Health inspection·June 1, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 notify a resident's representative of a change in condition. This affected one (Resident #2) of three residents reviewed for notification. The facility census was 56. Findings include: Medical record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including, coronary artery disease, atrial fibrillation, hypertension, depression, hypothyroidism, depression, malnutrition, chronic kidney disease stage 3, alzheimer's disease, and metabolic encephalopathy. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #2 was assessed with severely impaired cognition, dependent on staff for the provision of activities of daily living including eating, incontinent of bowel and bladder, received a modified texture diet, at risk for pressure ulcer development with no skin breakdown. Review of nurses progress notes revealed on 04/01/23 at 3:30 P.M. a state tested nurse aide and therapist notified the nurse Resident #2 did not eat breakfast or lunch and was not acting like her usual self. The resident was documented to be staring off into space, not talking as much. The resident was alert when name was called or when touched. The physician on call was notified. The physician ordered to continue to monitor the resident, if further decline, call the on-call physician. No documentation indicated the resident's representative was notified of the change in condition. On 04/02/23 at 8:48 A.M. progress notes documented by the Director of Nursing revealed a new order for a laboratory blood test to be obtained STAT, including a complete blood count (CBC) with differential and comprehensive metabolic profile (CMP). The resident representative was noted as notified. On 05/31/23 at 9:00 A.M. interview with the Director of Nursing confirmed Resident #2's medical record lacked documentation indicating Resident #2's responsible party was notified on 04/02/23, when the resident experienced a change in condition. According to the facility's notification of change of condition policy revised November 22, 2021 noted the facility will immediately notify the resident representative when there is a significant change in the residents physical, mental, psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00141682. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 2 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were provided with showers or bathing as scheduled. This affected two (Residents #2 and #3) of three residents reviewed for bathing assistance. Facility census 56. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #2 admitted to the facility on [DATE] with the diagnoses including, coronary artery disease, atrial fibrillation, hypertension, depression, hypothyroidism, depression, malnutrition, chronic kidney disease stage 3, alzheimer's disease, and metabolic encephalopathy. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with severely impaired cognition, dependent on staff for the provision of activities of daily living including eating, was incontinent of bowel and bladder, and at risk for pressure ulcer development. Review of the care plan revised 05/26/22 revealed Resident #2 had a activity of daily living self-care and/or physical mobility performance deficit related to Alzheimer's disease, confusion, and impaired balance. Resident #2 was dependent upon staff for showers and required extensive assistance of one staff with personal hygiene and oral care. Review of Resident #2's activity of daily living documentation noted the resident was scheduled for showers each Wednesday and Saturday on second shift. According to the shower documentation the resident received showers during the month of May 2023 on 05/03/23, 05/10/23, 05/17/23, and 05/27/23. Further review revealed no shower was documented as provided on 05/06/23, 05/13/23, 05/16/23, 05/20/23, 05/24/23, indicating Resident #2 did not receive twice weekly showers as scheduled. 2. Medical record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including, acute kidney failure, end stage renal disease, chronic respiratory failure, pulmonary fibrosis, type II diabetes mellitus, epilepsy, major depression, anxiety disorder, atrial fibrillation, hypertension, and anemia. According to the Minimum Data Set assessment dated [DATE], Resident #3 was assessed with intact cognition, completes activities of daily living with set-up help, independently mobile utilizing a walker or wheelchair, continent of bowel and bladder, and was at risk for pressure ulcer development. Review of the care plan revised 04/19/23 revealed Resident #3 had activity of daily living self-care and/or physical mobility performance deficit related to dementia and weakness. Resident #3 required staff assistance with bathing/showering and required staff assistance with personal hygiene and oral care. Review of Resident #3's activity of daily living documentation noted the resident to be scheduled for showers each Tuesday and Friday on second shift. According to the shower documentation the resident received showers during the month of May 2023 as indicated on 05/02/23, 05/09/23, and 05/30/23. Further review revealed no shower was documented on 05/05/23, 05/12/23, 05/16/23, 05/19/23, 05/23/23, 05/26/23, indicating the resident only received three showers for the whole month, and did not receive twice weekly showers as scheduled. Interview with Resident #3 on 05/31/23 at 7:50 A.M. revealed showers were given by their guardian at times due to requiring assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 3 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 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 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 05/31/23 at 11:43 A.M. with the Director of Nursing confirmed no additional documentation was available indicating Resident #2 and Resident #3 received twice weekly showers as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00140638. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 4 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident admitted with a surgical incision was provided with a physician ordered treatment application and wound monitoring. This affected one (Resident #1) of five residents identified with wounds in a facility census of 56. Residents Affected - Few Findings include: Medical record review revealed Resident #1 admitted to the facility on [DATE] with the diagnoses including, spinal stenosis, status post cervical spine surgery, coronary artery disease, left foot drop, and syncope. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed with intact cognition, required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use. Review of the hospital community referral physician orders dated 05/12/23 noted the following: change dressing daily for seven days and then can leave open to air. Documentation indicated the resident was discharged with a aquacel dressing to a cervical lumbar surgical wound. Review of the admission Screen and Baseline Care Plan dated 05/12/13 revealed Resident #1 with an incision to the upper back cervical (c) vertebra c3-c6 measuring 8.5 centimeters (cm) long. Further review revealed no documentation indicating a dressing was in place or applied to the incision. Review of the Treatment Administration Records (TARs) and associated medical record documentation between 05/12/23 and 05/19/23 revealed no documentation indicating if Resident #1 had a cervical incision dressing in place or if it was changed as ordered. Additionally, there was no assessment of the incision or monitoring after the 05/12/23 admission assessment. According to facility's skin care management policy revised November 17, 2022, revealed staff are to implement, monitor and modify, if needed, appropriate strategies to attain or maintain intact skin; prevent complications; promptly identify and manage complications; and involve resident and caregiver in skin care management. Identify and manage potential for infection. Interview on 06/01/23 at 11:35 A.M. with the Director of Nursing verified there was no documentation indicating Resident #1's surgical wound had a dressing applied, changed, or monitored as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00140638. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 5 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure residents received adequate hydration in accordance with dietary recommendations. This affected two (Residents #1 and #2) of three residents reviewed for fluids and hydration. The facility identified five residents as dependent on staff for the provision of eating and drinking. The facility census was 56. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #1 admitted to the facility on [DATE] with diagnoses including, spinal stenosis, coronary artery disease, left foot drop, and syncope. According to the Minimum Data Set assessment dated [DATE], Resident #1 was assessed with intact cognition, required extensive assistance with activities of daily living. Review of the comprehensive nutritional screen dated 05/25/23 revealed Resident #1's estimated fluid needs to be between 1898-2370 milliliters of fluid per day. It was recommended to encourage fluid intake. Observation on 05/30/23 at 10:52 A.M. noted Resident #1 seated in his room with no water accessible. At 10:54 A.M. State Tested Nurse Aide (STNA) #202 entered the room and provided a stainless steel lidded coffee cup containing ice and poured red gatorade into the cup. On 05/30/23 at 2:40 P.M. interview with State Tested Nurse Aide (STNA) #202 and STNA #203 verified no water pitcher or water was provided to Resident #1. Further interview revealed STNA #202 and STNA #203 worked together during the first shift between 6:30 A.M. and 2:30 P.M. and were unable to report any knowledge of Resident #1's fluid intake or encouragement of fluid intake. The STNA's indicated they were unaware of a facility hydration or fluid provision policy. On 05/30/23 at 2:54 P.M. interview with Licensed Practical Nurse (LPN) #300 verified no knowledge of Resident #1's fluid intake or encouragement of hydration during the shift between 6:30 A.M. and 2:30 P.M. On 05/31/23 at 6:00 A.M. interview with STNA #204 revealed working in the facility and assigned to Resident #1 between 10:30 P.M. and 6:30 A.M. STNA #204 verified no water was provided to residents in the facility during the shift unless the resident requested. STNA #204 was unaware fluid intake was to be encouraged with Resident #1 and confirmed no specific directive or policy was in place to ensure residents received fluids as recommended by the dietitian or physician. Observation on 05/31/23 at 6:13 A.M. noted Resident #1 in bed with no water accessible at bedside. 2. Medical record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including, coronary artery disease, atrial fibrillation, hypertension, depression, hypothyroidism, depression, malnutrition, chronic kidney disease stage 3, alzheimer's disease, and metabolic encephalopathy. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with severely impaired cognition and was dependent on staff for the provision of activities of daily living including eating. Review of the care plan initiated 02/24/22 revealed Resident #2 was at risk for constipation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 6 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 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 0692 Level of Harm - Minimal harm or potential for actual harm related to decreased mobility and medication regimen. Interventions included to encourage the resident to drink fluids. Review of the comprehensive nutritional screen dated 01/25/23 revealed Resident #2's calculated estimated fluid needs were to range between 1122-1530 milliliters fluid per day. Residents Affected - Few Observation on 05/30/23 at 9:54 A.M. revealed Resident #2 was in bed with no water accessible at bedside, nor were staff observed offering Resident #2 a drink. On 05/30/23 at 2:40 P.M. interview and observation with State Tested Nurse Aide (STNA) #202 and STNA #203 verified no water pitcher was accessible inside Resident #2's room and the resident was dependent on staff for eating and drinking. STNA #202 indicated giving Resident #2 a 120 milliliter health drink at approximately 8:30 A.M. and at lunch, however confirmed no water had been provided to the resident between 6:30 A.M. and 2:30 P.M. The STNA's were unaware of Resident #2's fluid requirements or provision of fluids to be encouraged when working with the resident. On 05/30/23 at 2:54 P.M. interview with Licensed Practical Nurse (LPN) #300 verified Resident #2 was dependent on staff. LPN #300 confirmed no access to water was provided to the resident other than two 120 milliliter health drinks during the shift between 6:30 A.M. and 2:30 P.M. LPN #300 indicated she was unaware of Resident #2's daily fluid recommendations. On 05/30/23 at 3:17 P.M. interview with the Administrator revealed the facility does no utilize a hydration protocol or policy directing staff to provide residents with access to fresh water or to ensure hydration is maintained as recommended by the dietitian and physician. The Administrator identified five total residents (#2, #16, #17, #18, #19) were dependent on staff for eating and drinking. This deficiency represents non-compliance investigated under Complaint Number OH00142916. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 7 of 8 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 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were given in accordance with approved physician orders within prescribed parameters resulting in significant medication errors. This affected one (Resident #3) of four residents review of medication administration. The facility's census was 56. Residents Affected - Few Findings include: Medical record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including, acute kidney failure, end stage renal disease, chronic respiratory failure, pulmonary fibrosis, type II diabetes mellitus, epilepsy, major depression, anxiety disorder, atrial fibrillation, hypertension, and anemia. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 was assessed with intact cognition with the ability to make needs known and completed activities of daily living with set-up help. Review of Resident #3's physician orders revealed an order dated 11/19/22 for hydralazine (blood pressure medication) 50 milligrams (mg) every eight hours to control hypertension (high blood pressure). The physician also prescribed the following parameters: If the residents systolic blood pressure was less than 110 or pulse rate was less than 60, the medication was to be held. Review of the Medication Administration Record (MAR) between 05/01/23 and 05/30/23 noted the hydralazine 50 mg with administration times of 12:00 A.M., 8:00 A.M., and 4:00 P.M. Further review revealed the hydralazine was given when the resident's blood pressure or pulse rate were outside the physician's prescribed parameters. On the following dates and times, the medication was given when the pulse rate (pr) was less than 60 beats per minute: 05/04/23 at 12:00 A.M. pr-51, 05/08/23 at 4:00 P.M. pr-58, 05/10/23 at 8:00 A.M. pr-59, 05/18/23 at 12:00 A.M. pr-55, 05/19/23 at 12:00 A.M. pr-58, and 05/20/23 at 12:00 A.M. pr-55. On the following dates and times, the residents systolic blood pressure (sbp) was outside of parameters and the medication was still administered: 05/07/23 at 4:00 P.M. sbp-97 and 05/19/23 at 12:00 A.M. sbp-98. Lastly, on the following dates no vital signs were documented and the medical record lacked entries indicating the resident's status and it was unclear if the medication was even administered: 05/06/23 at 4:00 P.M., 05/07/23 at 12:00 A.M., 05/12/23 at 4:00 P.M., 05/13/23 at 4:00 P.M., 05/19/23 at 4:00 P.M., 05/26/23 at 12:00 A.M., 05/27/23 at 4:00 P.M. Coinciding interview on 06/01/23 at 9:40 A.M. with the Director of Nursing verified Resident #3 received hydralazine 50 milligrams (mg) outside of physician ordered parameters and at times was not given the medication as prescribed. Review of the facility's Medication Administration Procedure revised 11/09/21 revealed medications were to be administered in accordance with written orders of the attending physician or physician extender. This deficiency represents non-compliance investigated under Complaint Number OH00140638. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 8 of 8