Health inspection·May 24, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review, observation and resident and staff interviews, the facility failed to ensure residents plan of care reflected the residents use of hearing aids. This affected one (#9) out of one resident reviewed for vision and hearing. Facility census was 35. Findings include: Review of medical record for Resident #9 revealed a readmission date of 01/01/2021 with diagnoses including heart disease, chronic embolism, and thrombosis of deep veins of right lower extremity and depression. Review of Resident #9's Minimum Data Set (MDS) assessments dated 11/6/21, 02/05/21, and 03/10/21, specifically Section B indicated the resident has minimal hearing difficulties and has no hearing aids or other appliances. Review of Resident #9's plan of care last updated on 02/16/21 revealed the residents use of bilateral hearings aids was not part of the plan of care. On 05/17/21, at 8:40 A.M. interview and observation with Resident #9 revealed she has bilateral hearing aids but is not currently wearing them. On 05/18/21, at 2:05 P.M. an interview with MDS Coordinator #18 confirmed Resident #9's hearing aids are not addressed in the residents plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 2 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation and resident and staff interviews, the facility failed to ensure a resident was provided and/or assisted with her bilateral hearing aids each morning. This affected one (#9) out of one resident reviewed for vision and hearing. The census was 35. Residents Affected - Few Findings include: Review of medical record for Resident #9 revealed a readmission date of 01/01/2021 with diagnoses including heart disease, chronic embolism, and thrombosis of deep veins of right lower extremity and depression. Review of Resident #9's Minimum Data Set (MDS) assessments dated 11/6/21, 02/05/21, and 03/10/21, specifically Section B indicated the resident has minimal hearing difficulties and has no hearing aids or other appliances. Review of Resident #9's plan of care last updated on 02/16/21 revealed the residents use of bilateral hearings aids was not part of the plan of care. On 05/17/21, at 8:40 A.M. an interview and observations with Resident #9 revealed she was not wearing her bilateral hearing aids. Resident #9 stated, A nurse or an aid are to bring them to me every morning and help me put them in, but they never do. An aide was observed bringing her hearing aids in during the interview. On 05/18/21, at 1:55 P.M. observation of Resident #9 revealed she had no hearing aids in her ears. 05/18/21, 1:58 P.M. an interview with State Tested Nursing Assistant (STNA) #17 confirmed Resident #9 keeps her hearing aids at the nurses' station overnight and the STNA's are to help her put them in every morning. On 05/18/21, 1:59 P.M. an interview with Registered Nurse (RN) #19 confirmed Resident #9 is to have her hearing aids put in every morning. They keep the residents' hearing aids in the nurses' station nightly to prevent the resident from losing them. On 05/20/21, at 9:40 A.M. an observation and interview with Resident #9 revealed she did not have her bilateral hearing aids in place. On 05/20/21, at 9:45 A.M. an interview and observation with STNA #15 confirmed Resident #9's bilateral hearing aids were sitting on the charger in the nurses' station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 3 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 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 0760 Ensure that residents are free from significant medication errors. 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 interviews, review of incident report, and review of facility policies, the facility failed to ensure a resident received the correct medications when staff administered medications to the wrong resident resulting in significant medication errors. This affected one (#8) out of five reviewed for potential medication errors. The facilities census was 35. Residents Affected - Few Findings included: Medical record review for Resident #8 revealed an admission dated of 07/18/20. Diagnoses included, Alzheimer's disease, dementia, high blood pressure, rheumatoid arthritis, anxiety disorder, hypothyroidism, and history of falling. Review of Resident #8's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating Resident #8 was cognitively impaired. Review of Resident #8's progress notes revealed on 05/17/21, the resident was given her roommate's (Resident #6) medication due to Resident #8 responding to Resident #6's name. Resident #8 was monitored for adverse reactions, her vital signs were taken, and she had no distress or discomfort. Interview on 05/19/21 at 12:26 P.M. with Licensed Practical Nurse (LPN) #12 reported he was an agency nurse and just started working at the facility. LPN #12 verified on 05/17/21 he administered Resident #6's medications to Resident #8 in error. LPN #12 reported he asked Resident #8 if she was Resident #6 and she responded she was, so he administered Resident #6's medication to Resident #8. LPN #12 stated the doctor was called and LPN #12 was instructed to proceed with administering Resident #8's medications as well. LPN #12 reported he thought the doctor instructed to hold one medication due to it being the same as Resident #6's that she had already received, but he could not remember. LPN #12 reported he was working the evening shift when the incident occurred. Interview on 05/19/21 at 12:55 P.M. with LPN #12 reported Resident #8 received all of Resident #6's medication including Xanax (anti-anxiety medication) and Hydralazine (high blood pressure medication) during the evening shift on 05/17/21. LPN #12 reported Resident #8 had no negative outcome. Interview on 05/19/21 at 2:28 P.M. with the Director of Nursing (DON) verified LPN #12 administered Resident #6's medications to Resident #8 on 05/17/21. The DON verified Resident #8 was cognitively impaired. Interview on 05/19/21 at 2:44 P.M. with LPN #14 verified LPN #12 administered Resident #6's medications to Resident #8 on 05/17/21. LPN #14 reported she notified the doctor and LPN #12 had been instructed to monitor Resident #8 for adverse outcomes. There were no negative outcomes. Further review of Resident #8's Medication Administration Record (MAR) for 05/17/21 revealed Resident #8 received the following medications in the evening: Donepezil 10 milligrams (mg) (for Alzheimer's), Bupropion 100 mg (for anxiety), and Buspirone five mg (for anxiety) in addition to receiving Resident #6's medications. Review of Resident #6's MAR for 05/17/21 revealed Resident #6 was ordered the following medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 4 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be administered in the evening: Melatonin five mg (for sleep), Buspirone 10 mg (for anxiety), Docusate Sodium 100 mg (for constipation), Calcium Carbonate Antacid 750 mg (for acid reflux), Hydralazine 25 mg (for high blood pressure), NuLev 0.125 mg (for diarrhea), Sucralfate one gram (for acid reflux), and Xanax 0.5 mg (for anxiety). All medications listed were administered to Resident #8. Review of incident report dated 05/17/21 revealed during medication pass, Resident #8 received Resident #6's night medications. Resident #8's vital signs were within normal limits and was monitored for adverse reactions. Review of facility policy titled, Medication Administration, dated 06/21/17 revealed the resident would be identified before administering medication. The resident would be asked their name without prompting or cueing. Review of facility policy titled, Medication Error Policy, dated 11/20/17 revealed the resident would be identified by using at least two resident identifiers, the right medication could be selected, and proper dose would be administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 5 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to ensure a resident was not served and fed food listed as an allergy. This affected one (#5) out of one resident reviewed for nutrition. The facility's census was 35. Findings included: Medical record review for Resident #5 revealed an admission date of 09/19/20. Diagnoses included, Parkinson's disease, generalized anxiety disorder, major depressive disorder, hyperlipidemia, hypothyroidism, and syncope and collapse. Review Resident #5's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating Resident #5 was cognitively impaired. Resident #5 required extensive assistance with eating. Review of Resident #5's allergies revealed the resident was allergic to apples, Benadryl, Cephalosporins, chicken, Doxycycline, Flagyl, milk, peanuts, and Penicillin's. Review of Resident #5's progress notes revealed on 01/25/21, Resident #5 ate apple pie for lunch and on 02/08/21, Resident #5 was given a bite of apple sauce. Observation on 05/17/21 at 12:49 P.M. revealed State Tested Nurse Aide (STNA) #16 delivered lunch to Resident #5 and began feeding Resident #5. STNA #16 verified Resident #5 required staff to feed her. Interview on 05/19/21 at 12:09 P.M. Licensed Practical Nurse (LPN) #13 verified Resident #5's allergies, including an allergy to apples. LPN #13 further verified further verified Resident #5 ate apple pie on 01/25/21 and apple sauce on 02/08/21 during mealtimes when STNA's fed her. The facility did not have a policy to address resident allergies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 6 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, review of an electronic mail (e-mail) communication and policy review, the facility failed to ensure visitors followed proper infection control guidelines while visiting a resident who was quarantined to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected one (#25) out of three residents reviewed who were quarantined. The census was 35. Residents Affected - Few Findings include: Review of medical record for Resident #25 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses include acute respiratory failure, chronic obstructive pulmonary disease, and chronic kidney disease stage 3. Resident #25 was discharged to the hospital on [DATE] for complaints of weakness and lower extremity swelling. Resident #25 was readmitted to the facility on [DATE]. Review of Resident #25's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. Further record review revealed Resident #25 has not been COVID-19 vaccinated and quarantined for 14 days. On 05/18/21, at 11:15 A.M. an observation with Registered Nurse (RN) #10 revealed two family members were visiting Resident #25 in her room. The two family member were wearing a loop mask and no other personal protective equipment (PPE). Prior to entering Resident #25's room there is a sign on the door stating, STOP! This room requires full PPE to enter, including N95 mask. A second sign, Before entering room, put following items on, mask, shield or goggles, gown, and gloves. A cart outside of Resident #25's room contained the necessary PPE items for use. The visitors explained they did not know they needed to put additional PPE on before entering the room. RN #10 explained to the visitors why they needed to wear the PPE. On 05/18/21, at 11:20 A.M. an interview with the Administrator, Director of Nursing (DON) and the Regional Clinical Director #11 revealed upon entry to the facility every visitor is screened and asked who they are visiting. At that time, the visitor is educated on what type of PPE is required to visit the resident. The family members of Resident #25 should have been told prior to entering their family members room they needed to put on additional PPE before entering Resident #25's room. On 05/19/21, at 1:41 P.M. review of an e-mail from the Administrator confirmed Resident #25's visit was a compassionate visit on 05/18/21. Review of the Facility's Precaution Guideline revealed if someone is on any type of transmission-based precautions (contact, droplet and airborne) individuals are to wear gloves, a masks or respirator and gown. Review of the COVID-19 policy and procedure revealed newly admitted residents to the facility who are not vaccinated, are required to quarantine in their private room and Transmission Based Precautions are in affect. Visitors and employees entering a quarantined room are to wear gloves, isolation gown, facemask, and an N-95 mask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 7 of 8 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 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein-Cridersville 100 Red Oak Drive Cridersville, OH 45806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Isolation Precautions Process policy (12/19) reveals Transmission Base Precautions include gowns, gloves, and mask (N-95) or respirator when entering a quarantined room. Review of a CMS Clinical Standards and Quality/Survey & Certification Group (CMS) QSO-20-39 Nursing Home Visitation -COVID-19 Memorandum revised 04/27/21, revealed residents who are on transmission based-precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. Event ID: Facility ID: 366050 If continuation sheet Page 8 of 8