Health inspection·December 24, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many refrigerator for breakfast and confirmed it was undated. CNA #103 further confirmed the additional undated and expired items in both refrigerators. 4. Observation and interview on 12/24/24 at 9:15 A.M. with CNA #104 in House #1 revealed a refrigerator in the kitchen area containing a sipper cup containing an off-white liquid. The sipper cup was unlabeled. Further observation and interview confirmed an opened and undated container of potato soup, a bowl of ground meat covered in plastic wrap without a label or date, and an opened container of commercial potato salad dated 12/08/24. CNA #104 stated she believe the sipper cup contained a nutrition supplement and confirmed it was undated and unlabeled. 5. Observation and interview on 12/24/24 at 9:49 A.M. with Life Enrichment Coordinator (LEC) #302 in House #3 confirmed the refrigerator in the kitchen area contained apple juice dated 11/01/24, and contained an opened and undated container of chicken broth. Further interview and observation with LEC #302 confirmed the refrigerator in the pantry area contained actual liquid at the bottom of the bottom drawer along with a wrapped ham. LEC #302 further confirmed the pantry contained a plastic tub of flour that was open to air, a scoop inside a container of oatmeal, and a bag of hamburger buns was open to air. Interview on 12/24/24 at 11:38 A.M. with Dietetic Technician (DT) #303 revealed each food item should have a delivery date and an opened date. Additionally, leftover food should be thrown out after four days and opened packaged food should be thrown out after four to seven days. Interview on 12/24/24 at approximately 3:00 P.M. with the Administrator revealed all 57 residents in the facility received food from the kitchen. Review of the policy titled, Food Storage Policy & Procedure, revised 05/2013, revealed bulk foods, such as flour, may be stored in a clean, covered container. Further review revealed prepared food should be should be covered, labeled and dated and should be used within four to seven days after the food was prepared. This deficiency represents non-compliance investigated under Complaint Number OH00160297. 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 12/24/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents except 12 (#13, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, and #68) residents residing in House #5. The facility census was 57. Findings include: 1. Observation and interview on 12/24/24 at 1:36 P.M. with Maintenance Director (MD) #301 in House #1 revealed a kitchen cabinet under the sink. Further observation revealed the floor of the cabinet was collapsed and the veneer was separated from the particle board on the floor of the cabinet. The cabinet measured approximately three feet and 10 inches wide. MD #301 confirmed the back wall of the cabinet was modified to allow for plumbing and therefore the back wall did not touch the base or side walls of the cabinet. MD #301 confirmed approximately three inches of drywall were visible between the cabinet floor and the bottom of the back wall. MD #301 confirmed a black and dark brown substance was visible on the drywall across the three feet and 10 inch width of the cabinet. In some areas the substance fully coated the drywall and no white of the drywall was visible. In other areas the black and dark brown substance appeared spotted. The black and dark brown substance appeared flat to the wall and did not appear to be raised. There was a musty odor which came from the cabinet. MD #301 stated he believed the musty odor came from the collapsed base of the cabinet and stated he believed the base collapsed due to excessive weight, although MD #301 further confirmed the veneer was separated from the particle board. The cabinet contained two plungers and a bottle of dish soap. 2. Observation and interview on 12/24/24 at 2:08 P.M. with MD #301 in House #4 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed a light brown substance on the drywall covering approximately six inches wide and one inch high. Observed on the light brown substance were white, black, and gray pinpoint-sized spots. MD #301 peeled the brown off the wall, revealing white drywall beneath. MD #301 stated the brown color was the drywall discolored and peeling. 3. Observation and interview on 12/24/24 at 2:15 P.M. with MD #301 in House #3 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately 12 inches wide and two inches high with light brown discoloration on the drywall. On the light brown areas were grey and black pinpoint spots. MD #301 confirmed the brown spotted areas and stated the drywall had been wet at some point but was dry during the current observation. Inside the cabinet were towels, scrub pads, and dishwasher soap. 4. Observation and interview on 12/24/24 at approximately 2:20 P.M. with MD #301 in House #2 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately two feet wide and two inches high with light brown discoloration on the drywall. On the light brown areas were gray and black pinpoint spots. MD #301 confirmed the brown spotted areas on the drywall. MD #301 further confirmed pieces of drywall, approximately one to two inches in diameter, were at the back of the cabinet. The cabinet contained several bottles of dishwashing liquid. (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 12/24/2024 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 0921 This deficiency represents non-compliance investigated under Complaint Number OH00160297. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366361 If continuation sheet Page 4 of 4