressing, change every other day, and as needed and offload. Wound #4 was identified as a stage II pressure ulcer to the left medial ankle measuring 1.0 cm x 1.0 cm x 0.1 cm and described as having 100% dermis with a scant amount of serosanguineous exudate. Wound care orders for the left medial ankle included: clean with wound cleanser, apply foam, change every other day, and as needed. The note revealed adjacent tissue of wounds #2, #3, and #4 were at risk for further breakdown. Review of physician orders revealed the orders listed in the CNP's wound care note from 11/15/22 were not listed. Review of Resident #39's Treatment Administration Record (TAR) for November 2022 and the medical record revealed no evidence of any treatments being applied to Resident #39's pressure ulcers since readmission from the hospital. The care plan was updated on 11/20/22 due to Resident #39 having actual impairment to skin integrity, including an unstageable left medial heel pressure ulcer, a stage III right medial heel pressure ulcer, and a stage II left medial ankle pressure ulcer. Interventions included pressure reducing devices as ordered, staff to encourage and assist with frequent turning and repositioning, treatment as ordered and wear slippers instead of Crocs. Review of physician orders dated 11/21/22 revealed to cleanse left medial ankle with wound cleanser and cover with foam dressing every other day; cleanse left medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day; and cleanse right medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day. Interview on 11/20/22 at 4:19 P.M. with Licensed Practical Nurse (LPN) #101 verified there were no wound care orders in place for Resident #39's unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel, or stage II pressure ulcer to the left medial ankle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 10 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0686 Level of Harm - Actual harm Residents Affected - Few Interview on 11/21/22 at 7:33 A.M. with the Director of Nursing (DON) verified the wound treatment orders from the wound care visit on 11/15/22 were not included in Resident #39's orders. The DON stated she caught the discrepancy this morning and she had nursing apply dressings per physician orders. The DON claimed nursing staff were following the treatment orders in the wound care note, despite the orders no orders being written. The DON did not have an explanation on how nursing staff would know how to complete the treatments if they were not included in the resident's orders or on the TAR. Interview on 11/21/22 at 9:33 A.M. with LPN #104 (an agency staff member) verified if treatments were not included in the resident's physician's orders she would not know if a treatment was even ordered or how to complete the treatment. Interview on 11/21/22 at 1:06 P.M. with Clinical Regional Nurse (CRN) #306 revealed Resident #39 had a left heel blister, which had resolved, prior to her hospitalization on 11/08/22. When Resident #39 returned from the hospital on [DATE], the resident had pressure ulcers on her left heel, right heel, and left medial ankle. Nursing completed the readmission screen on 11/10/22 and noted each of the pressure ulcers as blisters. CRN #306 stated the nurses were not comfortable measuring and staging wounds and noted them as blisters on the readmission screen. CRN #306 verified the wound treatment orders from the 11/15/22 wound care visit were not implemented until 11/20/22. Follow up interview on 11/21/22 at 3:27 P.M. with CRN #306 verified the treatments in the wound care notes from Resident #39's hospital admission were not ordered upon the resident's return to the facility. Resident #39 did not have any treatment orders implemented from 11/10/22 until 11/20/22 for the unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel and the stage II pressure ulcer to the left medial ankle. Observation on 11/21/22 at 4:50 P.M. of Resident #39's wound care completed by LPN #104 revealed LPN #104 refused to complete wound measurements. The surveyor requested further assistance from CRN #306 and the observation was completed with CRN #306. Observation of Wound #2, located on the left medial heel, revealed measurements of 2.8 cm x 3.4 cm x 0.1 cm of necrotic tissue. Adjoining the area of necrotic tissue to the left of the wound, was an area measuring 2.2 cm x 2.9 cm x 0/unable to be determined, which was described as a healing deep tissue injury. The area was 100% necrotic tissue, indicating an increase of 75% necrotic tissue from the 11/09/22 hospital wound care note and the 11/15/22 wound care note. Due to the necrotic tissue, the depth of the wound was unable to be determined. Observation of Wound #3, located on the right medial heel, revealed measurements of 1.5 cm x 1.5 cm x 0 and was noted to be healing. Wound #4 was observed to measure 0.9 cm x 0.7 cm. Each of the wound treatments were completed per physician order. Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of policy titled Skin Care Management Procedure, dated 11/02/18, revealed upon admission a full skin assessment should be conducted within two to six hours of arrival and documented in the EMR. Additionally, monitoring included with each dressing change or at least weekly at a minimum, documentation should include the date observed, location and staging, size, exudates, pain, wound bed color and type of tissue/character including evidence of healing or necrosis and percentage of tissue and a description of wound edges and surrounding tissue. Dressing and treatments were determined based upon individual practitioner's clinical judgements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 11 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of the National Pressure Injury Advisory Panel (NPIAP) Guidance via https://npiap.com/page/PreventionPoints revealed skin should be assessed upon admission as soon as possible (but within 8 hours). Review of the NPIAP Guidance titled, NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 12 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to ensure pneumococcal vaccinations were administered. This affected one (Resident #35) of five residents reviewed for pneumococcal vaccination. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #35's medical record revealed an admission date of 09/20/22. Diagnoses included disorientation, acute kidney failure, major depressive disorder, sepsis, hypertension and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired and was not up to date on the pneumococcal vaccination. Review of Resident #35's immunizations revealed the resident received the influenza vaccine on 10/26/22, declined the COVID-19 vaccination on 10/26/22 and the Prevnar 20 (pneumococcal vaccine) was required. Review of a consent form signed 09/20/22 revealed Resident #35 consented to the pneumococcal vaccination. Interview on 11/22/22 at 10:09 A.M. of Clinical Registered Nurse (CRN) #306 verified Resident #35 had signed a consent on 09/20/22 to receive the pneumococcal vaccination and did not receive it. CRN #306 stated she contacted the pharmacy and the vaccination had been ordered but Resident #35's insurance did not cover it and the Resident would have had to cover the cost. CRN #306 confirmed there was no evidence the facility followed up with either Resident #35 or the Resident's representative regarding the vaccination. Review of facility policy titled, Influenza and Pneumococcal Immunization, revised 06/19/19, revealed each resident, upon admission, would be offered the pneumococcal immunization. The resident or their legal representative would receive education regarding the benefits and potential side effects of the immunization prior to administration. The resident or their representative have the right to refuse the immunization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 13 of 14 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure bathrooms accessible to residents were equipped with a call light. This had the potential to affect seven (Residents #7, #15, #21, #34, #246, #247 and #248) identified by the facility as being independently mobile and residing on the 200 hall. The facility census was 44. Residents Affected - Some Findings include: Observations on 11/20/22 at 10:06 A.M., 11:09 A.M., 1:22 P.M. and 4:25 P.M. and on 11/21/22 at 7:37 A.M. and 10:00 A.M. of a bathroom located off the 200 hall dining room, revealed the bathroom door was open and there was no call light in the bathroom. Interview on 11/21/22 at 10:20 A.M. with the Regional Minimum Data Set Registered Nurse (RN) #313 verified the bathroom door was unlocked and the bathroom did not have a call light. RN #313 stated the bathroom was generally used for staff and visitors and confirmed the door should be closed and locked since there was no call light in the bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365571 If continuation sheet Page 14 of 14