Health inspection·November 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #21's medical record revealed an admission date of 10/09/23. Diagnoses included dementia and insomnia. Resident #21 resided on the secured memory unit. Review of Resident #21's MDS, dated [DATE], revealed a BIMS score of two, indicating Resident #21 was severely cognitively impaired. Resident #21 displayed wandering behaviors one to three days during the review period. Review of Resident #21's care plan, revised 10/16/23, revealed supports and interventions for self-care deficit, cognitive impairment, behaviors of resisting care, wandering, yelling out, cursing, being sexually inappropriate with staff, and elopement risk. Review of Resident #21's Wandering and Elopement Risk assessment dated [DATE] determined Resident #21 was at low risk for wandering and elopement. Resident #21 was reassessed on 10/28/23 and was found to be at moderate risk. Resident #21 was again assessed on 10/28/23 and was found to be at high risk for wandering and elopement. Review of the facility's Self-Reported Incidents (SRIs) from 09/14/23 through 11/10/23 revealed no SRI's were submitted for Resident #21. Review of Resident #21's medical record revealed on 10/27/23 at approximately 5:30 P.M. Resident #21 eloped from the facility by following a visitor out the door. Resident #21 was found sitting in his wheelchair, unsupervised, outside the facility by a staff returning to work. Interview on 11/08/23 at 11:02 A.M. with the Director of Nursing (DON) and the Administrator verified on 10/27/23 Resident #21 eloped from the facility. The DON also verified an SRI had not been completed for Resident #21's elopement. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property- Ohio Only, revised 10/25/22 revealed neglect was defined as the failure of the facility, it's employees, or facility service providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. All allegations involving neglect without serious bodily injury would be reported to the Ohio Department of Health (ODH) immediately, but no later than 24 hours from the time of the incident/allegation was made known to the staff member. The facility would submit an online Self-Reported Incident (SRI) form in accordance to ODH's current instructions. This is an incidental finding discovered during the investigation of Complaint Number OH00148063. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility investigations, review of a Sheriff's Office incident report, review of the weather forecast, review of hospital discharge documents, and review of facility policy, the facility failed to prevent the elopement of confused residents from the secured memory care unit. This resulted in actual harm when one resident (#20) eloped from the facility without staff knowledge, was outside for approximately three hours in cool weather temperatures and light rain, was subsequently admitted to the hospital for evaluation and stabilization and was diagnosed with hypothermia (a significant and potentially dangerous drop in body temperature most commonly caused by prolonged exposure to cold) and a hypothermic blanket was applied. Furthermore, the resident was diagnosed with hypokalemia (low potassium) requiring intravenous (IV) fluids for hydration and found to have an episode of non-sustained ventricular tachycardia (heart arrythmia). Additionally, the facility failed to prevent the elopement of a second resident (#21) that placed the resident at risk for the potential for more than minimal harm when Resident #21 exited the secured memory care unit and was noted sitting outside the south entrance at the F door by a staff member who was coming on shift. This affected two (#20 and #21) of three residents reviewed for elopement risk. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an admission date of 03/03/21. Diagnoses included major depressive disorder, schizoaffective disorder, dementia, Alzheimer's disease, delusional disorder, and mood disorder. Resident #20 resided on the secured memory unit. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #20 was severely cognitively impaired. Resident #20 required supervision, set up only for her activities of daily living. Resident #20 displayed verbal behavioral symptoms directed toward others one to three days during the review period. Resident #20 did not display any wandering behaviors at the time of the review. Review of Resident #20's care plan revised 11/03/23 revealed supports and interventions for self-care deficit related to dementia, impaired cognitive function, risk for wandering, and behavior of wandering. Review of Resident #20's Wandering and Elopement Risk assessment dated [DATE] revealed Resident #20 was at low risk. On 10/28/23, Resident #20 was reassessed due to having a history of elopement in the last 30 days and was assessed at high risk for wandering and elopement. Review of the facility's investigation documentation revealed on 10/28/23 at approximately 4:30 A.M. Resident #20 exited the building through the fire door and the door did not alarm when opened. The facility found Resident #20 was missing at approximately 6:30 A.M. when State Tested Nursing Assistant (STNA) #136 went to get Resident #20 up for breakfast. The elopement protocol was initiated and 911 was called at approximately 7:00 A.M. On 10/28/23 at 7:20 A.M. Resident #20 was found lying on the ground by the police. Resident #20 was determined to be outside wearing only a two-piece pajama set, socks and shoes for approximately three hours. Resident #20 was transferred to the hospital and was admitted for hypothermia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 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 0689 Review of the Weather Summary for 10/28/23 revealed it was between 53 and 60 degrees and lightly raining during the time Resident #20 had eloped from the facility. Level of Harm - Actual harm Residents Affected - Few Review of the Sheriff's Office Incident Report dated 10/28/23 revealed on 10/28/23 at 7:10 A.M. the facility called 911 and reported a missing person. The missing person was a resident at the facility. A deputy sheriff along with the local police department responded. While the deputy was enroute they were notified the missing resident was located lying on the ground behind one of the buildings. Resident #20 was noted to be responding but very cold and shaking. Review of the Medical Transportation Report dated 10/29/23 revealed Resident #20 was transported back to the facility following a hospital stay for a primary complaint of hypothermia. Review of Resident #20's progress notes revealed on 10/30/23 Resident #20 was seen by the physician for a routine visit and follow up from Resident #20's 10/28/23 hospitalization. It was noted staff reported Resident #20 wandered out of the facility in the early morning hours of 10/28/23 and was found lying on the ground. Resident #20's outdoor exposure was approximately three hours. Her downtime was thought to be approximately two hours after video surveillance was reviewed. In the emergency room she was found to have hypokalemia (low potassium) and admitted for further work-up and management. She was given IV hydration, and a hypothermic blanket was applied. She was also found to have an episode of non-sustained ventricular tachycardia (heart arrythmia). Resident #20 was consulted with cardiology and recommended to be followed. She returned to her baseline status with underlying dementia and confusion. The hospital course was uneventful. Resident #20 returned to the facility with a 48-hour [NAME] monitor (continuously measures the heart's electrical activity) in place and was to follow-up with cardiology in three to four days. Review of the Hospital Discharge documents dated 11/01/23 revealed Resident #20 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. It was noted Resident #20 was brought into the emergency room due to being confused and found lying on the ground in the rain. Resident #20 was discharged with the diagnoses of altered mental status, non-sustained ventricular tachycardia, volume depletion, elevated lactic acid levels and hypothermia. Interview on 11/08/23 at 11:02 A.M. with the Director of Nursing (DON) and the Administrator verified on 10/28/23 Resident #20 eloped from the facility from a non-functional alarmed door, was missing for approximately three hours, was found by the local police department, was transferred to the hospital for evaluation and admitted . Interview on 11/08/23 at 1:17 P.M. with STNA #136 verified she was the staff who found Resident #20 to be missing. STNA #136 reported she had entered Resident #20's room to get her up for breakfast around 6:40 A.M. on 10/28/23 and found Resident #20 was not in her room. They searched inside and outside of the facility and STNA #136 reported it was the police who found Resident #20 lying on the ground outside. Resident #20 was taken to the hospital after the police found her on 10/28/23 and Resident #20 returned to the facility on [DATE]. Follow-up interview on 11/14/23 at 1:44 P.M. with the DON verified Resident #20 was diagnosed with hypothermia at the hospital following her elopement. 2. Review of Resident #21's medical record revealed an admission date of 10/09/23. Diagnoses included dementia and insomnia. Resident #21 resided on the secured memory unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident #21's MDS dated [DATE] revealed a BIMS score of two, indicating Resident #21 was severely cognitively impaired. Resident #21 displayed wandering behaviors one to three days during the review period. Review of Resident #21's care plan, revised 10/16/23, revealed supports and interventions for self-care deficit, cognitive impairment, behaviors of resisting care, wandering, yelling out cursing, being sexually inappropriate with staff, and elopement risk. Review of Resident #21's Wandering and Elopement Risk assessment dated [DATE] determined Resident #21 was at low risk for wandering and elopement. Resident #21 was reassessed on 10/28/23 and was found to be at moderate risk. Resident #21 was again assessed on 10/28/23 and was found to be at high risk for wandering and elopement. Review of the facility's investigation for an incident on 10/27/23 revealed at approximately 5:30 P.M. Resident #21 exited the secured unit and was noted to be sitting at the outside entrance of the memory care unit by a staff member. Resident #21 was last noted to be seen in the dining room eating dinner at 5:00 P.M. At 5:25 P.M., STNA #109 left the dining area to assist another resident. Resident #21 was noted to still be at the dining table. At 5:30 P.M. Resident #21 exited the south entrance and STNA #114, who was coming on shift, found Resident #21 sitting in his wheelchair outside the facility by the F door. At 5:37 P.M. The DON was notified, and it was reported a visitor was previously in with another resident and Resident #21 may have exited when the visitor left. Interview on 11/08/23 at 11:02 A.M. with the DON and the Administrator verified on 10/27/23 Resident #21 eloped from the facility. The DON reported Resident #21 was outside the facility for only a few minutes when a staff member, who was coming on shift, found him outside the exit door and brought him back in. The facility investigated what happened and believed Resident #21 followed a visitor out of the building. Interview on 11/14/23 at 1:03 P.M. with STNA #114 verified she was the staff who found Resident #21 outside of the facility. STNA #114 reported she had just returned to the facility when she saw Resident #21 outside the facility in his wheelchair. STNA #114 reported she knew Resident #21 lived on the secured unit and was not able to be outside by himself. STNA #114 asked him what he was up to outside, and he told her he needed to feed the animals. She reassured Resident #21 his animals were taken care of and said it was time to go back in. Resident #21 was cooperative with going back in the building. Review of the facility policy titled, Missing Resident Policy and Procedure, revised 12/21/22 revealed elopement was defined when a resident leaves the nursing community without the location's knowledge or supervision. This deficiency represents non-compliance investigated under Complaint Number OH00148063. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365953 If continuation sheet Page 5 of 5