Inspection·April 11, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/10/23 at 2:40 P.M., of incontinence care for Resident #41 per State Tested Nursing Assistants (STNAs) #105 and #570 revealed resident had a low air loss mattress to her bed which was not inflated and was not functioning. Surveyor questioned aides about the mattress, and they said to ask the nurse. STNAs provided incontinence care and left the resident's room with the mattress not functioning. Interview on 04/10/23 at 2:40 P.M., of STNAs #105 and #570 confirmed Resident #41's low air loss mattress was not functioning, and they were unsure how long the mattress had been this way. Interview on 04/10/23 at 2:50 P.M., of Registered Nurse (RN) #540 confirmed Resident #41 had a physician's order for a low air loss mattress due to resident's risk for skin breakdown. RN #540 confirmed Resident #41's low air loss mattress was not functioning properly due to mattress was not plugged in. RN #540 plugged in the mattress, and it began to work. RN #540 confirmed she was unsure how long the mattress had been not working and also confirmed Resident #41 would not be able to unplug the mattress per self. Resident #41 did not respond to interview questions regarding the mattress. Interview on 04/11/23 at 11:06 A.M. with the Director of Nursing (DON) confirmed Resident #41 had a physician's order for a low air loss mattress, and resident was at risk for the development of skin breakdown. DON further confirmed Resident #41's record did not include documentation of staff checking the mattress for proper functioning each shift. Review of the policy titled Skin Care Management, dated 11/17/22, revealed the facility would identify individuals at risk for development of pressure ulcers and initiate management programs which would stabilize or minimize underlying risk factors or changes in condition. The facility would implement appropriate strategies to maintain intact skin. This deficiency represents non-compliance investigated under Complaint Number OH00141879. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 2 of 6 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 366393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, staff interviews, and review of policy, the facility failed to ensure safe transfer technique was utilized to prevent falls and/or fall-related injuries. This affected one (#18) of three residents reviewed for falls. The facility census was 55. Findings include: Review of the medical record for Resident #18 revealed an admission date of 02/12/23, with diagnoses including cellulitis, atrial fibrillation, and dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 02/19/23, revealed resident was cognitively impaired and required extensive assistance of two staff with transfers. Review of the fall risk assessment for Resident #18 dated 02/12/23 revealed resident was at risk for falls. Review of the care plan for Resident #18 dated 02/24/23 revealed resident was at risk for falls related to antihypertension medications, confusion, deconditioning, gait/balance problems, incontinence, medication side effects, psychoactive drug use, unaware of safety needs, and hearing problems. Interventions included the following: ensure resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair, anticipate and meet resident needs, be sure call light/pendant is within reach and encourage resident to use it for assistance as needed, provide a safe environment with even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach, provide activities that minimize the potential for falls while providing distraction, review information on past falls and attempt to determine cause of falls, record possible root causes, alter /remove any potential causes if possible, educate resident and caregivers as to causes of falls. Review of the care plan for Resident #18 dated 02/24/23 revealed resident had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, dementia, fatigue, impaired balance, musculoskeletal impairment, and weakness. Interventions included resident was weight bearing and required staff assistance to move between surfaces. Review of the nurse progress note for Resident #18 dated 04/07/23 timed at 1:55 A.M. revealed resident was sitting in the recliner in common area. A State Tested Nurse Aide (STNA) assisted the resident to stand, and the resident lost her balance. STNA grabbed the resident's right arm to steady her, but the resident continued to fall hitting her left side on the table next to the chair. Two nurses witnessed the fall and after assessing the resident, they assisted the resident into her wheelchair. Review of the nurse progress note for Resident #18 dated 04/07/23 timed at 7:44 P.M. revealed the resident was noted to have bruising to her buttocks and left side following the fall. Resident #18 was medicated with as needed Tylenol for pain with good effect. Interview on 04/11/23 at 11:06 A.M., with the Administrator and the Director of Nursing (DON) confirmed Resident #18 had a witnessed fall with minor injury on 04/07/23 on the night shift. Interview confirmed investigation showed State Tested Nursing Assistant (STNA) #415 was transferring Resident #18 from a chair in the common area into her wheelchair and resident lost her balance and fell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 3 of 6 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 366393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hitting her left side on the table adjacent to the chair. Interview confirmed the facility determined the root cause of the fall to be the resident losing balance during transfer. Interview confirmed the facility had not obtained a statement from the STNA and had no evidence aide used a gait belt during the transfer. Interview confirmed staff should use a gait belt when transferring Resident #18. Interview confirmed the facility interdisciplinary team (IDT) reviewed Resident #18's care plan following the fall but did not determine any updates were required to the resident's care plan. Interview further confirmed the facility had not provided any education to the staff regarding gait belt use following Resident #18's fall. Interview on 04/11/23 at 2:40 P.M., with STNA #415 confirmed she assisted Resident #18 with a transfer from chair to wheelchair on 04/07/23 and did not use a gait belt. STNA #415 further confirmed during the transfer resident became weak and had to be lowered to the floor. STNA #415 confirmed she held onto resident's right arm as she went down, and resident hit her left side on the table adjacent to the chair. Review of the policy titled Use of Gait Belt, dated January 2014, revealed it was in the interest of elder and partner safety to utilize a gait belt during elder transfer and ambulation. The gait belt is used to assist the elder in achieving maximum function and to provide assistance during transfer and ambulation. The gait belt can help prevent falls and injuries in elders. The gait belt is an essential tool for an Elder Assistant and nurse. Every Elder Assistant is required to have his/her own gait belt provided by the neighborhood during initial orientation. During orientation, therapy staff will demonstrate proper use of the gait belt to all new partners. The gait belt will be used by the Elder Assistant and/or nurse during every transfer or during ambulation of an elder that requires assistance. This deficiency represents non-compliance investigated under Complaint Numbers OH00141879 and OH00141437. This deficiency represents ongoing noncompliance from the survey dated 03/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 4 of 6 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 366393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview, and review of the facility policy the facility failed to implement appropriate monitoring of blood pressures in conjunction with administration of antihypertensive medications. This affected one (#9) of three residents reviewed for medications. The facility census was 55. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 04/01/22, with diagnoses including Wernicke's encephalopathy, affective mood disorder, and hypertension (HTN). Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 02/11/23 revealed resident was cognitively impaired and required supervision with activities of daily living (ADLs.) Review of April 2023 monthly physician orders for Resident #9 revealed an order dated 03/14/23 for resident to receive lisinopril 20 milligrams (mg) one tablet once daily in the morning at 9:00 A.M. The order did not include parameters for withholding the medication. Review of the nurse progress note for Resident #9 dated 03/17/23 revealed the physician gave an order for nurses to check resident's blood pressure prior to administration of lisinopril and to withhold the dose if systolic blood pressure was less than 110. Review of the March 2023 and the April 2023 Medication Administration Record (MAR) for Resident #9 revealed the resident's blood pressure was not recorded in the MAR and the order was not changed in the MAR to reflect the parameters for withholding the medication. Review of the facility vital sign record part of the electronic medical record (EMR) for Resident #9 revealed resident's blood pressure on 03/22/23 was 108/67, and on 03/29/23 it was 106/59. Review of the March 2023 MAR for Resident #9 revealed lisinopril was signed off administered on 03/22/23 and 03/28/23 even though resident's systolic blood pressure was under 110, the parameter ordered by the physician on 03/17/23. Review of the facility vital sign record in the EMR for Resident #9 revealed blood pressures were not obtained prior to administration on the following dates: 03/20/23, 03/23/23, 03/29/23, and 04/06/23. Review of the March 2023 MAR for Resident #9 revealed lisinopril was signed off as given on 03/20/23, 03/23/23, 03/29/23, and 04/06/23. Observation of medication administration for Resident #9 on 04/10/23 at 8:31 A.M. per Licensed Practical Nurse (LPN) #530 revealed nurse did not check resident's blood pressure prior to administration of lisinopril. Interview on 04/10/23 at 8:31 A.M., with LPN #530 confirmed the aides were supposed to check all resident's vital signs in the morning and place them on a clipboard for nurses to review. LPN #530 confirmed the nurses would transfer the vital signs to the EMR later in the day. LPN #530 confirmed Resident #9 had no parameters for withholding the lisinopril and she did not check the vital sign clipboard prior to medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 5 of 6 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 366393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/11/23 at 11:06 A.M., with the Director of Nursing (DON) confirmed the physician gave an order on 03/17/23 for nurses to check Resident #9's blood pressure prior to administration and gave parameters to withhold the medication if the systolic blood pressure was lower than 110. DON confirmed the order was not properly carried out and the MAR was not updated with the new parameter. DON confirmed Resident #9's systolic blood pressure was under 110 on 03/22/23 and 03/28/23 but the lisinopril was signed off as administered on these dates. DON confirmed the facility did not have a blood pressure recorded for Resident #9 on 03/20/23, 03/23/23, 03/29/23, and 04/06/23, but the lisinopril was signed off as given on these dates. Review of the policy titled Medication Administration dated 11/09/21 revealed licensed nursing staff would prepare, administer and record medication administration per physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00141437. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 6 of 6