Health inspection·August 15, 2022

F 0679 Level of Harm - Minimal harm or potential for actual harm Interview with the Activities Director (AD) #147 on 08/09/22 at 10:45 A.M. revealed she had been employed at the facility for a few days. The Activity Director was leading bingo in House #106. Interview with Resident #9 on 08/09/22 at 10:58 A.M. revealed she was not asked to go to bingo in House #106. Residents Affected - Few Interview with State Tested Nursing Aide (STNA) #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. 2. Medical record review for Resident #14 revealed an admission date of 09/24/20. Medical diagnoses included aftercare for orthopedic, coronary artery disease, and cerebrovascular disease. Review of Resident #14's progress notes from 05/11/22 through 08/11/22 revealed there was no documentation regarding activities or refusals. Review of Resident #14's care plan, dated 06/21/22, revealed she had preferences for activities which were: arts and crafts, listening to performers, listening to easy listening music on the radio, watching animal plant on my television, attending bible study when she feels up to it, holding the house bunny, movie night, bingo, listening to performers and would like to go out of the facility for a outing activity. Review of the Annual MDS assessment, dated 06/23/22, revealed Resident #14 was moderately cognitively impaired. Further review of the MDS revealed it was very important fpr Resident #14 to have books, newspapers, and magazines, be around animals, and keep up with the news. It was somewhat important to listen to music, to do her favorite activities, go outside, and to participate in religious activities. It was not very important to do things with groups of people. Review of the spiritual activity documentation revealed from 05/03/22 through 08/12/22 there were seven visits to see Resident #14. Review of the tasks for activities from 07/12/22 through 08/12/22 revealed there was nothing documented. Review of the activity calendar dated 08/08/22 through 08/11/22 revealed on 08/08/22 there was a lunch in House #102, manicures in all of the houses, and chaplain service in House #101 at 1:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 2 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/09/22, there was bingo in House #106, and the beauty shop was open for all houses. On 08/10/22, there was morning donuts in House #109 and smores in all of the houses after lunch. On 08/11/22, there was a button tree craft in House #106. Observation in House #101 on 08/08/22 at 10:00 A.M., 12:00 P.M. and 2:00 P.M. revealed there wasn't any manicures being provided or a Chaplain service in House #101. Observation in House #101 on 08/09/22 at 11:00 A.M. revealed there was no bingo activity occuring in the House #101. Interview with Resident #14 on 08/08/22 at 2:13 P.M. revealed she did not know about any activities in the facility and denied anyone would come into visit with her one on one. Interview with STNA #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. 3. Medical record review for Resident #11 revealed an admission date of 06/02/21. Medical diagnoses included metabolic encephalopathy, cervical disc disorder, and pseudobulbar. Review of spiritual activity documentation revealed from 05/03/22 through 08/12/22 there were three visits to see the Resident #11. Review of Resident #11's annual MDS assessment, dated 05/25/22, revealed Resident #11 was moderately cognitively impaired. Further review of the MDS revealed it was very important for Resident #11 to be around animals, keep up with the news, do things with groups of people, do her favorite activities, and participate in religious services. It was somewhat important for Resident #11 to have books, newspaper, and magazines, listen to music, and to go outside. Review of Resident #11's care plan, dated 05/25/22, revealed the resident enjoyed many activities and programs, but needed continuous encouragement, reminders and motivation. She preferred ice cream social, music and memories, and television. Review of Resident #11's tasks for activities from 07/12/22 through 08/12/22 revealed there was nothing documented. Review of the activity calendar dated 08/08/22 through 08/11/22 revealed on 08/08/22 there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 3 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lunch in House #102, manicures in all of the houses, and chaplain service in House #101 at 1:00 P.M. On 08/09/22, there was bingo in House #106, and the beauty shop was open for all houses. On 08/10/22, there was morning donuts in House #109 and smores in all of the houses after lunch. On 08/11/22, there was a button tree craft in House #106. Observation in House #101 on 08/08/22 at 10:00 A.M., 12:00 P.M. and 2:00 P.M. revealed there wasn't any manicures being provided or a Chaplain service in House #101. Observation in House #101 on 08/09/22 at 11:00 A.M. revealed there was no bingo activity occuring in the House #101. Interview with Resident #11 on 08/09/22 at 9:55 A.M. revealed she had not participated in any activities recently and no one comes into see her anymore. Interview with STNA #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. Review of policy titled Engagement and Activity, dated 02/06/09, revealed it was the goal of the facility to create a home where persons living in the home have a choice and excellent quality of life and care coupled with providing an environment rich in meaningful engagement experiences. Given this standard, we (the facility) hold accountable to proper documentation of the engagement experience by following Documentation of Engagement and Activity process. Furthermore, it is everyone's responsibility to engage the resident in all facets of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 4 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff and resident interview, the facility failed to ensure residents received new eyeglasses in a timely manner. This affected one (Resident #14) out of one resident reviewed for vision. The census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/24/20. Medical diagnoses included aftercare for orthopedic, coronary artery disease, and cerebrovascular disease. Review of an eye examination conducted on 02/07/22 revealed Resident #14 requested new eyeglasses and they were ordered. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. Interview with Resident #14 on 08/08/22 at 2:17 P.M. revealed her eyeglasses were broken and it had been quite sometime since she ordered new eyeglasses however she had not received the new eyeglasses yet. Interview with the Administrator on 08/11/22 at 10:40 A.M. revealed the eyeglasses were ordered for Resident #14, but the facility had not received them yet and they should have arrived already. She denied knowing whether or not a staff member had followed up with the eye company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 5 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, staff interview, and policy review, the facility failed to ensure hazardous chemicals were not accessible to residents. This had the potential to affect six (#7, #9, #19, #34, #45, and #210) cognitively impaired and independently mobile residents who reside in House #101 and House #102 out of the 24 total residents who reside in House #101 and House #102. The facility census was 56. Findings include: 1. Observation of an unlocked cabinet under the sink in the kitchen in House #101 on 08/08/22 at 11:30 A.M. revealed there was a container of sanitizing wipes, oven cleaner, floor cleaner, two liters of disinfectant, hydrogen peroxide base cleaner, multi-purpose cleaner, disinfectant deodorizer, potential of hydrogen (PH) acid, bathroom cleaner, and a gallon of mineral blend. Interview with State Tested Nursing Aide (STNA) #141 on 08/08/22 at 11:35 A.M. confirmed the chemicals in the unlocked cabinet under the sink in House #101 should have been locked up. STNA #141 confirmed lock on the cabinet under the sink was brokedn and was unable to be locked. 2. Observation on 08/08/22 at 2:45 P.M. revealed the second sink in the kitchen in House #102 had chemicals under the sink which included a cleaner, bleach wipes, and a lemon cleaner. Interview on 08/08/22 at 2:45 P.M. with Certified Nurse Aide (CNA) #113 stated there were chemicals under the sink in House #102, and it was not locked. CNA #113 stated there were ambulatory confused residents in House #102. Observation on 08/08/22 at 2:54 P.M. revealed the door to the kitchen by the counter in House #102 was open on the left and right side, and no staff were observed for five minutes. Review of the policy titled Storage and Use of Poisonous Substances Policy and Procedure (cleaning supplies, pesticides etc.), dated 06/01/08, revealed the purpose of the policy was to provide a place where toxic materials such as cleaning supplies, pesticides etc. may be stored without the risk of contaminating food or anything that may come in contact with food. The three categories of poisonous substances are: pesticides, detergents, sanitizers, corrosives and other chemicals and flammables. Each of these categories is to be stored separately from the others They may not be stored above or next to food, food equipment, utensils linens or disposables (single-service and single-use articles). However detergents and sanitizers are permitted to be stored in the locked cabinet under the sink next to the dishwasher. Other items are to stored in locked cabinets in the dirty utility room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 6 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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. Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a resident was provided incontinence care in a timely manner. This affected one (Resident #206) out of one resident reviewed for incontinence care. The facility identified 43 residents who were incontinent of bladder. The census was 56. Findings include: Review of the medical record for Resident #206 revealed an admission date of 08/03/22. Diagnoses included sepsis, cirrhosis of liver, and type two diabetes. Review of Resident #206's plan of care, dated 08/09/22, revealed Resident #206 was at risk for moisture associated skin damage to groin/buttocks, diabetic ulcer to left heel, pressure area to left lower back. Interventions include administer treatment as ordered apply moisture barrier to my perineal area and buttocks after incontinence episodes, apply moisture lotion to extremities, float heels while in bed or recliner, low air mattress for bed, monitor effectiveness, monitor for complaints of pain and provide interventions as needed, and turn and reposition for infection at site as evidenced by redness and edema. Observation of wound care for Resident #206 on 08/11/22 at 11:45 A.M. revealed Resident #206 had a depend on that was saturated with urine. Interview with Resident #206 at the time of the observation revealed he was trying to get staff to change him. Resident #206's bed was saturated with urine and there was a puddle when Resident #206 had to be rolled for his back treatment. Resident #206's hospital gown was saturated with urine. Interview on 08/11/22 at 12:00 P.M. with Respiratory Therapist (RT) #444 revealed no one had come yet to change Resident #206 due to the incontinent episode. RT #444 stated Resident #206 was saturated with urine and needed changed. Interview on 08/11/22 at 12:04 P.M. with Certified Nurse Aide (CNA) #181 revealed she had started working on 08/11/22 at 9:30 A.M. and had not changed Resident #206. CNA #181 stated the other aid (CNA #189) left for the day but had changed Resident #206 earlier. Observation on 08/11/22 at 12:04 P.M. of Resident #206 revealed his depends were saturated with urine and it was leaking onto his air mattress. The bed had a circumference of roughly three feet of urine under Resident #206, with several puddles of urine on his backside. Review of the Urinary Incontinence, Indwelling Catheters, and Urinary Tract Infections Policy, revised 07/20/11, revealed each resident who was incontinent of urine was identified, assessed, and provided with appropriate treatment and services to achieve and maintain as much normal urinary function as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 7 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, staff interview, and resident interview, the facility failed to ensure residents received oxygen according to physician orders. This affected one (Resident #35) out of two residents reviewed for oxygen. The facility identified six residents who utilized oxygen per nasal cannula. The facility census was 56. Residents Affected - Few Finding include: Review of the medical record for Resident #35 revealed an admission date of 10/10/20. Diagnoses included hemiplegia and hemiparesis affecting left side, cardiac arrhythmia, and shortness of breath. Review of Resident #35's Minimum Data Set assessment dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required extensive two-person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the physician order dated 03/27/22 for Resident #35 revealed an order to change oxygen tubing weekly on Sunday nights. Review of the physician order dated 05/10/21 for Resident #35 revealed an order for humidified oxygen at one to two liters per minute as needed to maintain oxygen saturation above 90%. Observation on 08/09/22 at 9:31 A.M. revealed Resident #35 had oxygen on at three liters per minute, and the sterile humidifier water for Resident #35's concentrator was empty. Resident #35's oxygen tubing was dated 08/01/22. Interview on 08/09/22 at 9:32 A.M. with Resident #35 revealed there was something wrong with his oxygen last night and it was irritating his nose. Interview on 08/09/22 at 9:28 A.M. with Certified Nurse Aide (CNA) #188 revealed the sterile humidifier water was empty on Resident #35's oxygen concentrator. Interview on 08/09/22 at 9:35 A.M. with Registered Nurse (RN) #154 verified Resident #35's oxygen concentrator was set at three liters per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 8 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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, staff and resident interview, and policy review, the facility failed to ensure a urinalysis was completed in a timely manner. This affected one (Resident #33) out of one resident reviewed for urinary tract infections (UTI). The census was 56. Residents Affected - Few Findings include: Medical record review for Resident #33 revealed an admission date of 02/24/22. Medical diagnoses included congested heart failure, coronary artery disease, chronic lung disease, and morbid obesity. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Her functional status was limited assistance for bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and bowel. Review of Resident #33's progress note dated 07/31/22 revealed Resident #33 complained of dysuria and had some mental status changes. The physician was notified and an order was received for a urinalysis. Review of Resident #33's progress notes dated 08/01/22 through 08/06/22 revealed no concerns for UTI symptoms for the resident. Review of Resident #33's progress note dated 08/04/22 revealed the urinalysis lab was rescheduled. Review of the laboratory results for Resident #33 revealed the urine was collected on 08/04/22 and the results were dated 08/07/22 and Resident #33 was positive for a UTI. Interview with Resident #33 on 08/08/22 at 2:39 P.M. revealed a staff member came and got the urine specimen, but because it sat in the refrigerator, someone had to get another specimen from her. She said it was sometime last week. She said the facility told her she had a UTI. Interview with the Director of Nursing (DON) on 08/10/22 at 2:28 P.M. confirmed Resident #33's urine sat in the refrigerator and another urine had to be retrieved which delayed the completion of the urinanalysis. Review of the policy titled Urinary Tract Infections, Urinary Incontinence, dated 07/01/07, revealed it was the policy of the facility to provide care and services to prevent urinary tract infections in the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 9 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 medical record review, observation, staff interview, resident representative interview, and policy review, the facility failed to ensure dental services were provided in a timely manner. This affected one (Resident #18) out of one resident reviewed for dental services. The census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 03/08/10. Diagnoses included history of traumatic brain injury, epilepsy, dementia, and personal history of malignant neoplasm (throat cancer). Review of Resident #18's Minimum Data Set assessment dated [DATE] revealed Resident #18 was severely cognitively impaired. Resident #18 required extensive one-person physical assist for personal hygiene. Review of the plan of care dated 06/21/22 revealed Resident #18 was at risk for having actual dental health problems such as carious teeth. Interventions included administer medication as ordered, coordinate arrangements for dental care, transportation as needed, lip balm, monitor and document oral or dental problems needing attention, follow diet as ordered, and provide mouth care as ordered for personal hygiene. Review of the dental note dated 01/24/22 revealed Resident #18 was seen by dentist who stated they needed to determine more information from the oncologist prior to proceeding. Resident #18 needed a referral to an oral surgeon. Resident #18 had silver diamine fluoride treatment applied to his teeth. The treatment was applied in hopes to arrest decay and prevent future decay from appearing. Interview on 08/09/22 at 1:50 P.M. with Resident #18's sister and Power of Attorney, revealed Resident #18's teeth were black and rotting, and the facility had not addressed the concern. The interview further revealed Resident #18 had no pain, and had already been on a pureed diet with thickened liquids. Observation on 08/09/22 at 1:50 P.M. of Resident #18 revealed Resident #18's mouth had missing teeth on both the bottom and the top. Resident #18 had four teeth visible on the top of the mouth which were entirely black and dull. The teeth exposed on his lower gums were a mixture of silver and black. Interview on 08/09/22 at 2:08 P.M. with Social Worker (SW) #164 revealed that the dentist does see the resident for his teeth and last saw Resident #18 on 01/24/22, and silver fluoride was applied to all his teeth on 01/24/22. Resident #18's sister consented to the treatment. On 01/24/22, the dentist recommended teeth extraction for Resident #18. SW #164 stated the facility needed a referral for the teeth extraction however at the time of the interview, there was no referral and it had been roughly six months. SW #164 stated Resident #18 had no referral and no extraction for his black teeth at that time. Interview on 08/09/22 at 2:08 P.M. with SW #164 revealed it was her job to schedule the referral for the Oncologist to see Resident #18 and then forward the referral to a dentist who could extract Resident #18's teeth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 10 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 Review of the Oral Assessment Policy and Procedure, revised on 02/20/21, revealed the facility staff will be responsible to make arrangements for dental services as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 11 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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. Based on observation, staff interview, and policy review, the facility failed to ensure food items had an open date and were were not expired. This had the potential to affect all 24 residents (#6, #8, #9, #11, #14, #16, #27, #28, #31, #33, #34, #38, #41, #44, #45, #49, #51, #54, #105, #205, #206, #207, #208, and #210) who resided in House #101 and House #102. The facility census was 56. Findings include: 1. Observation of the kitchen in the 101 house on 08/08/22 at 11:07 A.M. revealed there was cereal which was opened and was not dated, dark rye bread which was opened and had an expiration date of 08/04/22, hot dog buns which were opened and had an expiration date of 08/06/22, hamburger buns with an expiration date of 08/05/22, hoagie buns which were unopened and had an expiration date of 08/06/22, sweet and sour sauce dated 11/17/21, powdered sugar which was opened and was not dated, pecans which were opened and were not dated, heath bits which were opened and were not dated. In the refrigerator there were individual wrapped swiss and American cheese which was opened and was not dated, shredded sharp cheddar cheese which was opened and was not dated, swiss cheese slices which were opened and were not dated, cherries which were opened and were not dated, waffle cones which were opened and had an expiration date of 02/19/22, biscotti's which were opened and were not dated, crackers which were opened and were not dated, two bags of lettuce with use by dates of 08/08/22, 48 ounces of brewed coffee which was opened and was not dated, 52 ounces of strawberry banana cream which was opened and was not dated, 32 ounces of french vanilla coffee creamer which was opened and was not dated, 32 ounces of vanilla creamer which was opened and was not dated, 32 ounces of caramel vanilla creamer which was opened and was not dated, and 24 ounces of syrup which was opened and was not dated. Interview with the Diet Tech (DT) #143 on 08/08/22 at 11:11 A.M. verified all of the above items were supposed to be dated with an open date and the items that were expired should have been thrown away. Review of policy titled Food Labeling and Dating, dated 06/01/08, revealed the policy was to ensure all foods were easily identified so as to avoid confusion/errors during food preparation and to ensure stock was rotated properly. The policy revealed once a food item is opened it should be dated the month, day and year it was opened. 2. Observation on 08/08/22 at 2:42 P.M. with Certified Nurse Aide (CNA) #113 revealed the pantry refrigerator in house #102 had a bag of food from a fast food restaurant which was not labeled, an old round white foam container which had dried up baked beans which was not labeled, and an opened potato salad in a large container which was not dated or labeled. Interview on 08/08/22 at 2:43 P.M. with CNA #113 revealed the potato salad was just opened yesterday (08/07/22). CNA #113 stated that the bag of food from a fast food restaurant was from a resident who was discharged . Observation on 08/08/22 at 2:45 P.M. with CNA #113 revealed the house #102 refrigerator, which was located in the kitchen, had a large thick and chunky salsa which had open date of 05/04/22, a large jar of medium salsa which had an open date of 04/27/22, and a pitcher of tea which was not labeled or dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 12 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/08/22 at 2:46 P.M. with CNA #113 revealed she thought the tea in the pitcher in the refrigerator was made last Thursday (08/04/22). Interview on 08/12/22 at 1:30 P.M. with Dietitian #333 revealed the salsa should probably be thrown out seven days after opening. Dietitian #333 stated the facility did not have a chart that was followed in order to determine the number of days food was permitted to be used prior to being thrown out. Event ID: Facility ID: 366376 If continuation sheet Page 13 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the staff wore appropriate personal protective equipment when in resident rooms under quarantine precautions. This affected two (#44 and #205) residents and had the potential to affect all 12 residents (#27, #28, #31, #44, #49, #51, #54, #205, #206, #207, #208, and #210) who reside in House #102. The census was 56. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #44 had an admission date of 08/04/22. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, and aspergillosis. Review of Resident #44's plan of care, dated 07/19/22, revealed Resident #44 was at risk for possible Covid-19 and was on droplet and contact isolation as a precaution to prevent the spread of the virus to others in the event of a positive Covid-19 test result. Interventions included partners to wear personal protective equipment during care and follow isolation procedures, wear a mask during care, have all activities, meals, medication, and therapy in his room. Review of the medical record for Resident #44 revealed Resident #44 had not received a Covid-19 vaccination. 2. Review of the medical record for Resident #205 revealed an admission date of 08/11/22. Diagnoses included acute posthemorrhagic anemia, gastrointestinal hemorrhage, and cirrhosis of the liver. Review of Resident #205's plan of care, dated 08/02/22, revealed Resident #205 was at risk for being in quarantine for possible Covid-19. Resident #205 was in droplet and contact isolation as a precaution to prevent the spread of the virus to others in the event of a positive Covid-19 test result. Interventions included partners to wear personal protective equipment during care and follow isolation procedures. Resident #205 will have all activities, meals, medications, and therapy in their room. Resident #205 will have oxygen saturations monitored at least daily. Review of the medical record for Resident #205 revealed she received the first dose of a Covid-19 vaccine on 02/12/21 and the second dose on 03/22/21. Resident #205 had not recieved a Covid-19 booster. Observation on 08/08/22 at 10:08 A.M. revealed Certified Nurse Aide (CNA) #113 was leaving Resident #44's room and only had a surgical mask, face shield, and blue isolation gown on when in Resident #44's room. CNA #113 then left Resident #44's room and went to the main great room to use hand sanitizer. CNA #113 then went to Resident #205's room and only wore a surgical mask, face shield, and blue isolation gown when in Resident #205's room. Interview with CNA #169 on 08/08/22 at 10:23 A.M. revealed staff was supposed to wear a face shield, or goggles. CNA #169 stated she had eyeglasses on instead of her face shield. CNA #169 stated her shift started at 7:00 A.M. and she had not worn goggles or a face shield all shift to any of the rooms in Hosue #102, even the resident rooms who were on quarantine. Observation on 08/08/22 at 10:24 A.M. of CNA #169 revealed she only had on her personal eyeglasses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 14 of 15 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 and was not wearing goggles or a face shield. Level of Harm - Minimal harm or potential for actual harm Interview on 08/08/22 at 10:57 A.M. with STNA #132 revealed if staff enter a Covid-19 positive or Covid-19 quarantine room, they should wear an N95 respirator, isolation gown, face shield, and surgical gloves. Residents Affected - Some Interview on 08/08/22 at 11:59 A.M. with the Director of Nursing (DON) revealed the PPE boxes at the room doors should have hand sanitizer to utilize after doffing PPE upon leaving Resident #44 and Resident #205's rooms, who were under quarantine. The DON stated staff was to wear N95 respirator, isolation gown, surgical gloves, a hair net, and face shield when in Covid-19 positive or quarantine rooms. The DON stated no staff should be walking to the main great room to utilize hand sanitizer after leaving a resident room who was under quarantine. The DON stated the hand sanitizer should be in the PPE box outside the room. Review of the Covid-19 Policy and Procedures, revised 02/07/22, revealed new residents or those that have been readmitted and are not up to date with vaccines, are required to quarantine in their room with transmission-based precautions on the appropriate unit for 10 days or seven days with a negative test within 48 hours or longer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 15 of 15