Inspection·November 2, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eight hours for three days then when the IV antibiotic was completed start an oral antibiotic ciprofloxacin 500 mg twice a day for four weeks. Interview on 11/01/23 at 2:11 P.M., the Administrator revealed there was no documentation the physician was notified on 09/17/23 of the resident bumping the first left toe. The Administrator also verified there was no documentation the physician was notified of the signs of infection to the wound on 09/24/23 when the wound had an odor, and on 09/26/23 when the wound had purulent drainage. 2. Review of the medical record for Resident #08 revealed an admission date of 06/13/08. Diagnoses included quadriplegia, osteoarthritis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, transfers, toileting, and lower body dressing. Review of the care plan initiated 06/01/19 revealed potential for pressure ulcer development related to immobility due to quadriplegia, history of pressure ulcer. Interventions included to report redness, open areas, bruises, skin tears, and rashes. Review of a skin/wound progress note dated 09/14/23 at 11:45 P.M., revealed the nurse was notified after completion of a bath the resident was noted with skin on the coccyx which was red and broken. The nursing assistant stated the skin was not broken when she bathed the resident two days prior and barrier cream was being applied due to redness and irritation. The nurses assessed the coccyx and determined the provider would be informed of the skin tear the following morning. There was no documentation the provider was notified of the skin breakdown. Interview on 10/26/23 at 11:26 A.M., the Director of Nursing (DON) verified when the redness to the resident's back was first noticed there was no documentation the physician was notified. Review of the policy, Notification of Change in Condition, revised 11/22/21, revealed the facility would consult with the resident's physician or nurse practitioner when there was an accident involving the resident which results with or without injury and had the potential for requiring physician intervention. Also, when there was a significant change in resident physical status, and when there was a need to alter treatment significantly, discontinue an existing treatment or commence a new form of treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 2 of 10 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 11/02/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interviews and policy review, the facility failed to timely notify the physician of signs and symptoms of a wound infection leading to a delay in treatment. This resulted in actual harm when Resident #23's toe wound began to show signs and symptoms of infection and the facility staff had not notified the physician. Resident #23 required care from the emergency room for treatment of osteomyelitis (severe wound infection). Additionally, the facility failed to correctly implement wound treatments per physician orders and timely administer antibiotics per physician orders. This affected one (Resident #23) of three residents reviewed for wound care. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 had an admission date of 01/21/22. Diagnoses included end stage renal disease, type two diabetes mellitus, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS) assessment completed 10/05/23 revealed the resident had intact cognition. Review of the care plan initiated 06/07/23 for Resident #23 revealed actual skin breakdown related to diabetes. The resident had a diabetic ulcer to the left first toe. Interventions included to administer treatment as ordered; encourage to wear an open toe diabetic shoe for the left foot and closed toe diabetic shoe for right foot, may wear alternative footwear as requested or preferred, enhanced barrier precautions; monitor effectiveness of treatment and notify physician or nurse practitioner as needed if area worsens or does not respond, monitor for infection at site as evidenced by redness, edema, and a weekly skin screening of body. Review of the medical record revealed the resident had a diabetic wound of the left first toe beginning 06/07/23. The wound developed osteomyelitis and the resident was appropriately treated for the infection from 06/07/23 through 08/09/23. Review of a physician wound note dated 09/13/23 revealed the diabetic wound had improved and was scabbed over. The wound measured 0.5 centimeter (cm) in length, one cm in width with no measurable depth. There was no drainage. Review of a physician order dated 09/15/23 revealed to apply skin prep daily to the left first toe. Review of a nurse's note date 09/17/23 at 9:30 P.M. revealed the resident hit left great toe with wound on it while getting out of the shower. Wound opened slightly, and a small amount of pus and blood drained from wound. The wound was treated with betadine, triple antibiotic ointment was applied with a dry dressing, per standing physician orders. There was no documentation the physician was notified the wound had reopened. Review of a physician wound assessment dated [DATE] revealed the wound to the left first toe measured 0.3 cm by 0.4 cm 0.1 cm in depth with moderate serous drainage. The wound was noted as improved. The physician discontinued the daily skin prep and ordered alginate calcium with silver and to cover with composite dressing with border daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 3 of 10 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 11/02/2023 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 Level of Harm - Actual harm Residents Affected - Few Review of the Treatment Administration Record (TAR) revealed no documentation the calcium alginate with silver treatment was completed on 09/21/23, 09/22/23, 09/23/23, 09/24/23, and 09/25/23. The facility never entered the new treatment orders into the electronic medical record. Further review of the TAR revealed on 09/22/23, 09/23/23, and 09/24/23 the skin prep treatment was administered incorrectly as this treatment had been discontinued on 09/20/23. Review of a weekly skin observation tool dated 09/24/23 at 12:45 P.M. revealed the wound to the left first toe measured 0.3 cm in length, 0.4 cm in width, and 0.1 cm in depth. The wound was described as bleeding medium and mal odor. There was no documentation the physician was notified of the signs of infection. Review of a nurses note dated 09/26/23 at 5:00 P.M. revealed the resident had treatment changed on left great toe, resident had extra skin that was sloughing off with a moderate amount of purulent drainage. Discoloration was noted to the left first toe area, with swelling surround the medial foot area. Wound care to follow and treat on 09/27/23. There was no documentation the physician was notified of the purulent drainage and swelling of the foot. Review of a wound care note dated 09/27/23 revealed the resident's wound was exacerbated due to infection. The wound measured 3 cm in length, 3 cm in width, with a depth of 0.1 cm with moderate serous drainage. The wound had 30% necrotic tissue, 30% granulation tissue and 40% other tissue. The physician ordered to apply dakins solution with a gauze roll daily for 30 days. The physician recommended an intravenous (IV) antibiotic ancef 500 milligrams (mg) every eight hours for three days then when the IV antibiotic was completed start an oral antibiotic ciprofloxacin 500 mg twice a day for four weeks. Review of a nurse's note dated 09/27/23 at 1:50 P.M. revealed the resident was seen by wound care with new orders for the left great toe wound. The resident would need intravenous (IV) antibiotics. Orders were received for an osteomyelitis work up. Resident #23 originally refused IV antibiotic for infection in toe. The resident was educated it was for three days then could have oral antibiotic for four weeks and the resident then agreed. The area to the toe was debrided by the physician and an open toe boot was applied. The resident was encouraged not to wear tight socks to prevent any pressure damage. Review of a nurse's note on 09/27/23 at 7:29 P.M. noted the resident was not able to have a peripheral inserted central catheter (PICC) line inserted due to arm contraction and would need interventional radiology (IR) to get PICC line in. The wound physician was notified. Review of the x-ray dated 09/27/23 revealed the resident had subtle bone loss at the first tuft with swelling and the finding suggested osteomyelitis. Review of a physician order dated 09/28/23 revealed to apply quarter strength dakins solution to left great toe topically once daily. The order was entered incorrectly into the electronic medical record as cleanse with quarter strength dakins, apply calcium alginate and wrap with kerlix daily. Review of the TAR revealed the treatment was completed per the incorrectly entered orders until discontinued on 10/05/23. Review of a nurse's note dated 09/28/23 at 7:29 P.M. revealed the resident would receive the IV antibiotic at dialysis. Review of the Medication Administration Record (MAR) dated 09/01/23 through 09/30/23 revealed no documentation the resident received the IV antibiotic. There was no documentation in the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 4 of 10 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 11/02/2023 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 record the resident was administered the antibiotic at dialysis. Level of Harm - Actual harm Review of a nurse's note dated 09/29/23 at 1:47 P.M. revealed the resident was ordered ciprofloxacin 500 milligrams by mouth twice a day for six weeks. Residents Affected - Few Review of a physician order dated 09/29/23 revealed the resident was ordered ciprofloxacin 500 mg by mouth two times a day for osteomyelitis. Review of the MAR revealed the resident was administered the medication on 09/29/23. Review of a nurse's note dated 09/30/23 at 9:12 A.M. revealed the resident and Power of Attorney (POA) decided to go to the emergency room (ER). Review of nurses note dated 09/30/23 at 3:19 P.M. revealed the resident returned from the ER with new orders to discontinue the ciprofloxacin and start doxycycline 100 mg twice daily for ten days. POA stated she would make an appointment for vascular follow up. Review of an ER after visit summary note dated 09/30/23 revealed the resident was ordered doxycycline 100 mg twice a day by mouth for ten days for chronic osteomyelitis of toe of left foot. Review of a physician order dated 09/30/23 revealed the resident was ordered doxycycline 100 mg by mouth twice daily for ten days for osteomyelitis. Review of the MAR revealed the resident received the medication per physician orders until the resident was admitted to the hospital on [DATE]. Review of a physician wound note dated 10/04/23 revealed the wound had improved. The wound measured two cm in length, three cm in width by 0.1 cm in depth, with moderate serous drainage. The wound had 30% necrotic tissue, with 30% granulation tissue and 40% other tissue. Review of a physician order dated 10/16/23 revealed to cleanse the left great toe with normal saline, apply betadine, put Neosporin/bacitracin cream on toe, apply adaptic or xeroform gauze on top, apply four by four gauze on top of adaptic, wrap with kling or kerlix then wrap with coban strip or ace wrap daily. Review of the TAR revealed no documentation the treatment was completed on 10/20/23 or 10/23/23. Review of a weekly skin observation dated 10/22/23 at 1:53 P.M. revealed the diabetic ulcer to the left great toe had pink tissue, no drainage and no odor. Interview on 10/25/23 at 1:30 P.M. with Resident #23 revealed the treatments for the left toe were not getting done. Resident #23 revealed a nursing assistant bumped her left toe and later the left toe later got infected again and she had to go to the emergency room. Observation on 10/25/23 at 1:44 P.M. of wound care with Licensed Practical Nurse (LPN) #103 revealed the resident had an undated wound dressing on the left first toe. LPN #103 removed the undated dressing. The resident had no toenail on the left great toe. The wound was 90% granulation tissue and 10% slough, red and swollen. There was no wound odor. LPN #103 completed the wound treatment and dated the wound dressing per physician orders. Interview on 10/25/23 at 1:53 P.M. with Licensed Practical Nurse (LPN) #103 verified the removed wound dressing was undated and should have been dated when applied. LPN #103 also verified there was no documentation the wound dressing was completed on 10/20/23 and 10/23/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 5 of 10 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 11/02/2023 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 Level of Harm - Actual harm Residents Affected - Few Interview on 10/25/23 at 4:49 P.M. with the Director of Nursing (DON) revealed a service was called to insert a PICC line to administer the resident's antibiotic. The PICC line could not be inserted due to a contracture in the resident's arm. The other arm had a fistula for dialysis. The DON revealed a recommendation was received to call Interventional Radiology but could not be completed. Then the plan was to have dialysis administer the antibiotic but they would only be able to administer once a day. The DON revealed the IV antibiotic was never administered. The DON revealed the physician was contacted and ordered the resident to start receiving the oral antibiotic. Subsequent interview with DON revealed the resident went to the emergency room on [DATE]. The ER switched to a different antibiotic for osteomyelitis. The DON revealed the resident's toe was bumped during a transfer with a sit to stand lift. The DON revealed there was no documentation the treatments on 10/20/23 and 10/23/23 were completed but the nurse stated she completed the treatments. Interview on 11/01/23 at 2:11 P.M. with the Administrator revealed there was no documentation the physician was notified on 09/17/23 of the resident bumping the first left toe. The Administrator also verified there was no documentation the physician was notified of the signs of infection to the wound on 09/24/23 when the wound had an odor, and on 09/26/23 when the wound had purulent drainage. The Administrator revealed there was no documentation the wound was monitored on 09/25/23. The Administrator verified there was no documentation wound treatments were completed as ordered by the physician. The Administrator also revealed new physician orders were once not entered into the electronic medical record and on a second occasion were entered incorrectly resulting in treatments not completed as ordered. Review of the policy, Skin Care Management Procedure, revised 12/09/22, revealed staff would monitor and remain alert to potential changes in the skin condition and evaluate and document identified changes. The physician would be notified all skin areas of concern and consulted for treatment orders. The policy had no guidelines for administering wound treatments per physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00147024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 6 of 10 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 11/02/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, policy review, and review of manufacturer guidelines, the facility failed to monitor the position and inflation of a wheelchair back support cushion, resulting in avoidable skin breakdown. Additionally, the facility failed to effectively monitor and assess skin breakdown. This resulted in Actual Harm when Resident #08 developed a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum. This affected one (Resident #08) of three residents reviewed for wound care. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #08 revealed an admission date of 06/13/08. Diagnoses included quadriplegia, osteoarthritis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, transfers, toileting, and lower body dressing. Review of the care plan initiated 06/01/19 revealed potential for pressure ulcer development related to immobility due to quadriplegia and history of pressure ulcer. The resident was noted with a stage four pressure ulcer to the sacrum. Preferred position in wheelchair during day naps is reclined, causing increased pressure to sacral area. Interventions included enhanced barrier precautions; follow facility policies/protocols for the prevention/treatment of skin breakdown; report redness, open areas, bruises, skin tears, and rashes; encourage small frequent position changes, and a weekly skin assessment; monitor during routine care and bathing. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a weekly skin observation tool dated 09/13/23 revealed the resident had no skin impairment noted. Review of a skin/wound progress note dated 09/14/23 at 11:45 P.M., revealed the nurse was notified, after completion of a bath, the resident was noted with red and broken skin on the coccyx. The nursing assistant stated the skin was not broken when she bathed the resident two days prior and barrier cream was being applied due to redness and irritation. The nurse assessed the coccyx and determined the provider would be informed of the skin tear the following morning. Review of a late entry nursing note dated 09/15/23 at 4:58 P.M. revealed the area to the resident's coccyx was not open on observation, barrier cream would continue, wound care to observe as well during wound rounds. Review of a late entry nursing note dated 09/20/23 at 5:15 P.M. revealed wound rounds were completed, and Moisture Associated Skin Damage (MASD) was observed to Resident #08's right thigh, no open area to coccyx. Barrier cream to continue. Review of a weekly skin observation tool dated 09/20/23 revealed the resident had skin impairment, an area of redness was noted to the sacrum. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 7 of 10 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 11/02/2023 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 0686 Review of physician wound evaluations dated 09/20/23 and 09/27/23 revealed the physician assessed the MASD on the resident's thigh. There was no documentation the physician assessed the resident's sacrum. Level of Harm - Actual harm Residents Affected - Few Review of a weekly skin observation tool dated 09/27/23 revealed Resident #08 was noted with MASD to the thigh. No other areas of skin impairment were noted. Review of a physician wound evaluation dated 10/04/23 revealed the resident refused the assessment. Review of a weekly skin observation tool dated 10/07/23 revealed Resident #08 had no documented areas of skin impairment. Review of a weekly skin observation dated 10/11/23 revealed Resident #08 was noted with a stage four pressure ulcer to the sacrum. The area measured 0.6 centimeters (cm) by 4 cm in width by 0.2 cm in depth. The area was noted as two separate wounds measured in cluster. Muscle tissue was visible. Observation on 10/25/23 at 11:04 A.M. with Licensed Practical Nurse (LPN) #100 of wound care revealed the resident had a stage four pressure ulcer to the sacrum. The area measured one centimeter (cm) in length, 4.5 cm in width, with a depth of 0.1 cm. The wound was 60% granulation tissue, 10% slough and 30% dermis and subcutaneous tissue with moderate serous exudate. Further observations revealed the horizontal shape of the wound was similar in size and shape to the horizontal row of air bubbles on the resident's back cushion on the wheelchair. Interview on 10/25/23 at 11:04 A.M. with Wound Physician (WP) #108 revealed the resident's wound was found at a stage four pressure ulcer. WP #108 revealed the wound was improving. Due to the horizontal nature of the wound, WP #108 thought something fell behind the resident's back and, due to no feeling in her back, the resident was unaware. Interview on 10/25/23 at 3:28 P.M. with Resident #08 revealed nothing fell behind her back to cause the wound. Resident #08 revealed the nursing assistants had told her for a few weeks the area was red. Resident #08 revealed the nurses were also aware. Resident #08 thought the redness would just go away. Resident #08 revealed the nurse explained she needed to see the wound physician and she was seen about a week later. Interview on 10/26/23 at 8:51 A.M. with the Director of Nursing (DON) revealed the inflation was off on the back cushion of the resident's wheelchair, the resident had the technician come out in July, and a new cushion was ordered. The DON revealed the new cushion was delivered on 09/09/23, a week or two before the resident got the area on her sacrum. The DON revealed she had no knowledge of this prior to yesterday. The DON stated she let some of the air out of the resident's back cushion today. The DON revealed she requested a visit by the service provider to check the amount of inflation and complete a pressure test. The DON revealed the nursing assistants were responsible to report to nurse if there was an observed skin condition. Interview on 10/26/23 at 10:03 A.M. with State Tested Nursing Assistant (STNA) #115 revealed she first saw the area of the resident's back the first week in October. STNA #115 revealed she had a red circle by the tailbone. STNA #115 revealed the resident reported the area had not started until she got her new cushion for her chair. STNA #115 revealed not reporting the area as the resident told her everyone was aware of the area on her back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 8 of 10 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 11/02/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few Interview on 10/26/23 at 11:26 A.M. with the DON confirmed Resident #08's stage four pressure ulcer could potentially have been caused by the back cushion on the wheelchair, especially since the resident had no pressure before the cushion was installed. The DON revealed when the pressure ulcer was first investigated, she had no knowledge of the new cushion. The DON revealed she thought the pressure was caused by the positioning of the back cushion, which could go up and down depending on the tightness of the Velcro. The DON revealed she thought the Velcro was not attached correctly and the cushion moved up and down and side to side until she looped the cushion over the headrest of the wheelchair. The DON revealed she noticed the positioning of the cushion when the resident developed the pressure ulcer. The DON confirmed there were no monitoring interventions in place for the cushion. The DON verified when the redness to the resident's back was first noticed, there was no documentation the physician was notified. The DON revealed the nurse called the physician the next morning and was told to continue the barrier cream. The DON revealed the nurse should document characteristics of skin breakdown, if applicable, and measure and describe wound, if applicable. Interview on 11/01/23 at 7:45 A.M. with Resident #08 revealed the service provider for the wheelchair cushion completed a pressure mapping test on 10/26/23 or 10/27/23 and there was only blue color, indicating no pressure points. The provider thought the cushion was over inflated and took a fair bit of air out in the lumbar (lower back) area. Interview on 11/01/23 at 10:46 A.M. with the Administrator revealed the resident made her own arrangements for the wheelchair cushion and staff would not necessarily need to inform management if a wheelchair vendor was in the building. The Administrator verified there were no prescriber recommended inflation level for the cushion as it was based on the resident's preference. Subsequent interview with the Administrator verified there was no documented wound assessment for the resident prior to 10/11/23. Interview on 11/01/23 at 4:29 P.M. with LPN #109 revealed she rounded with the wound physician on 09/20/23. LPN #109 revealed the resident's sacrum was irritated and red but there were no open areas. LPN #109 revealed the physician told her to have the nurses continue the barrier cream. Review of the manufacturer instructions for the custom back support supplement revealed a warning to check inflation. Make sure there was at least one-half inch (1.5 cm) of air supporting the individual's bony prominences. Follow the prescriber's recommended inflation levels. Review of the policy, Skin Care Management Procedure, revised 12/09/22, revealed a stage four pressure ulcer was full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. A medical device related pressure ulcer/injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Staff would monitor and remain alert to potential changes in the skin condition and should evaluate and document identified changes. Documentation should include the date observed, location and staging, size, drainage and amount, color, odor, pain, a description of the wound bed and type and percentage of tissue present along with a description of the wound edges. The physician would be notified of all skin areas of concern and consulted for treatment orders. This deficiency represents non-compliance investigated under Complaint Number OH00147024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 9 of 10 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 11/02/2023 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 review of a physician wound note, review of physician orders, review of the medication administration record, staff interview, and policy review, the facility failed to ensure intravenous (IV) medications were administered per physician orders. This affected one (Resident #23) of one resident reviewed for medication administration. The facility census was 48. Residents Affected - Few Findings include Review of medical record revealed Resident #23 had an admission date of 01/21/22. Diagnoses included end stage renal disease, type two diabetes mellitus, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS) assessment completed 10/05/23 revealed the resident had intact cognition. Review of a wound care note dated 09/27/23 revealed the resident had a diabetic wound to the left first toe. The physician noted the wound was exacerbated due to infection. A subsequent x-ray on 09/27/23 suggested osteomyelitis. The physician recommended an Intravenous (IV) antibiotic ancef 500 milligrams (mg) every eight hours for three days, then when the IV antibiotic was completed, start an oral antibiotic ciprofloxacin 500 mg twice a day for four weeks. Review of physician orders dated 09/27/23 revealed the resident was ordered cefazolin sodium injection solution reconstituted 500 mg; use 500 mg intravenously every eight hours for left toe infection for three days. Review of the Medication Administration Record (MAR) dated 09/01/23 through 09/30/23 revealed the IV antibiotic cefazolin was never administered. Interview on 10/25/23 at 4:49 P.M., the Director of Nursing (DON) revealed a service was called to insert a PICC line to administer the antibiotic. The PICC line could not be inserted due to a contracture in the resident's arm. The other arm had a fistula for dialysis. The DON revealed a recommendation was received to call Interventional Radiology but could not be completed. The facility was going to have dialysis administer the antibiotic but they would only be able to administer once a day. The DON revealed the IV antibiotic was never administered. The DON revealed the physician was contacted and ordered the resident to start receiving the oral antibiotic. Review of the policy, Medication Administration Procedure, revised 11/09/21, revealed medications were administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 10 of 10