Health inspection·November 26, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete informed staff of the incident and the nurse on duty was contacted. The nurse on duty accompanied STNA #111 during questioning by the police at the facility and then she was walked to the time clock. STNA #111 was suspended pending investigation and subsequently terminated. The DON stated the police spoke to Resident #10 and she did not want to press charges; the DON shared a skin assessment and interview of Resident #10 was completed and not reveal any concerns. Resident #10 was assessed by the Medical Director as well as a psychiatric services and had no negative outcome noted. The staff were interviewed and each denied knowledge of the incident and were not aware STNA #111 had taken any pictures of Resident #10, or any other resident. Interview on 11/26/25 at 11:03 A.M with Resident #10 revealed she was informed by the police STNA #111 had taken a picture of her while she was in the whirlpool. Resident #10 shared she was told the picture was a side view. Resident #10 stated she did not know the picture was being taken by STNA #111. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revised 10/25/22 documented residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. Review of the facility policy titled, Social Networking Policy revised 03/31/23 documented partners are expected to protect the privacy of residents and elders. Partners may not publicly discuss residents or disclose photographs. Partners are prohibited from displaying private or public information about residents, especially anything that would be deemed as demeaning to residents. The deficient practice was corrected on 08/09/25, when the facility implemented the following corrective actions: On 08/07/25, Resident #10 was assessed by facility staff with no adverse findings, the POA and the Medical Director were notified and there were was no evidence of emotional or psychosocial harm. On 08/07/25, STNA #111 was removed from the facility and placed on administrative leave. On 08/08/25, education was provided to all staff regarding the Resident Abuse policy, Elder Abuse policy and Social Media policy. Staff were not permitted to work until the education was completed. On 08/08/25, Resident #10 was assessed by both the Medical Director and psychological services with no adverse findings. On 08/08/25, all interviewable residents were interviewed to ensure they did not have a concern for privacy and safety. No residents voiced concerns in these areas or of care from the staff. On 08/08/25, a skin assessment was completed on all non interviewable residents with no concerns. On 08/08/25, management reviewed the incident, investigation and initiated a follow up plan to prevent reoccurrence. On 08/09/25, interview audits were initiated of at least two residents to ensure no concerns for privacy and safety. On 08/09/25, interview audits were initiated of at least three staff to confirm compliance with social media and abuse policy. This deficiency represents non-compliance investigated under Complaint Number 2595612. Event ID: Facility ID: 366050 If continuation sheet Page 2 of 4 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 11/26/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a witness statement, review of a police report, staff and resident interviews and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#10) of three residents reviewed for privacy. The facility census was 48. Findings include: Review of medical record for Resident #10 revealed an admission date of 01/06/23. Diagnoses include chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), stoke and hemiparesis affecting the right dominant side. The resident remained at the facility. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of nine out of 15 indicating impaired cognition. Resident #10 required set up for eating and maximum assistance with toileting hygiene, bed mobility, transfers and showers. Review of a facility SRI documented on 08/07/25 at approximately 8:30 P.M. management was informed State Tested Nursing Assistant (STNA) #111 had allegedly taken a picture of a resident and posted it in a small group chat on social media. STNA #111 was placed on immediate administrative leave. Police interviewed STNA #111 and she admitted to taking the picture of Resident #10 in the bathtub. The police met with Resident #10 and informed her of the incident and she did not want to press charges. Resident #10 was assessed with no adverse findings. The Power or Attorney (POA) and Medical Director were notified of the incident. Resident #10 was assess by both the Medical Director and Psychosocial services with no adverse effects. Staff were interviewed and they denied knowledge of STNA #111 taking pictures of residents. Interviews and skin assessments of residents were completed. Staff education was provided. The allegation was substantiated by the facility. Review of the 08/07/25 written statement of Licensed Practical Nurse (LPN) #100 documented she was informed by the police of an indecent picture posted on social media application of Resident #10 by STNA #111. The DON was notified and LPN #111 was instructed to bring STNA #111 to the nurse's station to speak to the DON. STNA #111 admitted to taking the picture and sharing it on a social media group chat application. LPN #111 was then instructed by the DON to walk STNA #111 to the time clock and to the back of the facility to speak to the police. Further documentation revealed LPN #111 accompanied the police to Resident #10's room when she was informed a picture had been taken of her and she was given the opportunity to press charges and the resident declined. Review of the 08/07/25 police incident report revealed an investigation of voyeurism was initiated at the facility. The victim was listed as Resident #10. Interview on 11/26/25 at 9:23 A.M. with the Administrator, Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed STNA #111 had taken a picture of Resident #10 while in the whirlpool. STNA #11 had shared the picture with a group of four or five other people on Snapchat. None of the other people work at the facility. One of the girls called the sheriff in her county and they proceeded to contact the Auglaize County [NAME]. The sheriff called the facility and informed staff of the incident and the nurse on duty was contacted. The nurse on duty accompanied STNA #111 during questioning by the police at the facility and then she was walked to the time clock. STNA #111 was suspended pending investigation and subsequently terminated. The DON stated the police spoke to Resident #10 and she did not want to press charges; the DON shared a skin assessment and interview of Resident #10 was completed and not reveal any concerns. Resident #10 was assessed by the Medical Director as well as a psychiatric services and had no negative outcome noted. The staff were interviewed and each denied knowledge of the incident and were not aware STNA #111 had taken any pictures of Resident #10, or any other resident. Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366050 If continuation sheet Page 3 of 4 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 11/26/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on 11/26/25 at 11:03 A.M with Resident #10 revealed she was informed by the police STNA #111 had taken a picture of her while she was in the whirlpool. Resident #10 shared she was told the picture was a side view. Resident #10 stated she did not know the picture was being taken by STNA #111. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revised 10/25/22 documented residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. Review of the facility policy titled, Social Networking Policy revised 03/31/23 documented partners are expected to protect the privacy of residents and elders. Partners may not publicly discuss residents or disclose photographs. Partners are prohibited from displaying private or public information about residents, especially anything that would be deemed as demeaning to residents. The deficient practice was corrected on 08/09/25, when the facility implemented the following corrective actions: On 08/07/25, Resident #10 was assessed by facility staff with no adverse findings, the POA and the Medical Director were notified and there were was no evidence of emotional or psychosocial harm. On 08/07/25, STNA #111 was removed from the facility and placed on administrative leave. On 08/08/25, education was provided to all staff regarding the Resident Abuse policy, Elder Abuse policy and Social Media policy. Staff were not permitted to work until the education was completed. On 08/08/25, Resident #10 was assessed by both the Medical Director and psychological services with no adverse findings. On 08/08/25, all interviewable residents were interviewed to ensure they did not have a concern for privacy and safety. No residents voiced concerns in these areas or of care from the staff. On 08/08/25, a skin assessment was completed on all non interviewable residents with no concerns. On 08/08/25, management reviewed the incident, investigation and initiated a follow up plan to prevent reoccurrence. On 08/09/25, interview audits were initiated of at least two residents to ensure no concerns for privacy and safety. On 08/09/25, interview audits were initiated of at least three staff to confirm compliance with social media and abuse policy. This deficiency represents non-compliance investigated under Complaint Number 2595612. Event ID: Facility ID: 366050 If continuation sheet Page 4 of 4