Health inspection·April 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 and policy review, the facility failed to timely implement treatment orders for a newly identified pressure ulcer. This affected one (#38) out of three reviewed for pressure ulcers. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #38 revealed an admission on [DATE] with diagnoses including with traumatic subdural hemorrhage with loss of consciousness, cord compression, type two diabetes mellitus with diabetic polyneuropathy, pulmonary hypertension, chronic diastolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #38 revealed the resident was cognitively intact. Resident #38 required supervision to maximum assist with activities of daily living. Resident #38 was coded at risk for pressure ulcer development. Resident #38 did not have any skin issues coded at the time of the assessment. Review of the plan of care for Resident #38 dated 03/03/25 revealed the resident has actual impairment to skin integrity related to pressure wound to left heel. Interventions include encourage good nutrition, educate resident and family of causative factors, monitor location, size, and treatment of wound, weekly skin screens, enhanced barrier precautions, and encourage frequent turning and repositioning for pressure relief. Review of the active physicians' orders for Resident #38 revealed an order dated 03/03/25 for enhanced barrier precautions, gloves and gown with treatment and or care related to wound, float heels when in bed dated 01/23/25, low air loss mattress to bed dated 03/10/25, left heel dressing change apply medihoney, collagen powder and border gauze to area every night shift dated 04/08/25, monitor left heel dressing and replace as needed dated 03/10/25, skin prep to right heel every shift for preventative dated 04/14/25 and weekly skin assessment to be completed by a licensed nurse under the forms tab every Wednesday dated 02/10/25 with a start date of 02/12/25. Review of the discontinued physicians' orders for Resident #38 revealed an order dated 02/16/25 with a start date of 02/17/25 for the application of medihoney and bordered gauze to left heal every day for wound care, an order dated 02/21/25 with a start date of 02/22/25 to apply Santyl and bordered gauze to left heal every day and as needed (PRN) for wound care and an order to monitor left heel dressing and replace as needed dated 02/16/25 and discontinued on 02/16/25. Review of Wound Nurse Notification form dated 02/12/25 for Resident #38 revealed documentation of a pressure ulcer to the right heel measuring 2.5 cm x 3.0 cm. Further review of the form revealed treatment was initiated with medihoney and bordered gauze was applied. Review of the Treatment Administration Record (TAR) for Resident #38 for the month of February 2025 revealed an order to monitor left heel dressing and replace as needed dated 02/16/25, an order dated 02/26/25 for Santyl external ointment 250 unit per gram apply to left heel topically every day shift for wound and apply bordered gauze daily and as needed, an order dated 12/21/24 for weekly wound assessment to be completed by a licensed nurse every Saturday night and documented under the forms tab and discontinued on 02/10/25, an order for weekly wound assessment to be completed by a licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 2 of 13 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 04/23/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm nurse every Wednesday dated 02/12/25, and an order for skin prep to bilateral heels every shift for preventative for dated 12/15/24 and discontinued on 04/14/25. Review of the weekly skin observation tool dated 02/09/25 for Resident #38 was not completed as the resident was not available. Residents Affected - Few Review of the Braden scale completed on 02/10/25 for Resident #38 revealed the resident was at risk for the development of pressure ulcers. Review of the nurse's progress notes dated 02/12/25 at 8:57 P.M. for Resident #38 revealed the resident was yelling out while this nurse was in room that his foot was hurting. Upon assessing a pressure ulcer on the left heel was found. Drainage present. No odor or signs and symptoms of infection were noted. Wound was measured and dressed with medihoney and bordered gauze. Wound paper filled out for wound physician. Review of the initial wound evaluation for wound physicians for Resident #38 dated 02/18/25 revealed the resident was alert to person, place time and situation with right and left foot sensation intact. Wound site number one revealed an unstageable (due to necrosis) of the left heel, full thickness measuring 3.0 cm x 5 cm x unmeasured due to present of non viable tissue and necrosis. Wound site number one was assessed with light serous exudate and thick adherent black necrotic eschar. Observation on 04/17/25 at 1:09 P.M. of Resident #38's left heel revealed the extremity was elevated in a moon boot resting on the bed. Resident #38's sock was removed to reveal the dressing was rolled up exposing partial area of the wound left heel. Left heel posterior distal heel revealed an open area with macerated edges, pale pink tissue on the wound bed and small amount of draining on the dressing. Interview on 04/17/25 at 11:45 A.M. with the Assistant Director of Nursing (ADON) verified the treatment for the left heel was written and then discontinued on the same day on 02/12/25. ADON verified the TAR did not reflect any treatments were in place until 02/18/25 after Resident #38 was seen by the wound physician. Review of the facility policy titled Skin Care Management Procedure, dated 12/09/22 revealed under dressing and treatments that determination of the need for a dressing for an ulcer is based on the individual practitioner's clinical judgement and facility protocol based on current professional standards of practice. Additionally, the policy states that staff should evaluate and document identified changes as follows, evaluation of site if not dressing and weekly skin assessments will be completed and documented in the electronic health record to identify new or potential areas of concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 3 of 13 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 04/23/2025 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and staff and resident interviews, the facility failed to ensure resident's toenails were adequately trimmed. This affected one (#01) of one resident reviewed for podiatrist visits. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #01 revealed an admission date of 11/14/24 with medical diagnoses of cerebral infarction, diabetes mellitus, congestive heart failure, chronic kidney disease, and hypertension. Review of the medical record for Resident #01 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/02/25, which indicated Resident #01 had moderately impaired cognitive impairment and required partial/moderate staff assistance with toilet hygiene, supervision with bathing and transfers, and was independent with bed mobility. Review of the medical record for Resident #01 revealed no documentation to support Resident #01 was seen by podiatrist since admission to facility. Observation with interview on 04/14/25 at 10:56 A.M. of Resident #01 revealed toenails on bilateral feet to be long, jagged, and thick. The observation revealed several of Resident #01's toenails appeared to be curved downward toward the bottom of the toes. Interview with Resident #01 stated his toenails had not been trimmed since prior to admission to facility. Interview on 04/16/25 at 10:15 A.M. with Director of Nursing (DON) confirmed Resident #01's toenails appeared long, jagged, and thick with some of the toenails observed to be curved downward. DON confirmed the podiatrist was at the facility on 03/03/25 and 03/18/25 and Resident #01 was not seen by the podiatrist on those dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 4 of 13 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 04/23/2025 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 0698 Provide safe, appropriate dialysis care/services 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 record review and staff interview, the facility failed to perform post dialysis assessments. This affected one (#199) out of one resident reviewed for dialysis. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #199 revealed an admission date of 03/01/25 with diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and end stage renal disease. Review of the Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident required set-up assistance with eating and oral hygiene. Resident required partial assistance with ambulation up to 50 feet and resident required substantial assistance with toileting hygiene, bathing, dressing, bed mobility, and transfers. Resident also required hemodialysis. Review of the physician orders revealed an order dated 03/02/25 and 04/14/25 for Post Dialysis Form to be completed every Monday, Wednesday, and Friday. Review of the care plan dated 03/11/25 revealed Resident #199 needs hemodialysis related to end stage renal disease (ESRD) on Monday, Wednesday, and Friday with intervention of monitor vital signs as directed and notify physician of significant abnormalities. Further review of Resident #199's medical record revealed post dialysis assessments form were completed on 03/07/25 and 04/14/25. The post dialysis assessment form was not completed on 03/03/25, 03/05/25, 03/10/25, 03/12/25, 03/14/25, 03/17/25, and 03/19/25. Interview on 04/16/25 at 2:51 P.M. with the Director of Nursing (DON) confirmed there were only two post-dialysis form assessments completed on Resident #199. Interview confirmed Resident #199 should have had a post dialysis form assessment completed in the electronic health record after returning from dialysis every Monday, Wednesday, and Friday. Interview with the DON confirmed the only post dialysis assessment form were completed on 03/07/25 and 04/14/25. Interview with the DON also confirmed the post dialysis assessment form was not completed on 03/03/25, 03/05/25, 03/10/25, 03/12/25, 03/14/25, 03/17/25, and 03/19/25. The DON confirmed residents returning from dialysis should have a post dialysis assessment but was was unable to provide a policy on post dialysis assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 5 of 13 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 04/23/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review, the facility failed to ensure medication were stored securely and not at the bedside. Additionally, the facility also failed to ensure medication cart was securely locked when unattended on Rehab Hall. This affected three (#147, #22 and #38) of three residents reviewed for medication storage and had the potential to affect 13 (#20, #29, #41, #196, #197, #198, 199, #200, #201, #202, #203, #204, and #205) residents the facility identified as independently mobile and cognitively impaired. The facility census was 44. Findings include: 1. Medical record review for Resident #22 revealed an admission on [DATE] with diagnoses including but not limited to Parkinson disease, altered mental status, hypertension, and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 revealed a severely impaired cognition. Resident #22 required moderate to total assistance for activities of daily living. Resident #22 was coded with ointment application to areas other than feet. Review of the plan of care for Resident #22 dated 12/18/24 revealed resident had potential impairment to skin integrity related to incontinence and impaired mobility. Interventions included avoid scratching keep fingernails short, keep skin clean and dry, pressure reducing devices as ordered, encourage frequent turning and repositioning with weekly skin assessment. Review of the weekly skin assessment dated [DATE] revealed no areas on concern identified. Review of the active physicians orders for Resident #22 was silent for orders for antifungal powder. Observation on 04/14/25 at 3:37 P.M. revealed open unlabeled three ounce bottle of antifungal powder with miconazole nitrate two percent sitting on the bedside table next to residents bed. Resident #22 was in bed at the time of observation. Further observation of label on antifungal powder revealed a warning label stating if swallowed get medical help or contact the poison control center Interview on 04/14/25 at 3:41 P.M. with Licensed Practical Nurse (LPN) #224 verified the observation of antifungal powder at the bedside and without orders for application by Certified Nurse Assistance (CNA). 2. Review of the medical record for Resident #38 revealed an admission on [DATE] with diagnoses including with traumatic subdural hemorrhage with loss of consciousness, spinal cord compression, type two diabetes mellitus with diabetic polyneuropathy, pulmonary hypertension, and chronic diastolic congestive heart failure. Review of the MDS assessment dated [DATE] for Resident #38 revealed resident was cognitively intact. Resident #38 required supervision to maximum assist with activities of daily living. Resident #38 was coded at risk for pressure ulcer development. Resident #38 did not have any skin issues coded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 6 of 13 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 04/23/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the plan of care for Resident #38 dated 03/03/25 revealed the resident has actual impairment to skin integrity related to pressure wound to left heel. Interventions include encourage good nutrition, educate resident and family of causative factors, monitor location, size, and treatment of wound, weekly skin screens, enhanced barrier precautions, and encourage frequent turning and repositioning for pressure relief. Residents Affected - Some Review of the active physicians' orders for Resident #38 was silent for orders to keep antifungal powder at bedside. Review of the weekly skin observation tool dated 04/08/25 for Resident #38 revealed no identified concerns for antifungal powder administration. Observation on 04/15/24 at 2:34 P.M. revealed an open unlabeled three ounce bottle of antifungal powder with miconazole nitrate two percent. Further observation of label on antifungal powder revealed a warning label stating if swallowed get medical help or contact the poison control center. Interview 04/16/25 at 10:19 A.M. with LPN #224 verified Resident #38 did not have orders for the antifungal powder to be left at the bedside. Interview on 04/16/25 at 11:00 A.M. with the Director of Nursing (DON) verified the antifungal powder should not be left in the room without an order authorizing the staff to apply it as needed for skin irritation. 3. Review of the medical record for Resident #147 revealed an admission dated of 04/09/25 with diagnoses including but not limited to hypertensive heart disease with heart failure, arthritis, malignant neoplasm of colon, peripheral vascular disease, hypothyroidism, and osteoporosis. Review of the Comprehensive Minimum Data Set (MDS) assessment for Resident #147 dated 04/16/24 was in progress and not completed at the time of the survey. Review of the plan of care for Resident #147 dated 04/09/25 revealed resident had a self care deficit due to impaired ability to perform or completed activities of daily living (ADL) such as feeding, dressing, bathing, toileting, related to shortness of breath, cellulitis, edema of lower extremities and advanced age. Interventions include assist as needed to complete ADL's. Review of the physician's orders for Resident #147 were silent for any orders for medications to be left at bedside for self administration or staff application. Observation on 04/14/25 at 11:10 A.M. of an opened bottle of natural eye tears without a pharmacy label at bedside and an open unlabeled three ounce bottle of antifungal powder with miconazole nitrate two percent. Further observation of label on antifungal powder revealed a warning label stating if swallowed get medical help or contact the poison control center. Interview on 04/14/25 11:41 A.M. with LPN #224 verified the resident are allowed to have medication at bedside with orders. LPN #224 stated she will have to look to see if she has orders to keep the items at bedside. If she does not have any orders she will contact the physician for permission. LPN #224 stated they have to have orders for medications to be in the room. LPN #224 stated the resident just moved over to the long term care area from assisted living on April ninth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 7 of 13 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 04/23/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Medication Storage, dated 07/09/21 revealed medication will be locked and only accessible by a licensed nurse. 4. Observation of the facility on 04/17/25 at 11:45 A.M., revealed a medication cart on Rehab Hall in front of nurse's station was unlocked and unattended with no staff present. Residents Affected - Some Interview on 04/17/25 at 11:50 A.M. with Registered Nurse (RN) #214 with diabetic supplies in her hand and stated she forgot to lock the medication cart when she walked away. The facility confirmed there were 13 (#20, #29, #41, #196, #197, #198, 199, #200, #201, #202, #203, #204, and #205) residents who were independently mobile and cognitively impaired who could access unlocked/unsecured medications or a unlocked medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 8 of 13 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 04/23/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, review of dishwasher temperature logs and review of the dishwasher manual, the facility failed to ensure the dishwasher was washing and rinsing dishes at the proper temperatures to sanitize the dishes. This had the potential to affect all 44 residents residing in the facility. The facility census was 44. Findings include: Observation on 04/14/25 at 8:17 A.M. with Director of Culinary Services #324 revealed the main kitchen dishwasher rinse cycle was 176 degrees Fahrenheit (F). Interview on 04/14/25 at 8:17 A.M., at time of observation, with Director of Culinary Services #324 confirmed the dishwasher rinse cycle should be 180 degrees F. Observation on 04/14/25 at 8:19 A.M. with Director of Culinary Services #324 revealed the Long Term Care (LTC) area dishwasher wash cycle was 136 degrees F, and the rinse cycle was 188 degrees F. Observation on 04/14/25 at 8:20 A.M. with Director of Culinary Services #324 revealed the LTC area dishwasher wash cycle was 141 degrees F, and the rinse cycle was 191 degrees F. Interview on 04/14/25 at 8:20 A.M., at time of observation, with Director of Culinary Services #324 confirmed the dishwasher wash cycle should be 150 degrees F. Observation on 04/14/25 at 8:26 A.M. with Director of Culinary Services #324 revealed the post-acute area dishwasher wash cycle was 144 degrees F and the rinse cycle was 184 degrees F. Interview on 04/14/25 at 8:26 A.M., at time of observation, with Director of Culinary Services #324 confirmed the dishwasher wash cycle should be 150 degrees F. Interview also confirmed the dishwashers in the facility have been worked on weekly by the contractor. Observation on 04/14/25 at 12:27 P.M. with [NAME] #291 in the post-acute kitchen revealed the post-acute area dishwasher wash cycle was 146 degrees F and the rinse cycle ran at 178 degrees F. Interview on 04/14/25 at 12:27 P.M., at the time of observation, with [NAME] #291 confirmed the post-acute dishwasher wash cycle should be 150 degrees F, and the rinse cycle should be 180 degrees F. Interview on 04/14/25 at 12:44 P.M. with Director of Culinary Services #324 confirmed the dietary staff know what the temperatures should be when running the dishwashers and it is listed on the bottom of the Weekly Temperature Logs that staff is to fill out daily. The interview also confirmed that staff did not notify her of the dishwashers not meeting the temperature levels needed that were logged on the Weekly Temperature Logs for the weekly of 04/06/25 and for 04/13/25. Interview on 04/14/25 at 3:45 P.M. with the Administrator confirmed the manual supplied for the dishwashers revealed the wash temperature should be 150 degrees F and the rinse temperature should be 180 degrees F. The facility confirmed all 44 residents residing in the facility receive their meals/food from the kitchen. Review of the Weekly Temperature Logs for week of 04/06/25 for the skilled nursing dishwasher revealed on 04/08/25 a wash temperature and rinse temperature were not obtained on all three dishwasher cycles. On 04/09/25 the morning (AM) wash temperature was 148 degrees F, the mid-day wash temperature was 135 degrees F, and the PM wash and rinse cycle did not have temperatures logged. On 04/10/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 9 of 13 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 04/23/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the AM wash temperature was 148 degrees F, the mid-day wash temperature was 135 degrees F, and the PM wash temperature was 148 degrees F. On 04/11/25 the AM wash temperature was 148 degrees F, the mid-day wash temperature was 135 degrees F, and the PM wash temperature was 140 degrees F. On 04/12/25 the AM wash temperature was 148 degrees F, and the mid-day temperature was 135 degrees F. The bottom of the log revealed the dishwasher temperature should be at least 150 degrees F, the dishwasher rinse temperature should be at least 180 degrees F and that if temperatures are not within the parameters, you must contact the Director of Culinary Services #324 or cook on duty. Review of the Weekly Temperature Logs for 04/13/25 for the post-acute dishwasher revealed a wash temperature of 15 degrees F and a rinse temperature of 180 degrees F for the evening (PM) cycle. The bottom of the log revealed the dishwasher temperature should be at least 150 degrees F, the dishwasher rinse temperature should be at least 180 degrees F and that if temperatures are not within the parameters, you must contact the Director of Culinary Services #324 or cook on duty. Review of the Weekly Temperature Logs for 04/13/25 for the skilled nursing dishwasher revealed a wash temperature of 145 degrees F for morning (AM) cycle, a wash temperature of 145 degrees F for the mid-day cycle, and a wash temperature of 144 degrees F for the PM cycle. The bottom of the log revealed the dishwasher temperature should be at least 150 degrees F, the dishwasher rinse temperature should be at least 180 degrees F and that if temperatures are not within the parameters, you must contact the Director of Culinary Services #324 or cook on duty. Review of the Dish Washer Manual revealed the wash cycle temperatures should be 150 degrees F and the rinse cycle should be 180 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 10 of 13 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 04/23/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This affected one (#15) out of six residents reviewed for medication administration. The facility census was 44. Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/09/22 with medical diagnoses of right hemiplegia following cerebral infarction, trichomoniasis, aphasia, diabetes mellitus, and anemia. Review of the medical record for Resident #15 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/10/25, which stated Resident #15 had modified independence with decision making skills and required substantial/maximum staff assistance for toilet hygiene, bathing, transfers and partial/moderate assistance for bed mobility. The MDS indicated Resident #15 received seven days of insulin injections. Review of the medical record for Resident #15 revealed a physician order dated 02/03/25 for glucagon (an emergency medication used to treat severe hypoglycemia or low blood sugar levels) emergency injection to inject one milligram (mg) subcutaneously one time only for hypoglycemia. Review of the medical record for Resident #15 revealed on 02/03/25 a finger stick blood sugar (FSBS) reading of 55. Review of the medical record revealed no other documentation related to FSBS reading of 55, physician or family notification, or follow-up care after low blood sugar reading. Review of the facility nurse report sheet, dated 02/03/25, stated for Resident #18 had a low blood sugar of 55 and an order for glucagon one time was given. The report sheet stated Resident #18's daughter was notified, the glucagon was effective, and blood sugar was within normal limits. Interview on 04/16/25 at 11:26 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #18 did not have any documentation to support the facility notified the physician and received an order for the glucagon, notified Resident #15's family, or any monitoring of Resident #15's FSBS after the administration of the glucagon. DON stated the facility did not have a policy on accurate documentation in medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 11 of 13 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 04/23/2025 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 reviews, observations, staff interviews and policy review, the facility staff failed to complete hand hygiene after resident contact and failed to wear proper Personal Protective Equipment (PPE) when providing resident care for a residents in Enhanced Barrier Precautions (EBP). This affected three (#2, #8 and #38) of four residents reviewed for the infection control. The facility census was 44. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #38 revealed an admission on [DATE] with diagnoses including with traumatic subdural hemorrhage with loss of consciousness, cord compression, type two diabetes mellitus with diabetic polyneuropathy, Pulmonary hypertension, chronic diastolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #38 revealed resident was cognitively intact. Resident #38 required supervision to maximum assist with activities of daily living. Resident #38 was coded at risk for pressure ulcer development. Resident #38 did not have any skin issues coded. Review of the plan of care for Resident #38 dated 03/03/25 revealed the resident has actual impairment to skin integrity related to pressure wound to left heel. Interventions include encourage good nutrition, education for resident and family of causative factors, monitor location, size, and treatment of wound, weekly skin screens, enhanced barrier precautions, and encourage frequent turning and repositioning for pressure relief. Review of the active physicians' orders for Resident #38 revealed an order dated 03/03/25 for enhanced barrier precautions, gloves and gown with treatment and or care related to wound, float heels when in bed dated 01/23/25, low air loss mattress to bed dated 03/10/25, left heel dressing change apply medihoney, collagen powder and border gauze to area every night shift dated 04/08/25, monitor left heel dressing and replace as needed dated 03/10/25, skin prep to right heel every shift for preventative dated 04/14/25 and weekly skin assessment to be completed by a licensed nurse under the forms tab every Wednesday dated 02/10/25 with a start date of 02/12/25. Observation on 04/14/25 at 11:20 A.M. of EBP information sheet from the United States Department of Health and Human Services Center for Disease Control and Prevention attached to door to Resident #38's. EBP had a stop sign on both upper corners, large type advising everyone must: clean their hands, including before entering the room and when leaving the room. The sign had small photo of alcohol-based hand rub in a white box beside the information. Additionally, the sign advised providers and staff must: wear gloves and a gown for the following high contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care of use including central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. Observation on 04/14/25 at 11:23 A.M. of Resident #38 revealed two Certified Nurse Aide (CNA) #223 and #235 at the side of the bed in Resident #38's room. CNA #235 and #223 were not wearing protective gowns over clothing, only gloves on both hands. CNA #235 removed the covers from Resident #35 lower extremities and remove the protective boot from Resident #38 left lower extremity. CNA #235 and #223 assisted the resident to a sitting position on the edge of the bed and proceeded to assist the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 12 of 13 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 04/23/2025 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 resident with transfers to a wheelchair. CNA #235 then exited the room with gloves still on both hands walked down the hallway removing gloves, dropping the gloves into the trash container on the medication cart. CNA #235 did not complete hand hygiene before walking over to Resident #00 and handing her a small red handbag. Interview on 04/14/25 at 11:30 A.M. with CNA #235 confirmed she had assisted Resident #38 with transfers from his bed to his wheelchair without a gown on. CNA #235 verified CNA #223 was not wearing a gown either and they did not have to wear them with transfers, only with incontinent care or catheter care. Additionally, CNA #235 verified that she had exited Resident #38's room with gloves on both hands, removing them as she walked towards the dining area and did not complete hand hygiene prior to touching Resident #26 personal belongings. Interview on 04/15/25 at 11: 45 A.M. with the Director of Nursing (DON) verified staff should be wearing gowns and gloves when transferring to the residents in EBP. Review of the facility policy titled Infection Prevention and Control Program, dated 11/05/21 stated it is the facility's practice to prevent, recognize and control to the extent possible the onset and the spread of infection. Additionally, the policy states the development, implementation and maintenance of an effective infection prevention and control program to include implementation of practices consistent with accepted standards that will help reduce the spread of infections and prevent cross contamination. Review of the policy titled , Isolation Precautions Process, revised August 2022 documented EBP would be utilized for residents with wounds. EBP included wearing gloves and gowns during high contact resident care including transfers. 2. Observation on 04/14/25 at 12:16 P.M. revealed CNA #316 delivered room tray to Resident #8. CNA #316 placed tray on bedside tray table, set head of bed up, adjusted Resident #8's covers, moved items on bedside tray, placed bedside tray in front of Resident #8, raised height of bedside tray, and removed plastic wrap from food. CNA #316 went from Resident #8's room into Resident #2 room to answer a question and closed her closet door. CNA #316 proceeded next to Resident #24's room with a lunch tray. CNA #316 place lunch tray down, removed plastic from food, removed dessert on tray and placed on bedside table. Observations revealed CNA #316 did not perform hand hygiene was completed in between resident's meal tray passing when staff involved in direct resident contact. Interview on 04/14/25 at 12:21 P.M. with CNA #316 revealed no hand hygiene was completed in between meal tray passing after direct resident contact for Resident #8 and #2. Review of facility policy Hand Hygiene Procedure, dated 03/27/25, revealed hand hygiene is required after contact with inanimate objects in the immediate vicinity of the patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 13 of 13