Health inspection·April 17, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, and staff interviews, the facility failed to ensure the call lights were within the resident's reach. This affected one (Resident #1) of one resident reviewed for call lights. The facility census was 17. Residents Affected - Few Findings include: Medical record review revealed Resident #1 was admitted on [DATE]. Diagnoses included Alzheimer's disease, osteoporosis, osteoarthritis, hyperlipidemia, heart failure, and anxiety. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired, used a wheelchair, and required moderate assistance with dressing, personal hygiene, toileting, showering, and transferring. Observation on 04/14/25 at 11:09 A.M. revealed Resident #1 was in her room lying in bed and did not have a call light pendant within reach. Interview on 04/14/25 at 11:15 A.M. with Wellness Director #310 confirmed Resident #1 did not have a call light pendant within reach. Observation on 04/16/25 at 8:30 A.M. during medication administration for Resident #1 revealed the resident was in her room resting in her bed and did not have a call light pendant within reach. Interview on 04/16/25 at 10:35 A.M. with Registered Nurse (RN) #316 confirmed Resident #1 did not have a call light pendant within reach when she entered Resident #1's room to administer medications at 8:30 A.M. Observation on 04/16/25 at 10:35 A.M. in the common area of Cornerstone Cottage revealed Resident #1 was sitting in her wheelchair and her call light pendant was not within reach. Subsequent interview with RN #316 and the Director of Nursing (DON) confirmed Resident #1 did not have her call pendant around her neck and it should be. Page 1 of 11 366358 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Some Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure all required postings were displayed in the facility in a manner which was accessible to all residents. This affected all 10 (#1, #2, #5, #6, #8, #9, #10, #11, #171, and #172) residents who resided in the Cornerstone Cottage. The facility census was 17. Findings include: Observation upon arrival at the facility on 04/14/25 at approximately 7:30 A.M. revealed the facility was comprised of two houses, one being the Cornerstone Cottage and the other being the [NAME] House. Observation on 04/16/25 at approximately 10:12 A.M. of all facility common areas and hallways revealed there was no posted contact information for pertinent state agencies and advocacy groups, and no statement the residents may file a complaint with the State Survey Agency concerning suspected violations. Interview on 04/16/25 at 10:17 A.M. with the Administrator verified the Cornerstone Cottage did not have all required postings. 366358 Page 2 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

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 medical record review and staff interview, the facility failed to develop a care plan for dehydration for a resident who was at risk and a history for dehydration. This affected one (Resident #2) of one resident reviewed for hospitalization. The facility census was 17. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/09/24. Diagnoses included dementia and dysphagia. Her physician orders included a puree diet with mildly thickened liquids. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and was dependent on staff for feeding. Review of Resident #2's hospital discharge orders dated 03/10/25 revealed a diagnosis of dehydration and orders for one to one and a half liters of water intake daily. Review of the comprehensive care plan dated 04/14/25 for Resident #2 revealed no goals or interventions for the prevention of dehydration. Interview on 04/16/25 at 1:13 P.M. with Registered Nurse #315 confirmed Resident #2's care plan did not have measurable goal(s) and intervention(s) for the prevention of dehydration. 366358 Page 3 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident who was on a stool softener daily received the care and services related to absence of bowel movements for six days in a row. This affected one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 17. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 05/08/24. Diagnoses included dementia, generalized muscle weakness, thoracic disc degeneration, aphasia, and osteoporosis. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired, continent of bowel, and required substantial to maximum assistance with toileting. Review of the physician orders dated 11/27/24 revealed an order for Docusate Sodium oral tablet 100 milligrams (mg) one tablet two times a day for constipation. Review of Resident #6's bowel and bladder elimination records revealed there were six days in a row where Resident #6 did not have a recorded bowel movement on 03/25/25, 03/26/26, 03/27/25, 03/28/25, 03/29/25, and 03/30/25. The medical record did not include any nursing intervention and/or physician notification of Resident #6 not having a bowel movement for six days. There were no physician orders for a bowel protocol for Resident #6. Interview on 04/15/25 at 11:19 A.M. with the Director of Nursing (DON) confirmed Resident #6 did not have a bowel movement for six days in a row from 03/25/25 to 03/30/25 and there was no nursing intervention and/or physician notification of Resident #6 not having a bowel movement for six days. Subsequent interview on 04/15/25 at 2:30 P.M. with the DON confirmed six days was too long for a resident to go without a bowel movement and nursing interventions should have been initiated. The DON confirmed the facility did not have a bowel protocol in place for Resident #6. 366358 Page 4 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure nurse staffing information was posted as required. This affected all 10 (#1, #2, #5, #6, #8, #9, #10, #11, #171, and #172) residents who resided in the Cornerstone Cottage. The facility census was 17. Residents Affected - Some Findings include: Observation upon arrival at the facility on 04/14/25 at approximately 7:30 A.M. revealed the facility was comprised of two houses, one being the Cornerstone Cottage and the other being the [NAME] House. Observation on 04/16/25 at approximately 10:12 A.M. of all facility common areas and hallways revealed there was no daily nurse staffing information posted in the Cornerstone Cottage. Interview on 04/16/25 at 10:17 A.M. with the Administrator verified there was no daily nurse staffing information posted in the Cornerstone Cottage. 366358 Page 5 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policies, the facility failed to ensure food items were stored, labeled and dated and ensure refrigerators and freezers did not contain expired food items. This had the potential to affect all 17 residents who received food from the facility kitchens. The facility census was 17. Findings include: 1. Observation on 04/14/25 beginning at 7:37 A.M. of refrigerators and freezers located in the Cornerstone Cottage with Certified Nursing Assistant (CNA) #303 revealed the following findings and CNA #303 verified the below findings: One unlabeled container of fruit cocktail which expired on 04/12/25. One unlabeled container which contained an unknown white substance and expired on 04/12/25. One unlabeled and undated container which contained an unknown white substance. One unlabeled and undated container which contained an unknown brown substance. One unlabeled and undated bowl, which contained several pastries. One unlabeled and undated container which contained cake. One unlabeled and undated zip-lock bag which contained two donuts. One unlabeled and undated zip-lock bag which contained 10 sausage patties. 366358 Page 6 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0812 One unlabeled and undated package of sliced lunchmeat. Level of Harm - Minimal harm or potential for actual harm One unlabeled and undated package of sliced bacon. Residents Affected - Many One unlabeled and undated container of potato casserole. One unlabeled and undated plate wrapped in plastic wrap which contained an unknown meal. One unlabeled and undated zip-lock bag which contained cooked bacon strips. One unlabeled and undated container which contained oats. Numerous unlabeled and undated slices of cheese wrapped in plastic wrap. No thermometer was in the refrigerator located in the kitchen area. Review of the facility policy titled Personal Food Storage Policy and Procedure revised 05/18/18 revealed all refrigerators would have internal thermometers. 2. Observation on 04/14/25 beginning at 8:10 A.M. of the dry storage area located in the [NAME] House revealed there were eight boxes which contained nutritional shakes which were stacked and stored directly on the floor. In addition, there were five boxes of tube feeding formula which were stacked and stored directly on the floor. An interview on 04/14/25 at 8:31 A.M. with Registered Nurse (RN) #317 verified the nutritional shakes and tube feeding formula boxes were stored stacked and directly on the floor. 3. Observation on 04/14/25 beginning at approximately 8:15 A.M. of refrigerators and freezers located in the [NAME] House revealed the following: Two unlabeled bags of sausage patties which expired on 04/07/25. 366358 Page 7 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0812 One unlabeled and undated cup of soup. Level of Harm - Minimal harm or potential for actual harm One unlabeled and undated container of cottage cheese. Residents Affected - Many One unlabeled and undated container which contained sliced peaches. One unlabeled and undated bowl of coleslaw. One unlabeled and undated container of an unknown substance which was brown and red. One unlabeled and undated package of raw sliced bacon. One unlabeled paper bag which was dated 04/01/25 and contained a container of soup and a paper box with moldy bread. An interview on 04/14/25 at 8:31 A.M. with Registered Nurse #317 verified there were multiple bags and containers of food undated and unlabeled in the refrigerator and freezers in the [NAME] house. Review of the facility policy titled Food Storage Policy & Procedure, revised May 2013, revealed prepared food would be covered, dated, and labeled with the month and day on which it was prepared. The policy also stated the label would indicate the use by date which was four to seven days after the food was prepared. The policy further stated food containers would be stored at least six inches off the floor. 366358 Page 8 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed ensure there was a policy and procedure and staff were in knowledgeable on reverse isolation the physician ordered due to the resident being immunocompromised (at increased risk for infection). This affected one (Resident #13) of one resident reviewed for reverse isolation. The facility census was 17. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included pancytopenia, immunodeficiency due to drugs, and heart failure. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #13 had a mild cognitive impairment and required assistance from staff for all activities of daily living. Review of the facsimile dated 03/24/25 revealed the physician responded to Resident #13's laboratory results that Resident #13 should be in reverse isolation. Review of Resident #13's nursing progress notes dated 03/24/25 revealed the resident had a critical white blood cell and platelet count. There were new orders from the physician for reverse isolation. Review of the active physician orders for April 2025 identified an order dated 03/24/25 for reverse isolation. Observation on 04/14/25 at 10:21 A.M. revealed the door to Resident #13's room had a sign which read STOP Please see nurse. There was also a three-drawer bin which contained personal protective equipment including masks. At 10:22 A.M., Certified Nursing Assistant (CNA) #310 entered Resident #13's room without donning any personal protective equipment such as a mask, gown, or gloves. Interview on 04/14/25 at 10:25 A.M. with CNA #310 stated the staff were previously wearing a surgical mask into Resident #13's room to protect the resident but stated staff were no longer wearing a mask into the resident's room. Interview on 04/14/25 at 3:14 P.M. with Registered Nurse (RN) #317 verified Resident #13 currently had an order for reverse isolation due to previously going out for radiation appointments. RN #317 reported they believed reverse isolation meant the resident could not have any live flowers in their room or anything like that. RN #317 reported staff had not been required to wear any personal protective equipment such as a mask into the room. RN #317 reported Resident #13 no longer received radiation, so the reverse isolation could likely be discontinued. Observation on 04/14/25 at 5:05 P.M. revealed the signage was no longer on the door of Resident #13's room and the personal protective equipment was no longer in the room. Interview on 04/15/25 at 11:36 A.M. with CNA #307 stated Resident #13 had been on reverse isolation, which required staff to wear a surgical mask into the resident's room to protect the resident. Interview on 04/16/25 at 11:15 A.M. with RN #316 stated she was the staff member who was the nurse 366358 Page 9 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on duty on 03/24/25. On 03/24/25, RN #316 saw Resident #13's white blood cell count was really low so she called the physician and left a message. The physician then sent a faxed order for reverse isolation. There was no conversation regarding what the expectation for reverse isolation was. The nurse placed the stop sign on Resident #13's door, put the bin with personal protective equipment in the room, let staff know the resident was on reverse isolation, and let the oncoming nurse and the resident know the resident was on reverse isolation. RN #316 reported staff were to wear a surgical mask, a gown, and gloves when going into Resident #13's room. Interview on 04/16/25 at 12:21 P.M. with Physician #400 revealed the physician had ordered the reverse isolation for Resident #13. Physician #400 reported Resident #13's white blood cell count had been critically low, so he ordered reverse isolation to protect the resident when staff were going into the room to make sure they were practicing hand hygiene and being extra cautious with the resident. Physician #400 reported whether staff wore personal protective equipment into the room would depend on the facility's policy for reverse isolation. Physician #400 reported if there was personal protective equipment present in the room, he would assume staff should be wearing it. Interview on 04/16/25 at 1:45 P.M. with the Director of Nursing (DON) who was also the facility's Infection Preventionist revealed the DON was unsure of what the facility's procedure for reverse isolation was. The DON reported they thought that reverse isolation meant Resident #13 needed to wear a mask when going out to appointments. The DON verified the facility had not clarified what the physician's order for reverse isolation was supposed to encompass. Interview on 04/16/25 at 2:04 P.M. with the Administrator verified the facility did not have a policy that covered reverse isolation. The Administrator also reported the facility would obtain more clarification on physician orders going forward. 366358 Page 10 of 11 366358 04/17/2025 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interviews, and review of facility policy, the facility failed to offer annual influenza immunizations to the residents during the 2024-2025 influenza season. This affected two (#1 and #6) of five residents reviewed for immunizations. The facility census was 17. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/12/22. There was no evidence that Resident #1 was offered an annual influenza immunization during the 2024-2025 influenza season. Review of the medical record for Resident #6 revealed an admission date of 05/08/24. There was no evidence that Resident #6 was offered an annual influenza immunization during the 2024-2025 influenza season. Interview on 04/17/25 at 3:45 P.M. with the Administrator and Director of Nursing (DON) confirmed annual influenza immunizations had not been offered to Resident#1 nor Resident #6 during the 2024-2025 influenza season. Review of the facility policy titled Influenza and Pneumococcal Immunization dated 06/19/19 revealed the facility would offer the influenza immunization annually between October first and March 31st. 366358 Page 11 of 11