Health inspection·December 29, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to develop a comprehensive plan of care to address a resident's communication needs. This affected one (#27) of 15 residents reviewed for care planning. The facility census was 49. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included hearing loss, asthma, major depressive disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was moderately cognitively impaired. Review of the plan of care, revised 12/28/21, revealed Resident #27 had a communication problem related to poor hearing. Additionally, Resident #27 read lips, would do a thumbs up or down to indicate likes and dislikes. Interventions included using a thumbs up and down and a dry erase board. Observation on 12/27/21 at 10:28 A.M., of Resident #27 revealed the resident in bed watching television. A sign was hanging in the resident's room indicating the Resident's hearing aides were broken. Attempts to interview Resident #27 were unsuccessful. Resident #27 stated he could not hear. Interview on 12/28/21 at 12:38 P.M., of the Director of Nursing (DON) and Quality of Life (QOL) staff #432 revealed Resident #27 did not like to wear hearing aids. The DON stated it was more of a choice the resident did not wear them. QOL #432 stated an amplifying speaker box was purchased for Resident #27, but after a couple of days, he refused to use them. The DON and QOL #432 stated staff used a whiteboard most of the time to communicate with Resident #27. In addition, Resident #27 read lips well, but now that staff had to wear a facemask all of the time, he was not able to do that, which was frustrating for him. Both the DON and QOL #432 stated Resident #27 was able to communicate with a variety of gestures, such as thumbs up and down and staff who were familiar with him knew his gestures and how to communicate with him. The DON verified the facility used a number of agency staff and QOL #432 stated communication strategies were in Resident #27's plan of care. Interview on 12/28/21 at 12:47 P.M., of Elder Assistant (EA) #407 revealed Resident #27 had his own set of signs that he used to communicate with staff. EA #407 stated staff who worked with the Resident were familiar with his non-verbal signs of communication. Subsequent interview on 12/28/21 at 3:04 P.M., of QOL #432, after this surveyor reviewed Resident #27's plan of care, verified she added communication strategies to Resident #27's plan of care after this surveyor inquired about it. QOL #432 stated she had care planned Resident #27's hearing loss but, after speaking with this surveyor, thought it was a good idea to include communication strategies to assist new and agency staff. Review of facility policy titled Comprehensive Care Planning Procedure, effective 11/13/17, revealed the resident comprehensive care plan will include services to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being. The care plan will discuss needs, focus, strengths, and resident preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 2 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and policy review, the facility failed to provide dressing changes as ordered and apply compression stockings to the legs. This affected one (#145) of one resident reviewed for wound care and compression stockings. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the baseline care plan dated 12/26/21 revealed Resident #145 had no care plan to address wound care or application of compression stockings. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order to cleanse abdomen and lower back with normal saline and place dry ABD pad daily, until no drainage then leave open to air one time a day for dressing change and compression sock to right lower extremity on in morning and off at night. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed there was no evidence the nurses provided dressing changes to Resident #145's abdomen and back. In addition, there was no evidence of the nursing staff applying a compression stocking to Resident #145's right leg. Observation on 12/27/21 at 10:00 A.M., revealed Resident #145's dressing to his abdomen was dated 12/22/21 and was not wearing a compression stocking to his right leg. Observation on 12/28/21 at 12:56 P.M., revealed the dressing to the back was dated 12/28/21, the abdominal dressing was dated 12/22/21 and had no compression stocking on his right leg. Interview on 12/28/21 at 12:56 P.M., at the time of the observation, revealed the dressing to his back had just been changed. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she changed the dressing to Resident #145's back without having a physician order, because it was saturated and verified there was no compression stocking on Resident #145's right leg. Interview on 12/29/21 at 2:10 P.M., with the Director of Nursing (DON) verified there were no physician orders on the TAR or MAR for dressing changes to the abdomen and back or for the application of compression stocking to the right leg. The DON also verified that there were physician orders on the hospital discharge sheet for the compression stocking to the right leg and was missed. The DON verified the nursing staff should have verified with the physician what to do with the dressings since there were no orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 3 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #48 revealed the resident was admitted [DATE] and had diagnoses including acute cystitis with hematuria and acute kidney failure. The record indicated Resident #48 had a recent urethral stent placement that necessitated the indwelling urinary catheter. Review of physician orders for Resident #48 revealed an order for an indwelling urinary catheter, to be changed every month and as needed. The record included an additional order to provide urinary catheter care every shift. Review of the care plan for Resident #48 revealed it identified a risk for infection due to the indwelling urinary catheter. Interventions included urinary catheter care as ordered. Further review of the medical record for Resident #48 revealed there was no documented evidence staff provided the urinary catheter care every shift. 4. Review of the medical record for Resident #45 revealed the resident was admitted [DATE] and had diagnoses including acute kidney failure and obstructive reflux uropathy. Review of physician orders for Resident #45 revealed an order for an indwelling urinary catheter for obstructive uropathy, to be changed every month and as needed. The record included an additional order to provide urinary catheter care every shift. Review of the care plan for Resident #45 revealed it identified a risk for infection due to the indwelling catheter for obstructive uropathy. Interventions included catheter care as ordered. Further review of the medical record for Resident #45 revealed there was no documented evidence staff provided the urinary catheter care every shift. Interview on 12/29/21 at 2:47 P.M., with the Director of Nursing verified there was no documentation of catheter care being completed for Resident #3, Resident #145, Resident #45 and Resident #48. Review of the policy titled Indwelling Urinary Catheter Care, reviewed 11/19/21, revealed urinary catheter care is to be performed at least once daily and as needed. Based on medical record review, observation, staff interview, and policy review, the facility failed to provide urinary catheter care. This affected four (#3, #45, #48 and #145) of four residents reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. The facility census was 49. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/20/15. Diagnoses included unspecified dementia without behavioral disturbance, retention of urine, essential hypertension, major depressive disorder, recurrent, anxiety disorder, neuromuscular dysfunction of bladder and heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 4 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) score of 13 out of 15. Resident #3 had an indwelling catheter and was always continent of bowel. Review of the care plan dated 09/18/17 revealed Resident #3 had a Foley urinary catheter related to neurogenic bladder. The goal was to remain free from catheter related trauma through the review date. There were no catheter care interventions in the care plan. Review of the physician orders revealed there was an order dated 06/18/19 for a 16 French Foley Urinary Catheter in place. Foley care daily and prn (as needed). Further review of the medical record for Resident #3 revealed there was no documented evidence staff provided the urinary catheter care as ordered. 2. Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The MDS had not yet been completed. Review of the care plan dated 12/26/21 revealed Resident #145 had an urinary tract infection (UTI), goal was to resolve UTI. Administer antibacterial as prescribed, observe for changes in mental status or level of consciences, observe for pain signs, facial grimaces, moaning, holding sides of back and report to nursing immediately. Obtain laboratory work as ordered by physician. Resident had indwelling Foley catheter related to obstructive uropathy. The resident will show no signs and symptoms of UTI through review date. Resident had 16 French indwelling urinary catheter. There were no interventions for catheter care. Review of the physician orders revealed an order dated 12/27/21 provide urinary catheter care every shift. Further review of the medical record for Resident #3 revealed there was no documented evidence staff provided the urinary catheter care every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 5 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and policy review, the facility failed to provide care and services for Residents Affected - Few a resident's Peripheral Inserted Central Catheter (PICC) intravenous line. This affected one (#145) of one resident reviewed for intravenous therapy. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the care plan dated 12/26/21 revealed Resident #145 received Intravenous (IV) antibiotic therapy. Resident will not experience complications related to IV therapy. Change my IV primary and secondary tubing per protocol. Flush my peripheral, PICC (peripheral inserted central catheter), or midline per protocol. The care plan did not include interventions for wound care. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order for heparin lock flush solution 100 unit/milliliter (ml) use three ml IV for PICC maintenance heparin flush using 10 ml syringe one time a day, flush with three ml of heparin after flushing with five ml of normal saline, sodium chloride 0.9% use five ml IV one time a day for PICC normal saline flush maintenance followed with heparin flush. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed there was no evidence the nurses flushed the PICC line with normal saline followed by heparin to keep the PICC line patent until 12/28/21. Interview on 12/29/21 at 2:10 P.M., with the Director of Nursing (DON) verified there were no physician orders on the TAR or MAR for flushing the PICC line daily. The DON verified the staff had not flushed the PICC line since admission and the facility protocol is to flush the PICC line daily. Review of the policy titled Peripheral Inserted Central Catheter Flushing and Locking, revised 08/20/21, revealed the PICC line is to be flushed daily or after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 6 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to store oxygen tubing in a sanitary manner and failed to have a system in place to ensure oxygen tubing was changed regularly. This affected two (#2 and #42) of two residents reviewed for oxygen administration. The facility identified eight residents who received oxygen therapy. The facility census was 49. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. Review of the plan of care, initiated 03/27/19 revealed Resident #2 had oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs at 1-2 liters (L) as needed. Review of a physician order dated 04/21/20 revealed Resident #2 was ordered oxygen 2 L per nasal cannula for shortness of breath and/or pulse oxygen below 90 %. Observation on 12/27/21 at 10:59 A.M., of Resident #2's room revealed an oxygen concentrator next to the Resident's bed. Oxygen tubing was connected to the concentrator, with the tubing hanging on the concentrator. Continued observation revealed the oxygen tubing was undated and the cannula was uncovered and hanging within inches of the garbage can. Interview on 12/27/21 at 11:21 A.M., with Elder Assistant (EA) #402 verified Resident #2's oxygen tubing was undated and the cannula was uncovered and hanging next to the garbage can. 2. Review of the medical record for Resident #42 revealed an admission date of 05/22/20. Diagnoses included respiratory failure, type II diabetes, hypertension, congestive heart failure, dementia with behavioral disturbance, and obstructive sleep apnea. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 was moderately cognitively impaired. Review of the plan of care, revised 12/27/21, revealed Resident #42 had an alteration in respiratory status related to congestive heart failure. Interventions included oxygen as ordered. Additional review revealed Resident #42 had oxygen therapy related to congestive heart failure. Interventions included oxygen via nasal prongs at 2-4 liters (L) as needed. Review of a physician order dated 05/22/21 revealed Resident #42 was ordered oxygen 2-4 (L) to keep pulse oxygen above 90%. Observation on 12/27/21 at 11:46 A.M., of Resident #42 revealed the Resident in bed sleeping. Additional observation revealed a running oxygen concentrator set at 4 L. Resident #42 was not wearing the oxygen at the time of the observation. The oxygen tubing was draped over Resident #42's feeding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 7 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0695 pump. The tubing was undated, and the nasal cannula was uncovered, touching the feeding pump. Level of Harm - Minimal harm or potential for actual harm Interview on 12/27/21 at 11:49 A.M, with Licensed Practical Nurse (LPN) #431 revealed Resident #42 did not always wear her oxygen. LPN #431 verified the oxygen tubing was draped over the feeding pump, was undated, and the nasal cannula was not covered and stored in a sanitary manner. LPN #431 stated she believed oxygen tubing was changed weekly, but she was uncertain on what day and would have to check the physician orders. Residents Affected - Few Interview on 12/28/21 at 12:40 P.M., with the Director of Nursing (DON) revealed oxygen tubing should be changed weekly and the staff changing the oxygen tubing should date and initial the tubing when it was completed. The DON stated the facility did not have a good system in place to ensure oxygen tubing was being changed regularly and there should be physician orders to change oxygen tubing, prompting nursing staff to do it. The DON verified neither Resident #2 or Resident #42 had physician orders to change oxygen tubing and it was unknown when the tubing was last changed. Additionally, the DON stated nasal cannula's should be stored in a bag when not in use to ensure sanitary storage of equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 8 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 Based on medical record review, observation, resident interview, staff interview and policy review, the facility failed to provide pain management to a resident. This affected one (#145) of two residents reviewed for pain management. The facility identified 30 residents that receive pain management. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set (MDS) assessment was not completed at this time. Review of the care plan dated 12/26/21 revealed the resident had pain related to osteoarthritis. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain within a reasonable amount of time after approach through the review date. Administer analgesia as per orders. Give one half hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor pain characteristics. Review of the discharge physician orders from the hospital dated 12/26/21 revealed an order for oxycodone-acetominophen 5-325 milligram (mg) one tablet by mouth every six hours as needed for pain until 01/02/22, and pregabalin 100 mg one tablet every eight hours for muscle pain. Review of the Medication Administration Record (MAR) revealed the first dose of oxycodone-acetaminophen was administered at 12:01 A.M. on 12/27/21. Pregabalin was not administered until 12/28/21 at 10:00 P.M. Observation on 12/27/21 at 10:35 A.M., revealed Resident #145 was observed lying bed and started flinching in pain and stated oh oh, holding his left leg stump. Interview on 12/27/21 at 10:35 A.M., at the time of the observation, with Resident #145 stated he left the hospital at 4:00 P.M. on Sunday. He arrived to the facility and was put in bed by the ambulance staff and didn't see a staff member until two hours later. Resident #145 stated he pushed his call light at 6:00 P.M., requesting pain medication and they told him there was no medicine there for him yet. At 7:00 P.M., he called again asking for pain medication and a girl brought him water in. At 10:00 P.M., he pushed his call light and finally an aide came in and said the nurse had to go somewhere and was at one of the other houses. Resident #145 asked when he would get his pills and she said the nurse would be over at 11:00 P.M. When the nurse came in, Resident #145 told him he hadn't gotten his pills yet, was having terrible pain and he didn't get his pregabalin for his phantom pain. Resident #145 stated the nurse gave him a couple Advil. The nurse left and at midnight and came back with a Percocet. Resident #145 stated the following morning he asked the nurse when he was going to get his pregabalin and she stated that she would have to check. Resident #145 stated he told the nurse he was having a lot of phantom pain in his left stump. Interview on 12/28/21 at 2:10 P.M., with the Director of Nursing (DON) verified Resident #145 didn't receive his pregabalin every eight hours as ordered because the pharmacy did not send the Pregabalin, due to needing a written prescription from the physician. The DON verified the resident didn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 9 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receive pregabalin since admission and he was having phantom pain of his left leg. The DON stated she was going to have to investigate and see what happened or where the communication dropped with the pharmacy as to why the pregabalin was not here to administer. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she had not administered pregabalin and it had not been available since Sunday when Resident #145 was admitted . LPN #431 stated she had told the DON yesterday it wasn't at the facility. LPN #431 stated she told the MDS Nurse today that they still needed a prescription sent to the pharmacy and the MDS Nurse called the Nurse Practitioner and she sent a prescription to the pharmacy. They were going to drop ship the pregabalin, so it should arrive later today. LPN #431 verified that Resident #145 has been complaining of phantom pain since he has been admitted . Review of the policy titled Medication Administration, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 10 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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 reassess a resident for continued use of enabler bars according to the facility policy. This affected one (#2) of one resident reviewed for potential restraint. The facility census was 49. Findings include: Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive two-person assistance with bed mobility and transfers. Review of the plan of care, revised 06/17/19, revealed Resident #2 had an Activities of Daily Living (ADL) mobility performance deficit related to diabetes, contractures to the bilateral lower extremities, and COPD. Interventions included bilateral side enabler bars to the head of the bed to assist with bed mobility and increased independence. Review of a physician order dated 02/25/19 revealed Resident #2 had an order for bilateral side enabler bars to the head of the bed to assist with bed mobility and increased independence. Additional review of the medical record revealed Resident #2 was last reassessed for enabler bar use on 05/14/20. The Electronic Medical Record (EMR) was silent for any assessments after 05/14/20. Interview on 12/28/21 at 12:32 P.M. of the Director of Nursing (DON) revealed enabler bars were not considered restraints or restrictive devices, but the facility followed their policy for restraints and resistive devices for enabler bar use. The DON confirmed enabler bar screenings should be completed prior to implementation and quarterly thereafter and all assessments were completed and stored in the EMR. The DON verified Resident #2 had not been reassessed for the use of enabler bars since 05/14/20. Review of facility policy titled Physical Restraints/Restrictive Devices, revised 07/20/11, revealed an assessment would be completed prior to the application of the device and quarterly thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 11 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules and staff interview, the facility failed to provide a Registered Nurse (RN) at least eight hours daily in the facility. This had the potential to affect all 49 of 49 residents in the facility. The facility census was 49. Findings include: Review of the staffing schedules revealed the facility did not have a RN work eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. Interview on 12/29/21 at 12:15 P.M., with the DON verified the facility did not have a RN on duty eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. The DON denied having a policy for staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 12 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, observation, staff interview, resident interview and policy review, the facility failed to provide an antibiotic and pain medication to a resident. This affected one (#145) of five residents reviewed for medication administration. The facility identified 30 residents that receive pain medications and two residents receive antibiotics. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set assessment was not completed at this time. Review of the discharge physician orders from the hospital dated 12/26/21 revealed an order for oxycodone-acetaminophen 5-325 milligram (mg) one tablet by mouth every six hours as needed for pain until 01/02/22, pregabalin 100 mg one tablet every eight hours for muscle pain and ceftriaxone sodium solution reconstituted two gram intravenous (IV) one time a day for infection until 01/04/22. The hospital had administered ceftriaxone on 12/26/21 and the facility was to start the antibiotic on 12/27/21. Review of the Medication Administration Record (MAR) revealed Resident #145 did not receive ceftriaxone on 12/27/21 as ordered. The first dose of oxycodone-acetaminophen was administered at 12:01 A.M. on 12/27/21. Pregabalin was not administered until 12/28/21 at 10:00 P.M. Observation on 12/27/21 at 10:35 A.M., revealed Resident #145 was observed lying bed and started flinching in pain and stated oh oh, holding his left leg stump. Interview on 12/27/21 at 10:35 A.M., at the time of the observation, with Resident #145 stated he left the hospital at 4:00 P.M. on Sunday. He arrived to the facility and was put in bed by the ambulance staff and didn't see a staff member until two hours later. Resident #145 stated he pushed his call light at 6:00 P.M., requesting pain medication and they told him there was no medicine there for him yet. At 7:00 P.M., he called again asking for pain medication and a girl brought him water in. At 10:00 P.M., he pushed his call light and finally an aide came in and said the nurse had to go somewhere and was at one of the other houses. Resident #145 asked when he would get his pills and she said the nurse would be over at 11:00 P.M. When the nurse came in, Resident #145 told him he hadn't gotten his pills yet, was having terrible pain and he didn't get his pregabalin for his phantom pain. Resident #145 stated the nurse gave him a couple Advil. The nurse left and at midnight and came back with a Percocet. Resident #145 stated the following morning he asked the nurse when he was going to get his pregabalin and she stated that she would have to check. Resident #145 stated he told the nurse he was having a lot of phantom pain in his left stump. Interview on 12/28/21 at 2:10 P.M., with the Director of Nursing (DON) verified Resident #145 verified Resident #145 didn't receive the ceftriaxone antibiotic yesterday due to it not being at the facility because the pharmacy didn't send it. Also, Resident #145 did not receive his pregabalin every eight hours as ordered because the pharmacy did not send the Pregabalin, due to needing a written prescription from the physician. The DON verified the resident didn't receive pregabalin since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 13 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission and he was having phantom pain of his left leg. The DON stated she was going to have to investigate and see what happened or where the communication dropped with the pharmacy as to why the antibiotic and pregabalin was not here to administer. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she had not administered pregabalin and it had not been available since Sunday when Resident #145 was admitted . LPN #431 stated she had told the DON yesterday it wasn't at the facility. LPN #431 stated she told the MDS Nurse today that they still needed a prescription sent to the pharmacy and the MDS Nurse called the Nurse Practitioner and she sent a prescription to the pharmacy. They were going to drop ship the pregabalin, so it should arrive later today. LPN #431 verified that Resident #145 has been complaining of phantom pain since he has been admitted . Review of the policy titled Medication Administration, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 14 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure a PRN (as needed) order for a psychotropic medication did not exceed 14 days and the facility failed to perform a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving psychotropic medication. This affected two (#24 and #36) of five residents reviewed for unnecessary medications. The facility identified 33 residents that receive psychotropic medications. The facility census was 49. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 11/10/21. Diagnoses included weakness, essential hypertension, nonrheumatic mitral valve insufficiency, sick sinus syndrome, atrial flutter, presence of cardiac pacemaker, pulmonary hypertension, type 2 diabetes mellitus with diabetic neuropathy and unspecified dementia without behavioral disturbance. Review of the quarterly Minimum Data Set Assessment revealed Resident #24 had moderate cognitive impairment with a Brief Interview Mental Status score of 10 out of 15. No behaviors were exhibited during the assessment period. Resident received hospice services. Review of the care plan dated 08/24/21 revealed the resident received hospice services. The resident will be free of depression and anxiety through the review date. Interventions included consult with physician and social services to have hospice. Encourage resident to express feelings, listen with non-judgmental acceptance and compassion. Review of the physician orders revealed an order dated 08/24/21 for Ativan 0.5 milligram (mg) one tablet every four hours as needed for anxiety. Interview on 12/29/21 at 8:50 A.M., with Licensed Practical Nurse (LPN) #436 verified that Resident #24 had a PRN Ativan order since 08/24/21, with no stop date, and no documentation or evaluation of Resident #24's need for the continued use of a PRN Ativan. 2. Review of the medical record for Resident #36 revealed an admission date of 12/17/18. Diagnoses included paranoid personality disorder, essential hypertension, gout, unspecified psychosis not due to a substance or known physiological condition, muscle weakness, gastro-esophageal reflux disease without esophagitis, anxiety disorder, major depressive disorder, recurrent, dysphagia, oral phase, and venous insufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 was rarely/never understood. Resident had verbal behavioral symptoms directed towards others occur four to six days during the assessment period. Resident #36 received antipsychotic, antianxiety, antidepressant and diuretic seven days during the assessment period. Review of the care plan dated 12/17/18 revealed Resident #36 had potential for drug related complications related to antipsychotic medication seroquel for diagnosis of hallucinations. Resident will remain free of complications of antipsychotic therapy daily. Interventions included administer medications as ordered by physician . Monitor for side effects and effectiveness. AIMS test quarterly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 15 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as needed. Monitor document report as needed any adverse reactions of antipsychotic medications. Talk to resident in native tongue as able. Provide elder with outside visits, family phone calls and polka music when upset. Review of the physician orders for Resident #36 revealed an order dated 04/08/21, for trazodone 50 mg one tablet by mouth at bedtime for sleep aid, 05/04/21 quetiapine fumarate 25 mg one tablet one time a day and give 50 mg by mouth one time a day for hallucinations, 05/25/21 duloxetine delay release 60 mg one tablet by mouth every day for depression, 08/14/21 buspirone five mg one table by mouth three times a day for anxiety, and 10/29/21, observe for side effects of antipsychotic medications every shift. Review of the most current AIMS assessment dated [DATE] revealed minimal extremity movements of upper extremities. Include movements that are choreic, do not include tremor. Severity of abnormal movements, minimal. Patient awareness of abnormal movements-awareness but no distress. Do movements disappear in sleep-yes. Score one. Interview on 12/28/21 at 3:11 P.M., with the Director of Nursing (DON) verified Resident #36 has not had an AIMS assessment completed since 05/16/20 and the facility policy is to complete an AIMS assessment every quarter. Review of the policy titled Abnormal Involuntary Movement Scale Assessment Procedure, revised 07/20/11, revealed an AIMS assessment is to be completed on admission if on an antipsychotic, or when an antipsychotic is started, then quarterly. Review of the policy titled Gradual Dose Reduction, dated 11/29/17, did not address use of PRN antipsychotic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 16 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 - Few 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. Based on observation of medication supplies, manufacturer instruction reviews and staff interview, the facility failed to ensure open dates were marked on insulin products in use. This affected two (#23 and #17) of two resident's insulin medication observed . The facility identified 13 residents with orders for insulin administration. The census was 49. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/19/20. Diagnoses included Type 2 diabetes mellitus. Review of physician orders for Resident #23 revealed they included an order dated 08/18/21, for Lantus (Basaglar) SoloStar 100 units per milliliter insulin solution pen injector, inject 22 units twice daily. Observation on 12/29/21 at 7:30 A.M., revealed the medication storage cart in House #1 contained two Basaglar (Lantus) 100 units per milliliter insulin Kwikpens for Resident #23, with one approximately three-quarters full and the other one approximately two-thirds full. Neither pen was marked with an open date. Interview during this observation with Registered Nurse #434 confirmed the two Basaglar insulin pens were not marked with open dates and were in use. 2. Review of the medical record for Resident #17 revealed an admission date of 09/09/20. Diagnoses included Type 2 diabetes mellitus and Stage 3 chronic kidney disease. Review of physician orders for Resident #17 revealed they included an order dated 10/05/20, for Tresiba FlexTouch insulin solution pen injector 200 units per milliliter, inject 60 units one time per day for Type 2 diabetes mellitus. The record for Resident #17 also included an order dated 10/15/21, for Novolog solution 100 units per milliliter, inject per sliding scale with meals (three times per day). Observation on 12/29/21 at 1:52 P.M., revealed the medication storage cart in House #2 contained two Tresiba insulin pens for Resident #17, one containing approximately 100 units and the other containing approximately 500 units. The manufacturer labels stated the product should be discarded within 56 days after opening. The cart also contained a half-full vial of Novolog insulin for Resident #17. None of the three insulin products were marked with open dates. Interview during this observation with the Director of Nursing (DON), confirmed these three insulin products were not marked with open dates. The DON confirmed nurses are to follow insulin manufacturers' instructions and denied the facility has a written policy that speaks to this. Review of manufacturer instructions for the Basaglar Kwikpen found at www.basaglar.com, confirmed the insulin is to be discarded no later than 28 days after initial use. Review of manufacturer instructions for the Tresiba FlexTouch, found at www.mynovoinsulin.com, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 17 of 18 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 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 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 confirmed the insulin product is to be discarded no later than 56 days after initial use. Level of Harm - Minimal harm or potential for actual harm Review of manufacturer instructions for the Novolog Flexpen, found at www.novocare.com, confirmed the insulin product is to be discarded no later than 28 days after initial use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 18 of 18