Health inspection·November 14, 2019

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 record review, observation, and staff interviews, the facility failed to implement a resident's skin integrity care plan. This affected one (Resident #15) of 14 residents reviewed for implementation of care plans. The facility census was 42. Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a stage one pressure area. Review of Resident #15's progress notes dated 10/24/19 revealed the resident developed a small area that was 0.5 centimeters (cm) by 0.5 cm on his sacrum. The area was reported to be blanchable and pink with granulated tissue. Calmoseptine was put in place on 10/24/19. Further review of Resident #15's progress notes dated 11/08/19 revealed Resident #15's area on his sacrum was healed. Review of Resident #15's skin integrity care plan revealed the resident required a pressure reduction cushion. Observation of Resident #15 on 11/13/19 at 11:56 A.M. revealed Resident #15 was sitting in his wheelchair at the dining table in with no pressure reduction cushion in place. Observation on 11/14/19 at 8:16 A.M. revealed State Tested Nurse Aide (STNA) #32 and STNA #81 were providing care to Resident #15. Resident #15's wheelchair was observed to be in the room at the time of the observation. There was no cushion observed in Resident #15's wheelchair. Interview at the time of the observation with STNA #32 and STNA #81 revealed Resident #15 did not have a cushion for his wheelchair. Observation of Resident #15 on 11/14/19 at 11:36 A.M. revealed Resident #15 was sitting in his wheelchair at the dining table in his house with no pressure reduction cushion in place. Interview with the Director of Nursing (DON) on 11/14/19 at 11:36 A.M. verified Resident #15 was sitting in his wheelchair at the dining table in his house with no pressure reduction cushion in place. The DON also confirmed resident was to have a pressure reduction cushion as indicated on his care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 2 of 20 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 11/14/2019 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 and staff interview the facility failed to ensure staff did not falsify records in regard to dressing changes they did not personally complete. This affected one (Resident #21) of four residents reviewed for skin management. The census was 42. Residents Affected - Few Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of the Treatment Administration Record (TAR) for Resident #21 for November 2019 revealed she had daily dressing changes to both heels that were to be completed on day shirt. Further review revealed on 11/12/19, Licensed Practical Nurse (LPN) #50 signed that he completed the dressing to the right heel. Observation of the left heel wound on 11/13/19 at 1:23 P.M. with LPN #50 and the Director of Nursing (DON) revealed the old bandage was not dated. In a subsequent observation on 11/13/19 at 3:25 P.M. with LPN #50 of a dressing change to the right heel revealed the old dressing was dated 11/11/19. Interview with LPN #50 on 11/13/19 at 3:50 P.M. revealed in regards to the right heel he documented he changed it on 11/12/19, but didn't change it. He said he didn't want there to be any holes in his documentation and he thought second shift was going to change the dressing. He admitted there was no evidence the dressing was completed on 11/12/19 for the right heel. Interview with RN #47 on 11/14/19 at 5:30 P.M. revealed she took care of Resident #21 on 11/01/19, 11/06/19, 11/09/19, and on 11/10/19. She stated she did the dressing changes, but she didn't document them on the TAR. She stated she checked off all of her medications on the MAR, but didn't do the treatments on the TAR. She stated when she changed the dressings for the left heel there was a foul odor. She stated she didn't document this in the progress notes and didn't call the physician. She revealed she didn't feel like she needed to document or call the physician, since the appropriate people were following the residents wounds and felt it was normal for the wound to smell foul. She indicated the dressing changes were scheduled for day shift but the resident received a bath on second shift on Monday, Wednesday and Friday so the dressings were done on second shift. She explained there was no place to document on the TAR that the dressing changes were completed on second shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 3 of 20 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 11/14/2019 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff, nurse practitioner, and resident interviews, and review of facility policies, the facility failed to ensure staff monitored a wound for signs of infection and failed to report an odor to the physician. This affected one (#Resident 21) of four residents reviewed for skin conditions. The facility census was 42. Residents Affected - Few Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of physician orders dated 10/04/19 and discontinued on 10/26/19 revealed Hydrogel to apply to right and left heel topically one time a day. The wounds were to be cleansed with normal saline, pat dry, apply Hydrogel and cover with a ABD pad and wrap with kerlix. Further review of the orders revealed on 10/26/19 to cleanse left heel with antiseptic, wash, pat dry, apply hydrofera blue, place ABD pad and wrap in kerlix and change daily on day shift and this order was discontinued on 10/29/19. Further orders revealed on 10/30/19 to cleanse left heel with antiseptic, wash, pat dry, place hydrofera blue, ABD pad and wrap in kerlix and the wound was to be changed daily every day shift and this was discontinued on 11/01/19. A new order was placed on 11/02/19 to cleanse left heel with Vashe, pat dry, apply skin prep around the wound, apply silver alginate to the wound and cover with ABD pad and kerlix and to change daily and as needed on day shift. Review of the resident's care plan dated 10/25/19 revealed she had arterial ulcers to her bilateral heels. Interventions were to administer treatment as ordered, encourage and assist me to lay down in bed after lunch, heel lift boots to bilateral extremities at all times, as tolerated. low air loss mattress, monitor for effectiveness of my treatment and notify the physician as needed if area worsens or does not respond, monitor for infection at the site as evidenced by redness and edema, supplements per order, turn and reposition frequently and weekly skin screening of body. Review of Nurse Practitioner (NP) #200 notes dated 10/25/19 revealed Resident #21's left heel was a full thickness wound measuring 7.5 centimeters (cm) x 5.0 cm x 0.1 cm. The wound base was 70% eschar and 30% granulation tissue. The wound was slightly malodorous and had serosanguinous drainage. Periwound was without erythema, induration, edema, or crepitus. The resident did not demonstrate evidence of pain when affected area was palpated. Intervention in place was Doxycycline 100 mg twice a day for 10 days for wound infection. Review of Treatment Medication Record (TAR) dated from 10/26/19 through 11/13/19 for Resident #21 revealed no staff signed that the treatment for the residents left heel was completed on 10/26/19, 10/27/19, 10/31/19, 11/01/19, 11/06/19, 11/09/19, and 11/10/19. Review of report sheets dated 11/01/19 through 11/10/19 from Registered Nurse (RN) #47 revealed on 11/01/19 dressings were changed, on 11/06/19 dressings were changed, on 11/09/19 heel dressings were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 4 of 20 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 11/14/2019 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 0684 changed, and on 11/10/19 dressings were changed. Level of Harm - Minimal harm or potential for actual harm Review of NP #200 notes dated 11/08/19 revealed full thickness wound of the left heel, measuring 6.5 cm x 4.0 cm x 0.1 cm. The wound base was 60% eschar and 40% granulation tissue. Moderate nonodorous serosanguinous drainage. Periwound was without erythema, induration, edema or crepitus. The resident did demonstrate evidence of pain when affected area was palpated. Residents Affected - Few Observation of the left heel wound on 11/13/19 at 1:23 P.M. with Licensed Practical Nurse (LPN) #50 and the Director of Nursing (DON) revealed when they removed the bandage from the resident's left heel there was a foul odor. There was thick yellowish green drainage and the blood was coming out of the wound significantly. The DON stated the wound looked like it was 50% eschar and 50% slough The resident had pain when the wound was palpated. The old bandage was not dated. In a subsequent observation on 11/13/19 at 3:25 P.M. with LPN #50 of a dressing change to the right heel revealed the old dressing was dated 11/11/19. Interview with LPN #50 on 11/13/19 at 3:50 P.M. revealed the resident always had an odor to the left heel. LPN #50 denied notifying the physician about the odor. He stated he smelled the odor on 11/12/19 but didn't call the physician or the NP. He indicated he had done the dressing change on the left heel on 11/12/19 but forgot to date the dressing. He stated he didn't do the dressing change to the right heel on 11/12/19 even though he signed it off that he completed it. He said he signed it off because he didn't want to there to be any holes in his documentation. He thought the second shift nurse was going to change the dressing. He verified there was no evidence the dressing was completed to the right heel on 11/12/19. Interview with the DON on 11/14/19 at 9:19 A.M. revealed the NP had only been at the facility since 10/11/19. She revealed she spoke with the NP and explained to her the wound had been classified as an arterial wound for a long time, even though there was no evidence of testing that was completed to determine if the wounds were arterial wounds. She stated the resident had been on an antibiotic several times for infection in her left heel. She stated the wound had been getting better when using the hydrofera and if the treatment was changed it got worse. She stated the resident's wound was not without odor and after it was cleaned the odor went away. She stated she knew there was a problem with the holes in the documentation and the facility was working on that. She said RN #47 could not seem to document in the TAR for the treatments. She stated the NP was contacted about the odor on 11/13/19, after surveyor intervention, and a new order was received for Doxycycline. Interview with NP #200 on 11/14/19 at 1:02 P.M. revealed she was going to order vascular studies to determine if the wounds were arterial. She stated she also wanted an infectious disease physician to evaluate the resident. She revealed she didn't feel like the wounds had the typical shape for arterial wounds and those type of wounds were usually found on the ankle. She stated when she was in the facility on 10/25/19 she felt the wound on the left heel had worsened and she placed the resident on an antibiotic. She stated when she assessed the wound on 11/08/19, she felt like the wound was better and at that time she did not smell an odor. She said the staff called her on 11/13/19 and said the wound looked worse and had an odor, so she placed the resident on an antibiotic. Interview with RN #47 on 11/14/19 at 5:30 P.M. revealed she took care of Resident #21 on 11/01/19, 11/06/19, 11/09/19, and on 11/10/19. She stated she did the dressing changes, but she didn't document them on the TAR. She stated she checked off all of her medications on the MAR, but didn't do the treatments on the TAR. She stated when she changed the dressings for the left heel there was a foul odor. She stated she didn't document this in the progress notes and didn't call the physician. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 5 of 20 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 11/14/2019 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 0684 Level of Harm - Minimal harm or potential for actual harm revealed she didn't feel like she needed to document or call the physician, since the appropriate people were following the residents wounds and felt it was normal for the wound to smell foul. She indicated the dressing changes were scheduled for day shift but the resident received a bath on second shift on Monday, Wednesday and Friday so the dressings were done on second shift. She explained there was no place to document on the TAR that the dressing changes were completed on second shift. Residents Affected - Few Review of the facility policy entitled Skin Care Management dated 11/02/18 revealed it is the policy of the facility to follow the state and federal regulations concerning skin care management. The policy revealed to implement, monitor and modify if needed appropriate strategies to attain or maintain intact skin, prevent complications, and promptly identify and manage complications and identify and manage potential for infection. Review of policy entitled Notification of Change in Condition dated 07/20/11 revealed the facility will adhere to the regulations of both the Federal and State guidelines pertaining to notification in change in condition of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 6 of 20 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 11/14/2019 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy review the facility failed to ensure a resident with an indwelling catheter had an order for the catheter and failed to ensure catheter care was provided and/or the catheter was changed on a regular basis. This affected one (#21) of one resident for an indwelling catheter, The facility identified there were two residents with an indwelling catheter. The census was 42. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. She was coded for an indwelling catheter. Review of care plan not dated for an indwelling catheter related to history and potential for skin breakdown revealed to change catheter once monthly and report cloudiness to the physician. Review of physician orders, Treatment Administration Records and progress notes dated 01/01/19 through 11/13/19 for Resident #21 revealed they were silent for an indwelling catheter orders, care or changing of the catheter or even when it was placed in the resident. There was no evidence the resident had a urinary tract infection. Observation of catheter care for Resident #21 on 11/14/19 at 11:12 A.M. revealed she had an indwelling catheter and the tubing had cloudy urine with sediment noted. Interview with the Interim Director of Nursing (DON) on 11/14/19 at 4:00 P.M. verified there was not a physician order for the catheter, there was no progress notes about catheter care, and there was no documentation the catheter had been cleansed. The Interim DON stated the catheter had been changed recently, but could not produce documentation for it. She stated that for some reason the documentation had dropped off the electronic charting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 7 of 20 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 11/14/2019 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews, the facility failed to ensure a resident's physician evaluated and addressed a resident's significant weight loss. This affected one (Resident #15) of one resident reviewed for nutrition. The facility census was 42. Residents Affected - Few Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a weight loss of five percent or more in the last month or loss of ten percent or more in last six months. Resident #15 was not on a prescribed weight loss regimen. Review of Resident #15's nutrition care plan revealed resident was at risk for changes in his nutrition and that he was to have dycem under his plate at meals, evaluations by occupational therapy and speech therapy, review of his weights, lab and intakes and to be served soup in a cup instead of a bowl. Review of Resident #15's weights revealed Resident #15 weighed 177 pounds (lbs) on 05/05/19 and 155 lbs on 11/05/19 with Resident #15 having a significant weight loss 12.43 percent over six months. Review of Resident #15's nutrition screen dated 09/26/19 revealed resident had a weight loss of five percent or more in the last month or 10 percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #15's physician's notes dated 04/30/19, 06/18/19, 07/08/19, 08/14/19, 10/25/19 and 11/06/19, revealed resident's significant weight loss was not evaluated or addressed by the physician in the physician's notes. Further review of Resident #15's medical record revealed no documentation that Resident #15's physician evaluated or addressed Resident #15's significant weight loss of 12.43 percent from 05/05/19 to 11/05/19. Review of Resident #15's physician's orders revealed the resident was ordered bene-calorie one packet one time per day on 09/27/19 and high calorie boost four times a day on 01/23/18. Observation of Resident #15 on 11/12/19 at 12:06 P.M. revealed the resident was sitting at the dining room table in his house independently feeding himself a hamburger. Observation of Resident #15 on 11/12/19 at 11:56 A.M. revealed the resident was sitting at the dining room table in his house. State Tested Nurse Aide (STNA) #66 was assisting him with eating stir fry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 8 of 20 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 11/14/2019 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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with Dietary Technician #300 on 11/13/19 at 1:48 P.M. revealed Resident #15 used adaptive utensils at times and also required staff to assist him with meals. Dietary Technician #300 reported resident was ordered bene-calorie one packet one time per day on 09/27/19 and high calorie boost four times a day on 01/23/18. Follow up interview with Dietary Technician #300 on 11/17/19 at 11:22 A.M. verified Resident #15's medical record contained no documentation that Resident #15's physician evaluated or addressed Resident #15's significant weight loss of 12.43 percent from 05/05/19 to 11/05/19. Event ID: Facility ID: 366368 If continuation sheet Page 9 of 20 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 11/14/2019 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to ensure a resident that discharged from the facility had a written, signed and dated order from the physician. This affected one (Resident #46) of one resident reviewed for discharges to the community. The facility census was 42. Findings include: Record review revealed Resident #46 was admitted to the facility on [DATE] with the following diagnoses; unspecified fall, primary generalized osteoarthritis, vascular dementia without behavioral disturbance, vascular dementia without behavioral disturbance, muscle weakness, hypertension, hyperlipidemia, osteoporosis, iron deficiency, vitamin D deficiency and major depressive disorder. Resident #46 discharged to an assisted living facility on 08/22/19. Review of Resident #46's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #46 also required supervision with eating. Review of Resident #46's progress notes dated 08/22/19 revealed Resident #46 discharged to an assisted living facility in her resident representative's personal vehicle. Review of Resident #46's physician's orders revealed Resident #46's medical record did not contain an order for the resident to discharge from the facility on 08/22/19. Interview with Registered Nurse (RN) #43 on 11/13/19 at 3:43 P.M. verified Resident #46 did not have a written and signed discharge order to discharge from the facility on 08/22/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 10 of 20 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 11/14/2019 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, and staff interviews, the facility failed to ensure State Tested Nurse Aides (STNAs) received 12 hours of yearly in services. This affected five STNAS (#15, #35, #65, #69 and #76) of six STNAs reviewed for yearly in services. This had the potential to affect all residents residing in the facility. The facility census was 42. Residents Affected - Many Findings include: 1. Review of STNA #15's personnel file revealed a hire date of 07/11/12. Further review of the personnel file revealed STNA #15 only received 4.25 hours of in services from 07/11/18 to 07/11/19. 2. Review of STNA #35's personnel file revealed a hire date of 12/06/17. Further review of the personnel file revealed STNA #35 only received one hour of in services from 12/06/17 to 12/06/18. 3. Review of STNA #66's personnel file revealed a hire date of 08/20/15. Further review of the personnel file revealed STNA #66 received no in services from 08/05/18 to 08/05/19. 4. Review of STNA #69's personnel file revealed a hire date of 04/26/11. Further review of the personnel file revealed STNA #69 received no in services from 04/26/18 to 04/26/19. 5. Review of STNA #76's personnel file revealed a hire date of 12/29/15. Further review of the personnel file revealed STNA #76 only received 1.25 hours of in services from 12/26/17 to 12/26/18. Interview with Business Office Manager #37 on 11/14/19 at 10:37 A.M. verified the above STNAs did not receive 12 hours of annual in services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 11 of 20 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 11/14/2019 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure drug regimen review recommendations were addressed by the attending physician in a timely manner. This affected one (Resident #33) of five residents reviewed for unnecessary medications. The facility census was 42. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. Review of Resident #33's pharmacy recommendation dated 09/20/19 revealed the pharmacy recommended Resident #33's as needed hydroxyzine (antihistamine) 25 milligrams (mg) every eight hours as needed for anxiety have a stop date clarified. Further review of the 09/20/19 pharmacy recommendation revealed no documentation that Resident #33's physician addressed the pharmacy recommendation. Interview with the Director of Nursing (DON) on 11/13/19 at 1:12 P.M. verified Resident #33's pharmacy recommendation dated 09/20/19 was not addressed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 12 of 20 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 11/14/2019 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 #27 revealed an admission date of 07/09/18. Medical diagnosis included anxiety disorder. Review of the quarterly MDS dated [DATE] for Resident #27 revealed she was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, and toilet use. She was supervision for eating. Review of Pharmacy Recommendations dated 05/24/19 for Resident #27 revealed a request to discontinue PRN Ativan. Further review of the recommendations dated 08/23/19 revealed a request for the physician to clarify a stop date for the resident's PRN Ativan 0.25 milligram (mg) every 12 hours for agitation. The recommendation indicated per the Centers for Medicaid and Medicare Services (CMS) PRN anxiolytics cannot extend beyond 14 days without a specifically stated duration and a documented rationale for the extension. Both of these recommendations were not signed or acknowledged by the physician. Review of physician orders dated 08/23/19 revealed an order for Ativan 0.25 mg every 12 hours PRN for agitation. The PRN Ativan 0.25 mg was discontinued on 10/29/19. Review of physician order dated 10/29/19 revealed Ativan 0.5 mg give 1/2 a tablet every 12 hours PRN for agitation. An order was received to discontinue PRN Ativan on 11/13/19 after surveyor questioned the order. Interview with the DON on 11/14/19 at 9:34 A.M. verified the physician did not address the pharmacy recommendations in regards to the PRN She stated she requested the physician to discontinue the PRN Ativan today after the surveyor brought it to her attention. Review of policy entitled Medication Regimen Review Policy dated 11/09/17 revealed it was the policy of the facility the medication regimen review of each resident will be reviewed by the Pharmacist according to the Federal and State guidelines as well as standards of practice. A written report for all of the irregularities and recommendations will be submitted to the facility for the attending physician. The policy further revealed if the attending physician failed to address a recommendation the DON should be contacted and the DON and Medical Director shall review the incomplete recommendation with the attending physician. 3. Review of Resident #6's medical record revealed an admission date of 11/30/17. Medical diagnoses included Alzheimer's disease, osteoarthritis, anxiety, depression, psychosis, Vitamin D deficiency, muscle weakness, edema. Review of Resident #6's quarterly MDS assessment dated [DATE] revealed the resident's cognition was severely impaired. Resident #6's October and November 2019 Medication MAR revealed an order for Hydroxyzine (anti-anxiety) 25 mg one tablet by mouth every eight hours PRN for agitation dated 10/29/19 with no stop date indicated. Interview on 11/14/19 at 2:37 P.M. with the DON verified Resident #6 did not have a stop date or rationale for continuation of use of the PRN anti-anxiety medication and it had exceeded the allowable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 13 of 20 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 11/14/2019 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 14 day timeframe. Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident 16's medical record revealed an admission date of 07/21/19. Medical diagnoses included dementia, subarachnoid hemorrhage, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, restless leg syndrome, dysphagia, and chronic kidney disease. Residents Affected - Some Review of Resident #16's significant change MDS dated [DATE] revealed Resident #16's cognition was severely impaired. Review of Resident #16's October and November 2019 MAR revealed an order for Ativan (anti-anxiety) medication 0.5 mg one tablet by mouth every 12 hours PRN for agitation. Another anti-anxiety medication noted on the October 2019 MAR was Haloperiodol 0.5 mg one tablet by mouth every four hours PRN for agitation, which was dated from 09/07/19 through 10/29/19. Continued review of Resident #16's October and November 2019 MAR revealed no side effect or behavior monitoring was documented related to the use of anti-anxiety medications. Interview on 11/14/19 at 2:37 P.M. with the DON stated side effect monitoring and behavior monitoring should have been done and documented for Resident #16 who was prescribed and taking anti-anxiety medications. The DON further verified the facility had no duration for the PRN medications that were prescribed beyond the 14 day allowable timeframe with no rationale and no end date. Based on record review and interview, the facility failed to ensure as needed psychotropic medication orders were limited to 14 days or that a rationale and duration of the as needed (PRN) psychotropic medication was indicated in the medical record. This affected four Residents (#6, #16, #18 and #27) of five residents reviewed for unnecessary medications. The facility census was 42. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with the following diagnoses; essential hypertension, major depressive disorder, macular degeneration, psychosis, vascular dementia, and dysphagia. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, eating. Resident #18 also required total dependence with transfers, toileting and personal hygiene. Review of Resident #18's physician orders dated 02/19/19 revealed the resident was prescribed Ativan 0.5 milligrams (mg) PRN by mouth two times per day if vistaril was ineffective. Resident #18's PRN Ativan 0.5 mg was discontinued on 10/26/19. Review of Resident #18's Medication Administration Record (MAR) from 08/01/19 to 08/31/19 revealed Resident #18 received her Ativan 0.5 mg on 08/06/19, 08/07/19, 08/09/19, 08/19/19, 08/20/19, 08/21/19, 08/22/19, 8/25/19 and 08/30/19. Review of Resident #18's MAR from 09/01/19 to 09/30/19 revealed Resident #18 received her Ativan on 09/03/19, 09/04/19, 09/09/19, 09/10/19, 09/15/19, 09/19/19, 09/26/19 and 09/28/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 14 of 20 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 11/14/2019 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 Review of Resident #18's MAR from 10/01/19 to 10/31/19 revealed Resident #18 received her Ativan on 10/02/19, 10/03/19, 10/05/19, 10/06/19 10/17/19, 10/22/19 and 10/23/19. Further review of Resident #18's medical record revealed no documentation of a duration, stop date or rational for Resident #18's PRN Ativan extending beyond 14 days. Residents Affected - Some Interview with the Director of Nursing (DON) on 11/13/19 at 2:41 P.M. verified Resident #18 was prescribed PRN Ativan from 02/19/19 to 10/26/19 with no duration, stop date or rational documented in the chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 15 of 20 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 11/14/2019 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a resident received routine or annual dental services. This affected one (Resident #33) of one resident reviewed for dental services. The facility census was 42. Residents Affected - Few Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. The resident had obvious or likely cavity or broken natural teeth. MDS. Review of Resident #33's dental care plan revealed the resident had carious (decayed) and broken teeth due to poor oral hygiene. Resident #33's care plan indicated the facility would coordinate and arrange for dental care and transportation as needed, provide oral care as needed and to monitor for signs and symptoms of oral problems. Further review of Resident #33's medical record revealed no documentation that Resident #33 was seen by the dentist. Observation of Resident #33 on 11/12/19 at 11:34 A.M. revealed the resident had missing upper and lower teeth with areas of her teeth being black in color Interview with the Director of Nursing (DON) on 11/14/19 at 11:48 A.M. reported Resident #33 had not been seen by the dentist since 04/11/18. The DON stated the facility did not have any documentation of Resident #33's dental visit on 04/11/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 16 of 20 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 11/14/2019 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 3. Review of the planned menu spreadsheet for House 9349 dated 11/12/19 for lunch revealed 4 oz of mandarin oranges, 4 oz breakfast casserole, 4 oz asparagus, toast two slices, 8 oz milk, fruit pizza one slice. Review of the menu that was actually served for lunch on 11/12/19 revealed the residents received 4 oz of pineapple, 4 oz of macaroni and beef, 4 oz of asparagus, sugar cookies and 8 oz of milk. Further review revealed the menu was changed on the hard copy but wasn't posted for the residents to see. Interview with STNA #76 on 11/12/19 at 2:47 P.M. revealed she had someone call off sick and the menu got changed. She stated she didn't want to serve toast with the meal and didn't have any rolls to serve with the meal. She revealed the sugar cookies that replaced the fruit pizza didn't get passed out because she was assisting other residents to eat. 4. Review of the planned menu spreadsheet for House 9335 dated 11/12/19 for dinner revealed 4 oz chilled pears, 8 oz stuffed ravioli with sauce, broccoli 0.5 cup, one slice of garlic bread, 8 oz milk and German chocolate cake. Review of the actual menu served for dinner on 11/12/19 revealed the residents were served mixed vegetables, ravioli, slice of garlic bread, and a glass of lemonade. Observation of the menu posted on the back wall of the kitchen revealed only the German chocolate cake was crossed off and replaced with banana cream pie and wasn't posted for the residents to see the changes. Interview with STNA #11 on 11/12/19 at 5:15 P.M. revealed the menu was changed. STNA #11 said she didn't serve the pears with the dinner. She further stated she didn't serve the milk because the residents didn't want any milk. She verified she didn't ask the residents if they wanted milk with their dinner. Interview with Dietary Technician #300 on 11/13/19 at 10:00 P.M. was aware the menu was changed for House #9349 and House #9335 or 400 rooms. She stated the STNA's call her or someone else to get the menu changed. She verified the residents didn't get everything they should have on their meal trays. She stated the residents were not alerted of the menu changes and it wasn't posted for the residents to see the change. Based on observation, interviews and facilty menu spreadsheet review, the facility failed to follow menus that were prepared in advance or to notify residents when menu items changes. The facility also failed to follow menu spreadsheets for portion sizes. This had to potential to affect 35 Residents (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42. Findings include: 1. Review of House 9336's menu spreadsheet for 11/13/19 revealed residents were to receive 0.5 cup of applesauce, 4 ounces (oz) chicken stir fry, 0.5 cup of fried rice, 4 oz of oriental blended vegetables, three mini egg rolls and a slice of banana bread. Observation on 11/13/19 at 11:27 A.M. revealed State Tested Nurse Aide (STNA) #73 served residents applesauce, chicken stir fry and egg rolls. STNA #73 was observed to give regular and mechanical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 17 of 20 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 11/14/2019 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few soft diets an unknown amount of applesauce, an unknown about of chicken stir fry, an unknown amount of rice and an egg roll. Interview with STNA #73 at the time of the observation verified she served regular and mechanical soft diets an unknown amount of applesauce, an unknown about of chicken stir fry, an unknown amount of rice and an egg roll. STNA #73 reported House 9336 did not have any additional diet types besides regular and mechanical soft. STNA #73 confirmed she does not use scoop sizes as indicated on the menu spreadsheet when serving residents and she just poured or scooped an unknown amount onto the residents bowls and plates. Observation of House 9336 on 11/13/19 at 12:25 P.M. revealed residents were eating cookies for dessert for lunch. Interview with STNA #66 verified banana bread was not served per the menu spreadsheet. 2. Review of House 9350's menu spreadsheet for 11/13/19 revealed residents were to receive 4 oz of layered fruit salad, 4 oz of poppyseed chicken, 4 oz of buttered noodles, 4 oz of Brussels sprouts, one dinner roll, 8 oz of milk and a brownie. Observation of STNA #21 on 11/13/19 at 12:04 P.M. revealed STNA #21 served regular and mechanical soft diets an unknown amount of poppyseed chicken, an unknown amount of buttered noodles, an unknown amount of carrots and Brussels sprouts and one dinner roll. Interview with STNA #21 at the time of the observation verified she served regular and mechanical soft diets an unknown amount of poppyseed chicken, an unknown amount of buttered noodles, an unknown amount of carrots and Brussels sprouts and one dinner roll. STNA #21 verified she did not use scoop sizes as indicated on the menu spreadsheet to serve residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 18 of 20 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 11/14/2019 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 3. Observation of House #9335 on 11/12/19 at 9:40 A.M. revealed there was a gallon of two percent milk dated 11/11/19, a whole apple pie expiration date of 11/09/19, opened package of jumbo hot dogs with a hand written date of 10/23/19, a 16 ounce package of sliced ham opened and dated 11/06/19, and a 16 ounce package of oven roasted turkey breast opened and dated 10/23/19. Interview with STNA #77 on 11/12/19 at 9:50 A.M. revealed the food was dated when it came into the facility, but STNA #77 didn't know how long it was good for and when to throw it away. She verified food that had a expiration date on it should have been thrown away. 4. Observation of House #9349 or 500 on 11/12/19 at 9:55 A.M. revealed there were two 22 ounce strawberry ice cream syrup that had been opened and was not dated when opened, a 15 ounce chocolate ice cream syrup was opened and not dated, a 16 ounce bottle of ranch dressing opened and not dated, head of lettuce that was opened and not dated, bag of romaine lettuce opened and not dated, a 16 ounce package of cheddar cheese opened and not dated, a 10 ounce container of fresh spinach not opened but with an expiration date of 11/09/19, green pepper not dated and opened, 12 halves of hot dogs that had been chargrilled and not dated, powdered donuts expired 11/07/19, assorted Danish with an expiration date of 11/10/19, and assorted cupcakes with an expiration date of 11/09/19. Interview with STNA #14 on 11/12/19 at 11:26 A.M. revealed anything in the kitchen that didn't have a date on it should be thrown out. She said the food in the kitchen should be dated the day it was bought, but didn't know how long it should be kept and when it should be discarded. Further observation of tray line on 11/12/19 at 11:51 A.M. revealed STNA #14 took temperature of asparagus and it was 120 degrees. She proceeded to take the temperature of the macaroni and beef that was taken from the oven and it was 159 degrees. The observation further revealed the pureed macaroni and beef had been sitting on the counter since 11:18 A.M. Interview with STNA #14 on 11/12/19 at 12:00 P.M. revealed the asparagus was supposed to 120 degrees and at a safe temperature to serve was supposed to 100-120. She proceeded to take the pureed macaroni and beef and place a scoop of the hot macaroni and beef and was going to serve it that way and the surveyor intervened and asked if she was going to microwave the item to get to a safe temperature, she said her practice was not to do it this way, but that could be wrong. She proceeded to place in the microwave and the temperature was 140 degrees. She said the safe temperature should be from 130-140 degrees. Review of the food thermometer policy dated 05/2013 revealed the thermometer should be sanitized before and between each food item using an alcohol swab to sanitize the stem as well as the holding clip. Review of policy entitled Food Storage Policy and Procedures dated 05/01/13 revealed prepared food shall be covered and dated with the month and day it was prepared. The label should also indicated the use by date which is 4-7 days after food was prepared. shelf stable items that have been opened need to be dated with month and day. Review of policy for entitled Food Temperatures-Hot and Cold Policy and Procedures dated 05/01/13 revealed holding hot food should be kept at a temperature of 135 degrees. Reheating foods that have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 19 of 20 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 11/14/2019 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 - Some been cooked and then refrigerated shall be heated to a temperature of 165 degrees and remain at that temperature before serving. Based on observation, interviews and facility policy review, the facility failed to ensure food items were maintained, distributed and stored in a manner to prevent and protect food against contamination and spoilage. This had to potential to affect 35 Resident's (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42. Findings include: 1. Observation of house 9336 on 11/12/19 at 9:35 A.M. revealed there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen. Interview with State Tested Nurse Aide (STNA) #81 at the time of the observation verified there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen of house 9336. 2. Observation of house 9350 on 11/12/19 at 9:48 A.M. revealed the following: there was one expired bag of hot dog buns dated 10/24/19, one expired loaf of honey wheat bread dated 11/10/19 and a expired half a loaf of honey wheat bread dated 11/10/19 located in the drawer in the kitchen. Continued observation revealed there was one unlabeled and undated sandwich bag with one frozen donut and one unlabeled and undated sandwich bag with two frozen donuts. Interview with STNA #21 at the time of the observation verified there was one bag of expired hot dog buns dated 10/24/19, one expired loaf of honey wheat bread dated 11/10/19 and a expired half a loaf of honey wheat bread dated 11/10/19 located in the drawer in the kitchen. STNA #21 also confirmed there was one unlabeled and undated sandwich bag with one frozen donut and one unlabeled and undated sandwich bag with two frozen donuts. Observation of STNA #21 on 11/13/19 at 12:04 P.M. revealed STNA #21 was taking the temperature of food items. STNA #21 was observed to take the temperature of the poppyseed chicken casserole and then ran the thermometer probe under water for appropriately 2 seconds before wiping the thermometer probe with a paper towel and then taking the temperature of the buttered noodles. Interview with STNA #21 on 11/13/19 at 12:04 P.M. verified STNA #21 ran the thermometer probe under water and wiped it with a paper towel before taking the temperature of the buttered noodles. STNA #21 also confirmed the facility provided thermometer probe wipes with alcohol but she did not use one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366368 If continuation sheet Page 20 of 20