Health inspection·June 22, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/21/23 at 8:40 A.M. with Licensed Practical Nurse (LPN) #521 verified Resident #34 had an order for Depo-Provera 150 mg every 14 days and it had not been administered as it was not available on 05/18/23, 06/01/23, 06/03/23, and 06/17/23. LPN #521 was not able to see where the physician was notified of the medication not being administered. Interview on 06/21/23 at 2:31 P.M. with the Director of Nursing (DON) verified Resident #34's Depo-Provera was not administered on 05/18/23, 06/01/23, 06/03/23, or 06/17/23. The DON stated she would get in touch with the pharmacy to see if any notifications were made to the physician. Interview on 06/22/23 at 10:41 A.M. with the DON verified the physician was not notified when Resident #34's medication was not administered. Review of facility policy titled, Medication Administration Procedure, revised 11/09/21 revealed if a regular scheduled medication was withheld, refused or given at a time other than the scheduled time this would be documented in the electronic medical record. An explanatory note was entered within the residents chart including the physician notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to to ensure mobility positioning devices were in place as ordered. This affected one (Resident #18) of two residents reviewed for position and mobility. The facility census was 38. Findings Include: Review of the medical record for Resident #18 revealed an admission date of 04/26/23 with medical diagnoses including diabetes type II, urine retention, acute kidney failure, and pain in left and right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and required extensive assistance for bed mobility, transfers, walking, dressing, personal hygiene, and toileting. Review of Resident #18's care plan dated 04/27/23 revealed a self-care deficit for impaired ability to perform or complete Activities of Daily Living (ADLs). Review of Resident #18's physician orders dated 04/26/23 revealed Resident #18 had a physician order for a bilateral positioning bar (bars for the bed to assist with mobility/positioning) every shift for mobility. Observation on 06/20/23 at 10:37 A.M. revealed Resident #18 was lying in bed with the head of the bed elevated and no positioning bars in place. Interview on 6/20/23 at 10:40 A.M. with Resident #18 revealed he would like mobility bars added to his bed for turning and repositioning. Resident #18 reported he requested the mobility bars be applied to his bed to help with bed mobility and transfers. Resident #18 stated mobility bars were in his closet. Coinciding observation revealed mobility bars stored in the closet. Interview on 6/21/23 at 12:00 P.M. with Licensed Practical Nurse (LPN) #444 verified positioning bars were not applied to Resident #18's bed as ordered. Interview on 06/21/23 at 12:01 P.M. with Resident #18 revealed the resident told LPN #444, he requested enabler bars for his bed to help with his bed mobility, as he had them prior to his relocation to his current room. Resident #18 further indicated mobility bars were in his room in the closet and proceeded to point to the open door of the closet, revealing the enabler bars in his closet. LPN #444 verified mobility bars were not in place and would look into getting them attached. Review of policy titled, Assistive Devices, dated 10/31/22, indicated the use of assistive devices were for the purpose of supporting the function and ability of the resident with ADL functions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #32's medical record revealed an admission date of 04/13/23. Diagnoses included fracture of upper and lower end of right fibula subsequent encounter, protein calorie malnutrition, heart disease, Bell's palsy, cognitive communication deficit, and altered mental status. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #32 was moderately cognitively impaired. Resident #32 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #32 displayed no behaviors during the review period. Resident #32 had a fall prior to entry and no noted falls since admission at the time of the review. Review of Resident #32's care plan revised 06/20/23 revealed supports and interventions for self-care deficit and risk for falls. Fall interventions included anticipate and meet needs, be sure call light was within reach, bed against the wall to decrease chances of fall from bed (added 06/02/23), bed in low position at all times while in bed (05/05/23), keep area clutter free, keep needed items within reach, and mat by bedside while in bed (added 06/02/23). Review of Resident #32's Fall Risk assessment dated [DATE] revealed Resident #32 was at risk for falls. Review of Resident #32's physician orders revealed an order dated 06/02/23 for Resident #32 to have a fall mat by her bed when she was in bed. Observation on 06/20/23 at 10:07 A.M. revealed Resident #32 in bed in her room. Resident #32's bed was against the wall and she did not have a fall mat on the floor next to her bed. Observation on 06/21/23 at 8:29 A.M. revealed Resident #32 in bed in her room. Her bed continued to be against the wall. There was no fall mat on the floor next to her bed. Interview on 06/21/23 at 8:32 A.M. with Licensed Practical Nurse (LPN) #521 verified there was an order for Resident #32 to have a fall mat next to her bed when she was in her bed. Observation on 06/21/23 at 8:38 A.M. of Resident #32 found she continued to be in bed with no fall mat on the floor next to her. Coinciding interview with LPN #521 verified the ordered fall mat was not on the floor next Resident #32's bed. The fall mat was found folded up against the wall behind the recliner. Review of the facility policy titled, Falls Management, revised 12/03/19 revealed following a fall the facility was to institute interventions to prevent a further fall. Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure hot water was within appropriate parameters to potentially avoid burns. This had the potential to affect three residents (#15, #296, and #297) whose water supply shared the same water heater. In addition, the facility failed to ensure resident fall interventions were in place as ordered. This affected one resident (#32) of three reviewed for falls. The facility census was 38. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 0689 Findings Include: Level of Harm - Minimal harm or potential for actual harm Observation on 06/21/23 at approximately 9:52 A.M. revealed Former Resident #298's resident room revealed the resident bathroom sink temperature tempted at 130 degrees Fahrenheit. Residents Affected - Some Interview on 06/21/23 at 10:00 A.M. with the Administrator verified Former Resident #298's resident bathroom sink water tempted at 130 degrees Fahrenheit. The Administrator stated there had been no reports of the water being too hot or burns/blisters that had resulted due to hot water. The Administrator notified staff to halt any shower activity and notified maintenance. Water temperatures of other rooms were unable to be checked prior to the facility turning the temperature down. Interview on 06/21/23 at 10:07 A.M. with Environmental Director #463 stated the water temperature had been lowered and the hot water was being flushed out. Upon temping the bathroom sink again, the temperature was 127 degrees and after approximately five seconds began to drop down to 111 degrees Fahrenheit. Environmental Director #463 verified the water tank supplied and affected water to Resident #15, #296, and #297's rooms, in addition to a portion of the assisted living. Interview on 06/21/23 at approximately 11:30 A.M. revealed skin assessments had been completed on all residents with no concerns related to hot water. Review of policy Water Temperature Testing Procedure, dated 12/28/08, revealed water should be a minimum of 105 degrees Fahrenheit and not to exceed 120 degrees Fahrenheit. If water is outside the parameters, the maintenance partner shall make an adjustment to the house's hot water tank or call a service technician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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, resident interview, and staff interview, the facility failed to ensure a resident's pain was managed in a reasonable time. This affected one (Resident #295) of one resident reviewed for pain management. The facility census was 38. Residents Affected - Few Findings include: Review of the medical record revealed Resident #295 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with foot ulcer, non-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed, cellulitis of left lower lib, unspecified atrial fibrillation, unspecified systolic (congestive) heart failure, arthropathy, essential hypertension, major depressive disorder, hyperlipidemia, and hypothyroidism. Review of the care plan dated 06/14/23, revealed Resident #295 had the potential for pain with interventions including to monitor for pain characteristics and to notify the physician if interventions are unsuccessful or if the current complaint is a significant change from the resident's past experience of pain. Review of the physician order dated 06/14/23, revealed an order for hydrocodone-acetaminophen oral tablet 5-325 milligram (MG), give one tablet by mouth as needed three times a day (3 tabs only). Review of the Medication Administration Record (MAR) dated June 2023, revealed Resident #295 received hydrocodone-acetaminophen 5-325 MG on 06/14/23 with a pain scale rating of 5, on 06/15/23 with a pain scale of rating of 7, and on 06/16/23 with a pain scale rating of 8. Further review revealed the MAR had no documentation for pain medication administration or pain documentation for 6/17/23, 06/18/23, 06/19/23, and 06/20/23. On 06/21/23 Resident #295 received hydrocodone-acetaminophen 5-325 MG with a pain scale rating of 7. Interview on 06/20/23 at 11:34 A.M. revealed Resident #295 reported she had been asking for a pain pill since 06/16/23, and stated her pain was currently at a pain scale level of 7. Resident #295 stated she was at the facility because her heels were debrided. Subsequent observation revealed Registered Nurse (RN) #432 enter the resident's room. Resident #295 asked if the pain medication had been filled yet and stated approval needed to be provided to the pharmacy. RN #432 stated she was working with the physician for approval. Interview on 06/21/23 at 11:27 A.M. with RN #432 revealed prior to entry, Resident #295 had both heels debrided by the podiatrist and he only prescribed three tabs of pain medication. RN #432 reported on 06/16/23, before the physician left the facility, she provided a controlled substance form for the physician to sign for approval for the pain medication. RN #432 stated she followed up on 06/20/23 with the physician's office and the resident received the pain medication today. RN #432 stated she offered Tylenol yesterday, but the resident refused. Interview on 06/21/23 at approximately 4:30 P.M. with the Director of Nursing (DON) verified she was aware Resident #432 was asking for the pain medication to be refilled throughout the past weekend. The DON stated she instructed staff to offer the resident Tylenol and the resident refused. Further reivew of Resident #295's medical record revealed the resident did not even have an order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 0697 for Tylenol. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 interview, and review of facility policy, the facility failed to ensure medications for sexualized behaviors were administered as ordered. This affected one resident (#34) of one reviewed for mood and behaviors. The facility census was 38. Residents Affected - Few Findings Include: Review of Resident #34's medical record revealed an admission date of 01/18/23. Diagnoses included alcohol induced dementia, adult failure to thrive, anxiety disorder, conduct disorder, and emphysema. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating he was severely cognitively impaired. Resident #34 required supervision set up only with bed mobility, transfer, and toilet use. Resident #34 required limited assistance with dressing and personal hygiene. Resident #34 displayed no behaviors during the review period. Resident #34 reported feeling down, depressed or hopeless two to six days during the review period. Review of Resident #34's care plan revised 05/06/23 revealed supports and interventions in place for self-care deficit, impaired thought process, potential for pain, and behavior problem related to excessive sexual urges. Interventions for excessive sexual urges included administer medications as ordered, assist to develop more appropriate methods of coping, educate resident on need to be in a private room with the door and blinds shut if participating in sexual activity, and intervene when necessary to protect the rights and safety of others. Review of Resident #34's physician orders revealed an order dated 04/20/23 and discontinued 06/02/23 for Depo-Provera intramuscular suspension inject 150 milligrams (mg) at bedtime every 14 days for sexualized behaviors. Review of the corresponding Medication Administration Record (MAR) revealed Resident #34's injection was administered on 04/20/23 and 05/04/23. Resident #34's injection was not administered on 05/18/23 or 06/01/23. Further review of Resident #34's physician orders revealed an order dated 06/03/23 for Depo-Provera intramuscular suspension inject 150 milligrams (mg) at bedtime every 14 days for sexualized behaviors. Review of the corresponding MAR revealed Resident #34 was not administered his ordered Depo-Provera medication injection on 06/03/23 or 06/17/23. Resident #34 was provided no Depo-Provera medication in the month of June. Review of Resident #34's State Tested Nursing Assistant (STNA) Tasks for the last 60 days revealed Resident #34's behaviors were monitored daily. Resident #34 was noted to have had sexual inappropriate behaviors on 05/04/23, 05/09/23, 05/12/23, 05/13/23, 06/05/23, 06/08/23, 06/10/23, 06/11/23, 06/12/23, 06/16/23 and 06/19/23. An increase in sexualized behaviors was found increasing from four instances from 05/01/23 to 06/04/23, to seven instances taking place between 06/05/22 to 06/21/23. Interview on 06/21/23 at 8:40 A.M. with Licensed Practical Nurse (LPN) #521 verified Resident #34 had an order for Depo-Provera 150 mg every 14 days, and it had not been administered on 05/18/23, 06/01/23, 06/03/23, or 06/17/23 due to the medication being unavailable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 Interview on 06/21/23 at 2:31 P.M. with the Director of Nursing (DON) verified Resident #34's Depo-Provera was not administered on 05/18/23, 06/01/23, 06/03/23, or 06/17/23. Resident #34's increased behaviors between 06/04/23 and 06/21/23 were reviewed. There were seven occurrences in the last 17 days, where there were only four occurrences in the prior 33 days. The DON stated she would get in touch with the pharmacy to see if anything else had been done related to the missed dosages and behaviors. Residents Affected - Few Interview on 06/22/23 at 10:41 A.M. with the DON verified Resident #34's medications were not administered and no adjustments were made regarding the order, following the lack of administration. The DON reported she spoke with the pharmacy, and they learned Resident #34's Depo-Provera needed to be re-ordered every two weeks or it would not be available. The DON said they now know and would be making the necessary changes to ensure the medication was available. The DON reported Resident #34 was administered his Depo-Provera shot today as his 06/03/23 injection was located in the medication cart. Review of facility policy titled, Medication Administration Procedure, revised 11/09/21 revealed medications were to be administered according to physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 Based on staff interview, review of facility policies, and review of the Centers for Disease Control (CDC) guidance, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 38 residents in the facility. The census was 38. Residents Affected - Many Findings include: Review of the facility's undated, Legionella Water Management for Legionella Risk Reduction, policy revealed the facility would do the following: • Implement a water management program that included control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. • Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Interview on 6/22/23 at approximately 10:50 A.M. with Environmental Director #463 admitted he was unaware what the requirements were for the water management program and verified he had yet to do anything regarding water testing, flushing of empty rooms due to stagnant water, and did not have a risk assessment, did not complete a map/flow diagram of the facility and confirmed the only documentation for Legionella was the policy provided. The facility did not have additional documentation pertaining to Legionella besides the policies. Review of the facility's policy titled, Legionnaires Policy, effective date 09/06/17, revealed all relevant procedures and recordings related to the program will be kept, maintained, and reviewed as necessary. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: • Establish a water management program team • Describe the building water systems using text and flow diagrams • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 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 Burden of Waterborne Disease Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Many Read about various illnesses, including Legionnaires' disease, in CDC's first estimates of the impact of waterborne disease in the United States. • Identify areas where Legionella could grow and spread • Decide where control measures should be applied and how to monitor them • Establish ways to intervene when control limits are not met • Make sure the program is running as designed (verification) and is effective (validation) • Document and communicate all the activities FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 11 of 11