Health inspection·June 10, 2021

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/07/21 at 9:40 A.M. with Resident #15 stated she has had only one bed bath in the last month. Resident #15 stated she could not shower due to the immobilizer on her leg. Interview on 06/09/21 at 2:32 P.M. with Licensed Practical Nurse (LPN) #30 verified Resident #15's shower days were on Wednesday and Sunday on first shift from 04/14/21 to 05/24/21. After 05/24/21, Resident #15's scheduled shower days were changed to Monday and Thursday on first shift. Interview on 06/09/21 at 9:04 A.M. with the Director of Nursing (DON) stated Resident #15 takes bed baths and did not want showers. The DON verified bed baths should be documented under the bathing task in Resident #15's medical record. Subsequent interview on 06/09/21 at 2:31 P.M. with the DON verified Resident #15 did not receive showers on her scheduled shower days on 05/09/21, 05/12/21, 05/19/21, 05/24/21, 05/27/21 or 06/07/21. Resident #15 was not bathed for a week from 05/09/21 to 05/16/21 and not bathed for a week from 05/23/21 to 05/31/21. Interview with Regional Administrator #150 on 06/10/21 at 8:38 A.M. stated the facility had no specific policy that defines ADLs including resident showers as they follow resident preference and orders. Review of the State Tested Nurse Aid (STNA) Job Summary dated 04/15/19 revealed STNAs duties included to provide resident assistance with bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 2 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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, resident and staff interviews, and policy review, the facility failed to ensure non-pressure skin impairments were accurately assessed and routinely monitored. This affected one (#15) of two residents reviewed for non-pressure skin impairments. The facility census was 45. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/09/21 with diagnoses of fracture of the right fibula, chronic kidney disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed surgical wounds were present upon admission for Resident #15. Review of the nurse progress notes from admission on [DATE] to 06/07/21 revealed no information about a new wound on her right leg at any time. Review of the physician orders, dated 04/09/21, revealed a dry dressing change to the right lower extremity daily. Skin checks to the right lower extremity every shift was ordered on 04/09/21. An immobilizer to the right lower extremity at all times was ordered on 04/10/21. Review of the medical record revealed the facility was using a photographing imaging wound assessment tool and Skin and Wound Evaluation form for Resident #15. Resident #15 had no initial surgical wound assessments upon admission. The first documentation of any wound assessment was a photograph dated 04/19/21 at 6:51 P.M. identified as wound #4, undiagnosed, body location was not set, age was unknown and where the wound was acquired was not set. Dimensions were 71.21 cm area, 23.87 cm length and 10.77 cm width. The image revealed four surgical wounds, one each at the lateral knee, lateral shin, medial knee and medial shin with staples intact. The four surgical wounds were not documented separately. Review of the assessment/photograph, dated 04/20/21 at 1:04 P.M., revealed wound #4 was a surgical wound with staples and the incision was approximated, six days old and present upon admission (eleven days prior). The location of the wound was not identified. Dimensions were 14.2 cm area, (80 percent improvement in one day), 20.92 cm length (12 percent improvement) and 9.77 cm width (9 percent improvement). The four surgical wounds, one each at the lateral knee, lateral shin, medial knee and medial shin with staples intact continued to be evaluated as one wound. The next assessment, dated 04/25/21 at 3:34 P.M., revealed wound #4 was 100 percent healed with zero area, length and width. The location was not identified. The wound was approximated with staples. Treatment included to wash with soap and water and no dressing was ordered. the image revealed staples were still present at the lateral shin, medial shin and medial knee surgical incisions. The lateral knee surgical incision was poorly visualized and the status of staples were unknown visually. No scabbing was visually noted at any of the four surgical wounds. Wound #4 was re-evaluated on 05/01/21 at 10:22 A.M., again identified as surgical with staples, approximated, present upon admission and with no location identified. Dimensions were 47.19 cm area, (232 percent increase), 22.27 cm length and 9.8 cm width. The image of Resident #15's right knee/shin revealed the four surgical wounds appeared well approximated with staples remaining in an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 3 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 undetermined number and with scabbing noted at the lateral shin, medial knee and medial shin. Wound #4 was the only assessment for the four surgical wounds. Wound #4 assessment one day later on 05/02/21 remained essentially the same as the assessment dated [DATE], however the dimensions were 15.55 cm area (67 percent improved), 22.27 cm length and 9.37 cm width. The next assessment was ten days later on 05/12/21 at 6:53 P.M. for wound #4. The location was still not identified, the four surgical wounds were still being evaluated as one wound. The image revealed increase scabbing at the lateral shin about three or four inches in length and about half an inch wide with irregular edges. The next assessment was eleven days later dated 05/23/21 at 3:53 P.M. for wound #4 identified to be surgical with staples at the right calf, well approximated and with zero area, length or width and 100 percent closed. Review of the corresponding wound photograph dated 05/23/21 revealed there were no staples on the four surgical wounds. The medial side of her right knee had two scabbed areas, each about an inch long. The medial side of her calf had one area which appeared to be scabbed about one inch long and half inch wide. Resident #15's lateral shin had a large area which appeared to be scabbed about three to five inches long and about an inch wide, increased in size from 05/12/21. No open areas were visually noted in the photograph. There was no further assessment of the wound from 05/23/21 to 06/08/21. The four surgical wounds were never evaluated separately. The first wound assessment identified as wound #4 was not completed until ten days after admission. There was no weekly wound assessment completed for ten days from 05/02/21 to 05/12/21. Interview with Resident #15 on 06/07/21 at 9:28 A.M. stated she had a wound under her right leg immobilizer. She verified she had surgical wounds from the repair of her fractured fibula and she wore a knee immobilizer. Resident #15 stated there were new wounds on her shin/ankle area in the front. The (unnamed) nurse found the wounds a couple of days ago but did not do anything to it when it was found. The nurse told her that the physician would need to be contacted for a new treatment. The nurse did cover the wound with a dry pad which was an existing treatment for the surgical wound near the location of the new wounds. Resident #15 stated that yesterday (06/06/21), the dry pad was sticking to the wound. The (unnamed) nurse did put a treatment on the new wounds on 06/06/21 then again covered the entire area with the dry pad. Resident #15 stated the staff were not routinely removing the knee immobilizer and not routinely completing dressing changes for the surgical wounds. Observation on 06/07/21 at 9:28 A.M. revealed Resident #15 was wearing a removable knee immobilizer on her right leg from her ankle to above her knee. The knee immobilizer had Velcro straps holding it in place. Observation on 06/08/21 at 2:20 P.M. with Licensed Practical Nurse (LPN) #49 revealed she removed Resident #15's knee immobilizer from her right leg. There were two abdominal (ABD) pads across her shin/calf area, not secured with any tape. LPN #49 removed the two pads revealing another small dressing which looked like adaptic approximately one inch square under the ABD pad at the medial mid-calf area. LPN #49 verified there was some sort of dressing about one inch square under the ABD pad and near an open wound. She removed it and verified it looked like an adaptic dressing. LPN #49 verified there was no order for adaptic, only a dry dressing was ordered. Further observation revealed three wounds at the medial mid-calf area. The most distal area appeared to be about 0.5 centimeters (cm.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 4 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 long and 0.1 cm. and scabbed. The center wound appeared to be about 2.0 cm. long and 0.5 cm. wide, open with scant drainage. The periwound area was red. The third most proximal area was about 2.0 cm. long and 0.5 cm. and scabbed. LPN #49 verified the middle wound at the medial mid-calf area appeared to have been caused by rubbing and was not surgical a wound. LPN #49 verified she had not noted the open wound during her skin inspection that morning and she did not see the adaptic dressing during her skin inspection that morning. LPN #49 verified Resident #15's medial mid-calf had a new non-surgical wound previously covered with an adaptic dressing. She could not say how long the wound had been there. LPN #49 verified the open wound was draining and may need separate treatment and she would update the physician. Further observation of the right lower leg revealed a healed surgical incision lateral to the knee. The surgical incision medial to the shin had scabbed areas; the surgical incision medial to the knee had small scabbed areas. The surgical incision lateral to the shin was covered with a large irregular scabbed area three to five inches long and about an inch wide. LPN #49 verified Resident #15 still had these scabbed areas at three of the four surgical incision areas. Interview on 06/09/21 from 9:56 A.M. to 2:38 P.M. with Assistant Director of Nursing (ADON) #36 verified there was no initial assessment of Resident #15's surgical wound incisions upon admission. The four surgical incisions were never evaluated separately but were documented and evaluated as a single surgical wound. The first wound assessment identified as wound #4 was not completed until ten days after admission. Weekly wound assessments were not completed. ADON #36 verified the wounds were documented as 100 percent closed on 04/25/21 and on 05/23/21. ADON #36 verified that was not accurate as evidenced by the photographic images dated 04/25/21 and 05/23/21, showed there was still scabbing present at Resident #15's shin and knee. ADON #36 verified there was no wound assessment completed since 05/23/21 to 06/08/21. ADON #36 viewed the photograph of Resident #15's right leg taken on 05/23/21 and the new photograph taken by LPN #49 on 06/08/21 showing the new wound at her medial mid-calf. ADON #36 verified there was a new wound on the photo dated 06/08/21 which not present on 05/23/21. ADON #36 verified she was not aware of the new open area, there was no documentation of the new open area at her medial mid-calf, no physician notification and no new order for adaptic or any other treatment of the new wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 5 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and review of the facility's policy, the facility failed to accurately assess and routinely monitor residents with pressure ulcers. This affected two (#4 and #25) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 45. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 03/05/21. Diagnoses included stage four pressure ulcer to sacral region (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.), mononeuropathy, protein calorie nutrition, dementia with behavioral disturbance, muscle weakness, and colostomy. Review of Resident #4's plan of care, dated 03/10/21, revealed the pressure wound was to be assessed and monitored with length, width and depth when possible. The wound perimeter, wound bed and healing process was to be documented with improvements and declines in wound healing reported to the physician accordingly. Review of Resident #4's five-day Minimum Data Set (MDS) assessment, dated 03/11/21, revealed the resident was rarely/never understood with long and short term memory problems. The resident required assistance with bed mobility, transfers and toileting. The resident was admitted to the facility with a stage four pressure ulcer. Review of Resident #4's wound record revealed on 03/05/21, the resident was admitted with a stage four pressure ulcer to the sacrum which measured 11.9 centimeters (cm.) in length by 3.34 cm. in width. There were no measurements documented on 03/10/21, 03/17/21, 04/21/21, 05/21/21 and 06/08/21. The last documented wound measurement was dated 05/26/21 and measured 2.66 cm. in length by 1.83 cm. in width. Continued review of Resident #4's wound documentation revealed it to be silent for documented wound characteristics on 03/05/21, 03/07/21, 03/24/21, 03/31/21, 04/07/21, 04/14/21, 04/28/21, 05/05/21, 05/12/21, 05/14/21 and 05/25/21. Interview on 06/09/21 at 8:50 A.M. with the Director of Nursing (DON) confirmed there to be a lack of wound measurements documented for Resident #4 on 03/10/21, 03/17/21, 04/21/21, 05/21/21 and 06/08/21. The facility uploads photos, however, the measurements were not calculated on the above dates through the computerized system. The DON also confirmed there was a lack of documented wound characteristics documented for Resident #4 on 03/05/21, 03/07/21, 03/24/21, 03/31/21, 04/07/21, 04/14/21, 04/28/21, 05/05/21, 05/12/21, 05/14/21, 05/26/1 and 06/08/21. The DON confirmed Resident #4 was followed by an infectious disease physician for his wound. 2. Review of the medical record for Resident #25 revealed an admission date of 04/06/21. Diagnoses included acute and chronic respiratory failure, stage three pressure ulcer of sacrum (Full thickness tissue loss. Subcutaneous fate may be visible but bone, tendon, or muscle is not exposed), obesity, protein calorie malnutrition, muscle weakness, pressure ulcer right buttock - unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar), cognitive communication deficit, dysphonia, neuromuscular dysfunction of bladder, and an unstageable sacral region pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 6 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #25's plan of care, initiated on 04/06/21, revealed the pressure wounds were to be monitored for effectiveness and to notify the advanced level provider as needed if the area worsens or does not respond. Review of Resident #25's five-day MDS assessment, dated 04/13/21, revealed the resident had intact cognition. The resident required extensive assistance of staff for bed mobility, transfers and toileting. The resident was identified to be at risk for pressure ulcers with a documented unhealed stage three present upon admission. Review of Resident #25's wound record revealed on 04/09/21 the resident was admitted with a stage three pressure ulcer to the coccygeal which measured 7.54 centimeters (cm.) in length by 4.43 cm. in width. The assessment was silent for documented wound characteristics on this date. Continued review of the wound record revealed there were no wound characteristics documented on 04/27/21, 05/04/21 and 05/18/21. Review of the wound record revealed on 06/09/21 the wound was documented as being 2.45 cm. in length and 0.38 cm. in width with 60% slough, moderate serosanguineous drainage with attached epithelial erythema and fragility surrounding the wound site. Observation of wound care for Resident #25 on 06/09/21 at 7:45 A.M. with LPN #30 revealed the resident to have two small pea sized open areas on the right buttock and one pea size open area near the sacral region. Interview on 06/09/21 with LPN #30 confirmed the resident was admitted with the open areas to the sacral and buttock areas. Interview on 06/09/21 at 8:50 A.M. with the Director of Nursing (DON) confirmed the lack of wound characteristics being documented for 04/09/21, 04/27/21, 05/04/21 and 05/18/21. The DON confirmed the resident to have documented open areas to right buttock that were being monitored as one wound site with one measurement as the wound initially entailed one area. The facility did a house sweep on 06/08/21 and realized they have issues with documentation of skin wounds and were putting a plan of action in place along with staff training. The DON confirmed Resident #25 was being followed by an infectious disease physician and surgeon for her wounds. Interview on 06/09/21 at 1:05 P.M. with Regional Administrator #150 confirmed the facility was lacking in required weekly wound documentation along with lack of documented wound characteristics which they have identified at the time of this survey in progress. Review of the facility's policy titled, Skin Care Management, with a revision date of 11/02/18, revealed with dressing changes or at least weekly at a minimum, documentation should include the date observed, location and staging, size inclusive of length and width of the wound, exudate (odor, color and approximate amount), pain, description of the wound bed to include color and type of tissue (granulation, necrosis, slough or eschar), and description of the wound edges and surrounding tissue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 7 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and facility policy review, the facility failed to have a diagnosis for the need of a catheter and failed to have physician orders for catheter care for a resident. This affected one (#93) of two residents reviewed for urinary catheters. The facility identified three residents with an indwelling catheter. The facility census was 45. Findings include: Review of the medical record for Resident #93 revealed she was admitted on [DATE] with diagnoses of acute respiratory failure, dysphagia, cardiomyopathy, pneumonia, diabetes mellitus and hypertension. Her admission Minimum Data Set (MDS) assessment was not yet completed. Review of the initial plan of care revealed a focus area for the use of a urinary catheter with goals and interventions for the use of the catheter. Further review of Resident #93's medical record revealed there was no diagnoses for the use of a catheter and no physician orders for the use and care of a urinary catheter. Observation on 06/07/21 at 2:47 P.M. revealed Resident #93 had a indwelling urinary catheter draining dark amber urine hanging at the right side of the bed. Observation on 06/08/21 at 12:27 P.M. and at 2:14 P.M. and on 06/09/21 at 10:47 A.M. revealed Resident #93 continued to have a catheter. Interview with Director of Nursing (DON) on 06/09/21 at 12:05 P.M. verified Resident #93 was admitted to the facility with a indwelling catheter. The DON stated she did not know why she had a catheter and would have to look at the hospital notes. Interview with Licensed Practical Nurse (LPN) #30 on 06/09/21 at 12:14 P.M. verified Resident #93 had a indwelling catheter, verified there was no diagnosis for the reason for the catheter and verified there were no catheter orders in place for the use and care of Resident #93's indwelling catheter. Interview on 06/10/21 at 9:23 A.M. with Assistant Director of Nursing (ADON) #36 verified there was no diagnosis for the use of a catheter and no physician orders for the catheter for Resident #93. ADON #36 verified after reviewing her admission records, they had found no reason for the catheter and Resident #93 should not have continued with the catheter after her admission. ADON #93 stated it was now discontinued and Resident #93 had expressed relief that it was gone. Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Care and Management, dated 11/20/20, revealed to review the necessity of continued urinary caterer use. Remove the catheter according to the physician order or facility protocol as soon as it is no longer clinically indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 8 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 0759 Ensure medication error rates are not 5 percent or greater. 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, staff interview and facility policy review, the facility failed to ensure their medication error rate of less than five percent (%). There were 35 medication opportunities with 11 medication errors, resulting in a 31% significant medication error rate. This affected one (#94) of six residents observed for medication administration. The facility census was 45. Residents Affected - Few Findings include: Review of the medical record for Resident #94 revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction, atrial fibrillation, dysphagia and hemiparesis and hemiplegia. Review of the physician orders, dated 06/10/21, revealed medications including vitamin C (vitamin) 500 milligrams (mg.), Aspirin (anti-inflammatory and blood thinner) 81 mg, calcium citrate plus vitamin D (vitamin) 315 mg./200 units, cartia (treats high blood pressure) 120 mg., Geritol complete (vitamin) one tablet, Lutein (vitamin) 100 mg., Miralax (treats constipation) 17 grams, Clonidine (treats high blood pressure) 0.1 mg., Eliquis (blood thinner) 2.5 mg., Metoprolol (treats high blood pressure) 25 mg. and UTI-stat (helps support urinary tract health) 30 milliliters (ml.). Review of the Medication Administration Record (MAR) for Resident #94 revealed all the medications noted above were scheduled to be administered daily at 7:30 A.M. Observation on 06/10/21 at 9:55 A.M. revealed Licensed Practical Nurse (LPN) #144 prepared medications for Resident #94 which included vitamin C 500 mg., Aspirin 81 mg., calcium citrate plus vitamin D 315 mg./200 units, cartia 120 mg., Geritol complete one tablet, Lutein 100 mg., Miralax 17 grams, Clonidine 0.1 mg., Eliquis 2.5 mg., Metoprolol 25 mg. and UTI-stat 30 ml. LPN #144 administered these medications to Resident #94 on 06/10/21 at 10:10 A.M. When Resident #94 received her medications, she told LPN #144 she usually takes them at 7:30 A.M. every day. This resulted in 11 medication errors out of 35 medication opportunities. Interview with LPN #144 at the time of the observation verified she was late giving the medications for Resident #94 which were due at 7:30 A.M. and should have been administered no later than 8:30 A.M. Interview with Director of Nursing (DON) on 06/09/21 at 8:00 A.M. verified the morning medication administration was scheduled at 7:30 A.M. and the nurses had one hour before and one hour after 7:30 A.M. to complete medication administration. Review of the facility's policy titled Medication Administration, dated 06/21/17, revealed medications will be administered by legally-authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 9 of 10 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, manufacturer's instructions and facility policy review, the facility failed to properly store medications. This affected one resident (#237) whose medications were found to be preset in one medication cart of two medication carts observed and one medication room of two medication rooms observed for medication storage. The facility had a total of three medication carts and two medication rooms. The facility census was 45. Findings include: 1. Observation on 06/07/21 at 8:07 A.M. on the North Hall at the nurse's station revealed a vial of Albuterol sulfate (bronchodilator) 3.0 milligrams (mg.) in 3.0 milliliters (ml.) was laying on the window ledge, unattended, not in a locked container or cart and not in any prescription package. The nurse was in a resident room. Interview with Licensed Practical Nurse (LPN) #49 on 06/07/21 at 8:12 A.M. verified the vial of Albuterol sulfate 3.0 mg. in 3.0 ml. was laying on the window ledge, unattended, not locked and not in any prescription package. LPN #49 stated she was not aware it was there and did not leave it there. 2. Observation on 06/09/21 at 7:58 A.M. revealed LPN #30 was at the south unit medication cart. She opened the top drawer of the cart which revealed two medication cups containing preset medications. LPN #30 stated she had prepared the medications earlier and they were for Resident #237. LPN #30 verified rather than administering the medications, she left them in the top drawer while she completed a dressing change for another resident. LPN #30 stated one medication cup contained Resident #237's crushed medications Gabapentin (treats nerve pain) 400 mg., Levothyroxine (treats thyroid disease) 25 micrograms (mcg.), amiodarone (treats heart rhythm problems) 100 mg, Abilify (antipsychotic) 7.5 mg., aspirin (anti-inflammatory and blood thinner) 325 mg., buspar (treats anxiety) 15 mg. and Diltiazem (treats high blood pressure) 60 mg. The second medication cup contained his Depakote sprinkles (anticonvulsant) 500 mg. LPN #30 then opened the Depakote sprinkle capsule, emptied it into the other medication cup, added pudding and proceeded to administer the medications to Resident #237. 3. Observation on 06/10/21 at 10:28 A.M. of the south medication room with LPN #13 revealed one opened vial of influenza vaccine in the refrigerator dated 09/27/20. LPN #13 stated she did not know how long it was good and verified it was opened on 09/27/20. Review of the manufacturer's instructions for the influenza vaccine 2020-2021 formula revealed once the stopper of the multi-dose dial has been pierced the vial must be discarded within 28 days. Review of the facility's policy titled General Guidelines for Medication Storage, dated 07/23/19, revealed medications are stored safely, securely and properly following manufactures' recommendations or those of the supplier. The medications are accessible only to licensed nursing personnel, pharmacy personnel or others authorized to administer medications. Medications are dispensed in packaging/containers that meet regulatory requirements. Medication shall be kept and stored in these packages/containers. Transfer of medications from one container to another is not permitted. Only those authorized to administer medications are allowed access to medications. Medication carts, rooms and medication supplies are locked or attended by those authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 10 of 10