Inspection·July 7, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 07/07/23 at 4:39 P.M., with the Administrator confirmed no additional documentation was available indicating Resident #7 and Resident #25 received showers/bathing twice weekly as scheduled. This deficiency represents the continued non-compliance from the survey dated 06/01/23 and under Complaint Number OH00143812. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 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 Based on observation, staff interview and review of policy, the facility failed to ensure residents were free from significant medication errors. This affected two (#28 and #7) of two residents observed for medication administration. The facility census was 54. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 01/28/22. Diagnoses included congestive heart failure, atrial fibrillation, hypothyroidism, protein calorie malnutrition, kidney disease, and chronic obstructive pulmonary disease. Review of the physician orders for Resident #28 revealed orders written on 12/19/22 for Aspirin 81 milligrams (mg), one tablet by mouth in the morning every Monday, Wednesday and Friday, Levothyroxine Sodium 150 micrograms (mcg), one tablet once daily, Digoxin 125 mcg, one tablet daily by mouth in the morning, Ferrous Sulfate 325 mg, one tablet daily in the morning, Claritin 10 mg, one tablet by mouth in the morning, Toprol extended release 100 mg, one tablet by mouth each morning, multiple vitamin with minerals, one tablet by mouth daily in the morning. Observation on 07/07/23 at 8:05 A.M., of medication administration for Resident #28, completed by Licensed Practical Nurse (LPN) #110 revealed the following medications: Synthroid 150 micrograms (mcg), one tablet, Aspirin 81 milligrams (mg), one tablet, Digoxin 0.125 mg, one tablet, Feosol 325 mg,one tablet, Claritin 10 mg, one tablet, Toprol, extended release 100 mg, one tablet, and Multivitamin, one tablet, were removed the pharmacy pill pack. The medications were removed from the individually sealed package and placed into a medicine cup. A Perservision Ared2 capsule was removed from the packaging and placed in a second and separate medicine cup, LPN #110 stated the capsule cannot be crushed. LPN #110 proceed to pour the medications from the first medicine cup into a plastic sleeve, placed the sleeve into the pill crusher and crushed the pills all together, poured the medications back into the medication cup and added a spoonful of applesauce, stirred the medications in the applesauce, secured a glass of water and the second medication cup and proceeded to the Resident #28's room. LPN #110 knocked on the door, entered, placed the two medication cups and the water on the overbed table, positioned the resident and proceeded to assist feeding the applesauce with the medications to the resident in three separate bites, provided water and then the Perservision capsule. Interview on 07/07/23 at 8:11 A.M., with LPN #110 verified all medications except for the Perservision were crushed together and placed in applesauce and administered to Resident #28 and further verified the pill pack identified the Feosol and Toprol extended release were label do not crush. 2. Review of the medical record for Resident #7 revealed an admission date of 05/29/20. Diagnoses included hypertension, heart disease, dementia, lymphedema, and polyneuropathy. Review of the current physician orders revealed an order written on 08/15/22 for natural balance tears solution 0.1 - 0.3%, instill one drop in both eyes four times a day for dry eyes. Observation on 07/07/23 at 8:24 A.M., of medication administration for Resident #7, completed by LPN #100 revealed one drop of lubricating eye drops 0.3% were placed in each eye of Resident #7, the bottle of lubricating eye drops was labeled for Resident #10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/07/23 at 8:26 A.M., with LPN #100 verified the eye drops administered to Resident #7 belonged to another resident. Review of the policy titled, Medication Administration, dated 11/09/21, stated if safe to do so, medications tablets may be crushed. Tablets which can be appropriately crushed may be ground coarsely and mixed with appropriate vehicle so that the resident receives the entire dose ordered. Crushed medications should not be combined and given all at once. Medications are administered on accordance with the written order of the physician. Prior to administration, the medication and the dosage schedule on the medication administration record is compared with the medication label and residents are identified before medication is administered. This deficiency represents the continued non-compliance from the survey dated 06/01/23 and under Complaint Number OH00143812. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 4 of 4