Health inspection·September 27, 2018

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and policy review the facility failed to ensure residents information was kept private. This affected one Resident (#41) of five residents reviewed during medication administration. The census was 43. Residents Affected - Few Findings include: Medical record review for Resident #41 revealed an admission date of 03/16/17. Medical diagnoses included dementia and Parkinson's. Observation of medication administration on 09/26/18 at 8:11 A.M. revealed Registered Nurse (RN) #184 took the package of medications for Resident #41 and removed the top portion of the package, which had the resident's name listed, and threw it in the trash on the side of her cart. Interview with RN #184 on 09/26/18 at 8:15 A.M. revealed her practice was to tear off the top portion of the medication packages and put it in the trash. She stated in her pharmacy training she was taught as long as she separated the name from the package of medication it would be fine. She stated the bag of trash then goes into the big trash can after the end of her shift. She stated the portion of the package that contained the names of the residents were not shredded for privacy. Review of policy entitled Health Insurance Portability and Accountability Act (HIPPA) Compliance revised 07/20/11 revealed it is the policy of the facility to comply with the HIPPA of 1996 or specially the Administrative Simplification section of the act. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 2 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents, and/or the residents representative was provided a notice of transfer discharge. The facility also failed to notify the ombudsman when the resident was sent out to the hospital. This affected one Resident (#22) of eighteen reviewed for hospitalization. The census was 43. Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and a Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of progress notes dated 07/31/18 revealed Resident #22 was sent out to the hospital for high blood sugar. Further review of the notes revealed resident returned to the facility on [DATE]. There was no evidence the resident and/or the resident representative was discharge, transfer notice or that the Ombudsmen was notified. An interview was conducted on 09/26/18 at 2:08 P.M. with the Administrator verified there wasn't a discharge, transfer notice given to the resident and/or resident representative. The Administrator verified the Ombudsman was not notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 3 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to ensure residents were provided a bed hold policy when they were sent out to the hospital. This affected one Resident (#22) of eighteen reviewed for hospitalization. The census was 43. Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and supervision for eating. Review of progress notes dated 07/31/18 revealed Resident #22 was sent out to the hospital for high blood sugar. Further review of the notes revealed resident returned to the facility on [DATE]. An interview was conducted on 09/26/18 at 2:08 P.M., the Administrator verified a bed hold policy was not given to the resident. Review of the policy entitled Bed Hold Policy dated 11/13/17 revealed all residents and representative are notified of the bed hold policy on admission and prior to any transfer at the time of transfer. If the transfer is emergent, the resident and representative must be notified within 24 hours. The bed hold policy applies to all residents regardless of payment source. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 4 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 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, observation, and staff interview the facility failed to ensure a care plan was followed regarding teeth brushing. This affected one Resident (#18) of sixteen reviewed for dental. The census was 43. Findings include: Medical record review for Resident #18 revealed an admission date of 07/09/18. Medical diagnoses included dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was cognitively impaired. She was an extensive assistance for bed mobility, transfers, and toilet use and supervision for eating. She was coded for natural teeth. Review of the care plan for Resident #18 revealed oral care routine was to brush teeth in A.M., after meals, and at bedtime. Observation conducted on 09/24/18 at 1:53 P.M. of Resident #18 revealed her bottom teeth had yellow slimy matter on them. Subsequent observation on 09/26/18 at 11:17 A.M. revealed the resident had yellow slimy matter on the bottom teeth. An interview conducted with Elder Assistant #128 on 09/26/18 at 11:32 A.M. revealed the resident's teeth were only brushed once a day, in the A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 5 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to insure a meaningful care conference was provided for residents. This affected one Resident (#10) of 16 reviewed for care conferences. The census was 43. Findings include: Medical record review for Resident #10 revealed she was admitted on [DATE]. Her medical diagnoses included peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Review of the care conference dated 04/30/18 revealed the resident or the Power of Attorney (POA) was not in attendance and the only one in attendance was Social Worker (SW) #154. It was documented in the note Resident #10 didn't have any concerns and to continue with the plan of care. It was also documented the resident wasn't available. It was checkmarked the plan of care was not reviewed. Review of care conference dated 01/24/18 revealed Resident #10 and POA were not in attendance and the only one in attendance was SW #154. Review of care conference dated 07/27/18 revealed the resident or the POA were not present for the conference and the only one in attendance was SW #154. Further in the note revealed the resident was asked of any concerns and there were no concerns at the time. The care plan and advanced directives were reviewed with no changes. It was checkmarked in this care conference the resident declined conversation. Interview with Resident #10 on 09/25/18 at 8:37 A.M. revealed she had not had a care conference since she had been admitted into the facility. She stated her daughter told her she was able to speak for herself and to ask for a care conference. She stated someone comes into her room and asks how she is doing, but doesn't inquire about anything else. Interview with SW #154 on 09/26/18 at 11:00 A.M. revealed she was the only one in the care conferences and she did not have anyone from the interdisciplinary team (IDT) at the conferences. She said normally the Director of Nursing would attend. She also stated a nurse could attend if the resident requested one to be in attendance. Interview with MDS Registered Nurse #116 on 09/26/18 at 1:40 P.M. revealed the IDT was involved with the care planning, but not all of the staff attended the care conference unless the resident requested the members. Review of policy entitled Comprehensive Care Planning Procedure dated 11/13/17 revealed the Care conference is held to discuss the current care plan, any quarterly updates and any significant changes in resident status. During the conference the IDT obtains input of the residents and/or the resident representative. Residents are encouraged to identify, express, and develop the potential they possess. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 6 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, family interview and staff interview the facility failed to provide ear care to a resident as ordered. This affected one Resident (#11) of one resident reviewed for hearing. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #11's medical record revealed an admission date of 10/09/15 with diagnoses that included atherosclerotic heart disease, anxiety disorder, insomnia, major depressive disorder and muscle weakness. Resident #11's brief interview for mental status (BIMS) score on 07/03/18 was rated a two, severe cognitive impairment. Further review of Resident #11's medical record revealed a physician order dated 01/23/18 to irrigate ears twice daily with half strength peroxide 1.5 %, then remove wax every Sunday evening. Review of Resident #11 treatment administration records (TARs) for 08/2018 and 09/2018 revealed ear wax removal was not documented as being completed on the following Sundays: 08/26/18, 09/09/18, 09/16/18 or 09/23/18. Further review of these TARs revealed there was no documentation of Resident #11's ears being irrigated with peroxide twice daily. Review of an audiologist appointment note dated 08/20/18 revealed a large white double dome (hearing aid ear piece) was found in Resident #11's left ear canal and was removed. A family member of Resident #11 stated in an interview on 09/25/18 at 9:20 A.M. that Resident #11 was supposed to be getting his ears flushed at the facility. This family member also stated a part of Resident #11's hearing aide was found in his hear at a recent audiologist appointment. Resident #11's family member was concerned Resident #11's ears were not being flushed and cleaned as ordered. The Director of Nursing (DON) confirmed during an interview on 09/27/18 at 10:40 A.M. that there was no documentation of Resident #11's ears being irrigated twice daily and that ear wax removal was not documented on 08/26/18, 09/09/18, 09/16/18 or 09/23/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 7 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview and policy review the facility failed to ensure a gait belt was used during a transfer. This affected one (#20) of three residents reviewed for accidents. The census was 43. Findings include: Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Observation on 09/24/18 at 12:16 P.M. revealed Resident #20 was sitting in a chair in the common area. Elder Aide (EA) #193 took the hands of the resident and pulled her out of the chair up to touch her walker, without using a gait belt. Interview on 09/24/18 at 12:36 P.M. with EA #193 verified he should have used a gait belt to get Resident #20 out of the chair, but stated he forgot. Review of policy entitled Use of Gait Belt dated October 2013 revealed the gait belt will be used by the EA and or nurse during every transfer or during ambulation of an elder that required assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 8 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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, observation, interview and policy review the facility failed to ensure a resident was medicated for pain prior to a dressing change. This affected one (#22) of three residents reviewed for pressure/arterial ulcers. The census was 43. Residents Affected - Few Findings include: Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of physician orders dated 01/16/18 revealed Tramadol 50 milligram (mg) tablet give one every eight hours as needed for pain and also Tramadol 50 mg tablet give two every eight hours as needed for pain. Review of the care plan for pain dated 01/25/18 revealed to administer analgesia as per orders, give 1/2 hour before treatments or care and anticipate needs for pain relief and respond immediately to any complaint of pain. Review of medication administration record (MAR) from 09/01/18 through 09/27/18 revealed no evidence of pain medication being administered to Resident #22. Observation on 09/27/18 at 12:05 P.M. of a dressing change to the right heel of Resident #22 with Licensed Practical Nurse (LPN) #122 revealed when LPN #122 removed the sock from the resident's foot she said you are already hurting me. At this time, LPN #122 did not offer pain medication to Resident. #22. LPN #122 continued with the treatment and removed the Kerlix from the foot and the bandage from the wound. Resident #22 was observed to flinch. LPN #122 cleansed the wound and the resident winched when he touched the wound. As LPN #122 placed the ointment and the abdominal pad on the wound, Resident #22 flinched and said Ow. At the time of the observation, LPN #122 stated he had not medicated the resident right before the treatment but had medicated her earlier in the day with Tylenol. Further observation on 09/27/18 at 12:11 P.M. of the left heel wound dressing change of Resident #22 with LPN #122 revealed she moaned when the aide, who was assisting, lifted her leg. Resident #22 said it hurts, but I don't give into the pain. LPN #122 cleansed the wound and touched her heel. The resident said, ouch. LPN #122 placed the ointment on the residents heel and when he placed the Kerlix around her foot, she said ouch. Interview with LPN #122 on 09/27/18 at 12:20 P.M. verified he should have given the resident pain medication prior to the dressing change. At the time of the interview the MAR was reviewed with LPN #122, and he verified he did not give Resident #22 any Tylenol that morning. Review of policy entitled Pain Management dated September 2007 revealed to identify, significantly reduce, and/or abolish pain, resulting in an improved quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 9 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview and staff interview the facility failed to assess a resident's fistula. This affected one Resident (#26) of one resident reviewed for dialysis care. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #26's medical record revealed an admission date of 07/24/18 with diagnoses that included hypertension, end stage renal disease, anxiety disorder and muscle weakness. Resident #26's brief interview for mental status (BIMS) score on 08/07/18 was 13, cognitively intact. Review of Resident #26's physician orders revealed an order dated 08/25/18 to check for thrill over arteriovenous (AV) fistula every shift. Review of Resident #26's treat administration record (TAR) revealed there was no documentation of her AV fistula being checked for thrill on 09/01/18 second or third shift, 09/02/18 second or third shift, 09/04/18 third shift, 09/05/18 third shift, 09/06/18 all shifts, 09/07/18 first and second shift, 09/09/18 all shifts, 09/11/18 third shift, 09/12/18 second shift, 09/13/18 third shift, 09/14/18 all shifts, 09/15/18 third shift, 09/16/18 all shifts, 09/17/18 second shift, 09/18/18 third shift, 09/19/18 third shift, 09/20/18 third shift, 09/21/18 second shift, 09/22/18 third shift, 09/23/18 all shifts and 09/26/18 second shift. During an interview on 09/24/18 at 10:22 A.M. Resident #26 stated that facility staff did not assess her fistula. During an interview on 09/27/18 at 7:43 A.M. registered nurse (RN) #184 stated she had not yet checked Resident #26's AV fistula for the first shift. RN #184 confirmed that she had already documented checking for thrill on Resident #26's electronic TAR for 09/27/18 first shift. RN #184 was unable to define what a thrill was when asked by surveyor. The Director of Nursing (DON) confirmed during an interview on 09/27/18 at 10:30 A.M. that there was no documentation of staff checking for thrill over Resident #26's AV fistula for the above dates in September 2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 10 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, observation, staff interview and review of the facility's Medication Administration policy the facility failed to properly secure a resident's medications. This affected one Resident (#16) observed in the 9350 C cottage of the facility. No residents in the 9350 C cottage were identified as being cognitively impaired and independently mobile. The facility census was 43. Findings include: Review of Resident #16's medical record revealed an admission date of 09/01/17 with diagnoses that include atrial fibrillation, constipation, anxiety disorder, hypertension and generalized edema. Resident #16 was identified as being cognitively intact. During the initial tour of the facility cottage 9350 C on 09/24/18 at 9:18 A.M. medications were observed in a medication cup beside Resident #16 while she was eating breakfast in the dining area. There was no nurse in close proximity to Resident #16. At the time of the observation the Director of Nursing (DON) confirmed Resident #16's medications were in a medication cup beside her at he dining room table and that a nurse was not in close proximity to Resident #16. The DON confirmed medications should not be left with residents to take without a nurse present. Registered nurse (RN) #184 during an interview on 09/24/18 at 9:20 A.M. stated she left the medications with Resident #16 and did not observe her take the medications. RN #184 presented a list of medications that were left with Resident #16. Review of the facility's Medication Administration Policy revealed medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 11 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Residents Affected - Some Review of quarterly Minimum Data Set (MDS)dated 07/25/18 revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of care plan dated 01/25/18 revealed the focus of diabetes and interventions were to check blood sugars and provide medication for diabetes as ordered by the physician. Review of PO dated 06/05/18 revealed Novolog Sliding Scale to inject as per sliding scale subcutaneously before meals and at bedtime, PO dated 08/03/18 revealed Novolog, inject eight units subcutaneously before meals PO dated 08/08/18 revealed Lantus to inject 36 units subcutaneously one time a day at 9:00 P.M. Review of MAR from 09/01/18 through 09/27/18 revealed there was missing documentation for Lantus on 09/08/18, 09/12/18, 09/14/18, and 09/16/18. There was missing documentation for Novolog eight units on 09/08/18 and 09/12/18 for the 5:00 P.M. dose. Further review of the MAR for Novolog sliding scale revealed missing documentation on 09/08/18 and 09/12/18 for the blood sugar and administration of the insulin for the 5:00 P.M. and 9:00 P.M. dose and on 09/16/18 there was missing blood sugar and insulin administration. Review of progress notes from 09/01/18 through 09/27/18 revealed they were absent for an explanation as to why there was missing documentation for the Lantus and Novolog. Interview with the DON on 09/27/18 at 2:44 P.M. revealed she did not know why the Lantus and Novolog were not given and why the blood sugars weren't taken. 3. Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly MDS dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Review of care plan for Resident #20 revealed hypertension and the intervention was to administer medications as ordered and obtain the blood pressure as directed. Review of PO dated 04/13/18 for Resident #20 revealed Lisinopril 40 mg take one tablet daily. Review of blood pressures for Resident #20 revealed there was one on 04/13/18 on admission which was 197/114. Review of progress notes for 04/13/18 for Resident #20 revealed no followup for the high blood pressure. There wasn't another blood pressure recorded until 09/12/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 12 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0757 Interview with the DON on 09/27/18 at 2:40 P.M. verified the high blood pressure should been monitored. Level of Harm - Minimal harm or potential for actual harm Based on review of medical records and staff interview the facility failed to document medication administrations and monitor medication side effects for residents. This affected three Residents (##20, #22 and #35) of five reviewed for unnecessary medications. The facility census was 43. Residents Affected - Some Findings include: 1. Review of Resident #35's medical records revealed an admission date of 02/27/10 with diagnoses that include dementia, psychosis, atrial fibrillation, hypertension, anorexia nervosa and major depressive disorder. Resident #35's brief interview for mental status (BIMS) score on 08/29/18 was 9, moderate cognitive impairment. Further review revealed a physician order (PO) for Percocet (narcotic pain medication) 5/325 milligrams (mg) every six hours by mouth for pain. Review of Resident #35's 09/2018 medication administration record (MAR) revealed Percocet was not documented as being administered on the following dates and times. 09/06/18 at 6:00 A.M., 09/08/18 at midnight and 6:00 A.M., 09/10/18 at 6:00 A.M., 09/14/18 at midnight and 6:00 A.M., 09/15/18 at 6:00 A.M., 09/16/18 at midnight and 6:00 A.M., 09/17/18 at midnight and 6:00 A.M., 09/20/18 at midnight and 6:00 A.M., and 09/24/18 at 6:00 A.M. A physician order dated 02/28/18 was to observe for anticoagulation medication side effects such as discolored urine, black tarry stools, sudden severe headache, etc. Staff wee to document Y if side effects noted and N if no side effects were noted. Resident #35 was currently taking Xarelto (anticoagulant) 20 mg by mouth daily. Further review of Resident #35's MAR for 09/2018 revealed there was no documentation of anticoagulation medication side effect being monitored on the following dates and times. 09/01/18 at 2:00 P.M., 09/02/18 at 2:00 P.M., 09/04/18 at 2:00 P.M. and 11:00 P.M., 09/05/18 at 2:00 P.M. and 11:00 P.M., 09/06/18 at 2:00 P.M. and 11:00 P.M., 09/07/18 at 2:00 P.M. and 11:00 P.M., 09/11/18 at 11:00 P.M., 09/13/18 at 11:00 P.M., 09/14/18 at 11:00 P.M., 09/15/18 at 11:00 P.M., 09/16/18 at 2:00 P.M. and 11:00 P.M. , 09/18/18 at 11:00 P.M., 09/19/18 at 11:00 P.M., 09/20/18 at 11:00 P.M., 09/21/18 at 2:00 P.M., 09/23/18 at 11:00 P.M. Review of progress notes for 09/2018 revealed no explanation for the missing documentation. During an interview on 09/27/18 at 11:45 A.M., the Director of Nursing (DON) confirmed there was missing documentation for the administration of Percocet and for anticoagulation side effects during 09/2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 13 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #20 revealed an admission date of 04/13/18. Medical diagnoses included vascular dementia. Review of quarterly MDS dated [DATE] revealed Resident #20 was cognitively impaired. The resident was an extensive assistance with two person for mobility, transfers, and toileting. She was an extensive assistance with one-person assistance for eating. Review of care plan dated 04/18/18 for Resident #20 revealed potential for drug complications for Seroquel with interventions to monitor/document/report as needed any adverse reactions to antipsychotic medications. Review of PO dated 05/08/18 for Resident #20 revealed Ativan 0.5 mg give 1 tablet every six hours as needed for anxiety. This Ativan was discontinued on 07/30/18. Further review of PO revealed the resident was prescribed Seroquel (antipsychotic) 25 mg every morning, 40 mg every evening and 100 mg at bed time for mood stabilization and psychosis. Review of MAR from 05/01/18 through 05/31/18 revealed Resident #20 received the Ativan on 05/16/18, 05/19/18, 05/20/18, 05/21/18, 05/22/18, and 05/28 18. Further review of MAR from 09/01/18 through 09/27/18 revealed there wasn't any behavioral monitoring. Review of physician notes for Resident #20 from 05/25/18 through 07/19/18 revealed they were silent to a rationale why the physician kept the Ativan on the order. Interview with the DON on 09/27/18 at 2:40 P.M. verified the physician did not show a rationale as to why the as needed Ativan was continued. She also verified there should have been behavioral monitoring for use of Seroquel. 3. Medical record review for Resident #22 revealed an admission date of 05/14/12. Medical diagnoses included peripheral vascular disease, neuropathy, chronic venous and arterial insufficiency and Alzheimer's. Review of quarterly MDS dated [DATE] revealed Resident #22 was cognitively impaired. She was an extensive assistance for bed mobility, transfer, toilet use and a supervision for eating. Review of PO for Resident #22 dated 01/16/18 revealed Zoloft 50 mg, give one every day related to major depressive disorder. Review of care plan for Resident #20 dated 01/25/18 revealed for potential for drug related complications related to antidepressant medication. Interventions were to monitor/report as needed adverse reactions to antidepressant. Review of MAR for Resident #20 from 09/01/18 through 09/27/18 revealed behaviors were not monitored on 23 out of 79 opportunities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 14 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the DON on 09/27/18 at 2:40 P.M. verified there was missing documentation for monitoring behaviors for Resident #22. Based on review of medical records and staff interview the facility failed to monitor psychoactive medication side effects and monitor behaviors. This affected three Residents (#20, #22 and #35) of five reviewed for unnecessary medications. The facility census was 43. Findings include: 1. Review of Resident #35's medical records revealed an admission date of 02/27/10 with diagnoses that included dementia, psychosis, atrial fibrillation, hypertension, anorexia nervosa and major depressive disorder. Resident #35's brief interview for mental status (BIMS) score on 08/29/18 was 9, moderate cognitive impairment. Review of physician orders (PO) revealed Resident #35 was ordered Olanzepine (antipsychotic) 2.5 milligrams (mg) two times daily and Remeron (antidepressant) 15 mg daily. Further review of PO revealed orders dated 02/28/18 to monitor for side effects of antidepressant and antipsychotic medication every shift. An order dated 02/28/18 was to monitor for behaviors such as itching, hitting, increase in complaints, biting, etc. every shift. Review of Resident #35's medication administration record (MAR) from 09/01/18 through 09/26/18 revealed that antidepressant medication side effects were not monitored 19 out of 78 opportunities and that antipsychotic medication side effects were not monitored 19 out of 78 opportunities. Behaviors were not monitored 19 out of 79 opportunities. During an interview on 09/27/18 at 11:45 A.M., the Director of Nursing (DON) confirmed there was missing documentation of antidepressant and antipsychotic side effects and behavior monitoring for Resident #35. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 15 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of the facility's Dishwashing policy, the facility failed to prevent possible contamination of sanitized dishes. This had the potential to affect all eight Residents (#3, #5, #11, #17, #27, #35, #39 and #41) who reside in cottage 9336 B of the facility. The facility census was 43. Findings include: During an observation of lunch service in cottage 9336 B on 09/24/18 at 12:03 P.M. , Elder Assist (EA) #152 was observed washing dishes. At 12:07 P.M., EA #152 removed plates from a drying rack, picked a towel up from the top of the counter, wiped the plates dry and put them away in a cabinet. At 12:30 P.M. , EA #152 removed plates and coffee pots from a rack from the dishwasher/sanitizer and placed the rack on the counter. EA #152 took the plates and coffee pots from the rack and wiped them dry with a towel she had pulled from a cabinet drawer. EA #152 then put the plates in a cabinet and put the coffee pots back in the coffee makers. EA #152 confirmed during an interview on 09/24/18 at 1:04 P.M., she had wiped the plates and coffee pots dry with a towel before putting them away. Review of the facility's Dishwashing Policy revealed that upon completion of the dishwashing cycle, open the door and allow dishes to air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 16 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's Quality Assessment and Assurance (QAA) meeting sign-in logs and staff interview the facility failed to have the required QAA committee meetings and have the required QAA members. This had the ability to affect all the residents of the facility. The facility census was 43. Residents Affected - Many Findings include: Review of QAA committee sign-in logs revealed on 01/25/18 four staff members where in attendance (Administrator, Medical Director and the Director of Nursing (DON)). On a QAA committee sign-in log dated 04/27/18 three staff members (Administrator, Medical Director and DON) and two outside service providers had signed in. On a QAA committee sign-in log dated 07/25/18 three staff members (Administrator, Medical Director and DON) had signed in. The facility was unable to provide a QAA committee sign-in log for the third quarter of 2017. The Director of Nursing (DON) stated in an interview on 09/26/18 at 9:52 A.M. the QAA committee had three members, the Administrator, herself (DON) and the medical director. The DON stated they would invite other providers to attend. The Administrator confirmed in an interview on 09/27/18 at 3:10 P.M., the QAA committee did not comprise of five total staff members. The Administrator confirmed there was no documentation of sign-in logs for a QAA committee meeting held the third quarter of 2017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 17 of 18 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 366368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Springboro 9320 Avalon Circle Centerville, OH 45458 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's Water Management Program for Legionella Risk Reduction, review of water temperature logs and staff interview the facility failed to have a Legionella plan in place. This had the ability to effect all of the residents of the facility. The facility census was 43. Residents Affected - Many Findings include: Review of the facility's Water Management Program for Legionella Risk Reduction dated 06/28/18 revealed that control measures for hot water was to set hot water tank to 122 degrees Fahrenheit (F) and circulate water at 120 F. Hot water system temperatures were to be monitored and recorded weekly. Cold water was be monitored at set locations weekly. Temperatures for cold water should be below 70 F. All water exit points are to be flushed for three minutes on a monthly basis. Review of water temperature logs dated 06/15/18 through 09/19/18 revealed that there was no documentation of hot water tank monitoring and that cold water temperatures recorded exceeded 70 F. There was no documentation of water exit points being flushed. Maintenance Director (MD) #149 stated in an interview on 09/26/18 at 1:40 P.M. that he did not have any documentation of any water temperature monitoring for Legionella before he started working at the facility. MD #149 stated he started at the facility in May 2018. MD #149 started he started checking water temperatures and flushing exit points in June 2018. MD #149 stated the facility had recently requested quotes from water management companies for facility water assessments. MD #149 confirmed there was no documentation of hot water tank temperatures, water exit flushing and that cold water temperatures were recorded above 70 F. During an interview the Administrator on 09/27/18 at 12:45 P.M. confirmed the Water Management Program for Legionella Risk Reduction was dated 06/28/18. The Administrator was unable to provide a policy in place before 06/28/18 and stated she though it was put in place after the last annual survey. The Administrator stated that quotes for a facility water assessment had been requested from water management companies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 18 of 18