Health inspection·February 6, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #11 hit the shins on Hoyer bar during transfers. Resident #11 stated she was not able to feel when this happens because of her paraplegia. Resident #11 stated that it happens when the STNAs were not making sure her legs were pulled back enough during transfers. Resident #11 denies she was in any increased pain. The STNAs were educated on making sure the resident's legs were monitored and protected when the resident was being transferred by Hoyer lift. There was no documentation in the medical record Resident #11's physician was notified of Resident #11's right lower leg bruising until 01/23/24. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician for Resident #11's right lower extremity (RLE) was showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern possible injury. The nurse received a new order for an RLE x-ray. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Review of LPN #139's statement, dated 01/30/24, stated she was on duty on night shift of 01/19/24. LPN #139 stated she found Resident #11's right lower extremity to be bruised. LPN #139 asked questions to Resident #11 and investigated why this bruise was on her right leg. LPN #139 stated she notified ADON #166 regarding Resident #11's bruise and of concerns that was possible due to injury from Hoyer lift transfers. LPN #139 stated she returned to work on 01/23/24 and then called the on-call physician about Resident #11's bruise and obtained an x-ray order. On 01/23/24, LPN #139 stated that she received a call back from physician giving directions to place an order for an x-ray to be performed. LPN #139 stated she wrote a progress note in Resident #11 medical record. Interview on 02/06/24 at 1:07 P.M. with the Administrator and LPN #139 revealed the Administrator asked LPN #139 if she notified the physician on 01/20/24, instead of on 01/23/24. LPN #139 verified she did not originally call the on-call physician about Resident #11's bruise on 01/20/24. LPN #139 verified she did when she came back to work on 01/23/24. LPN #139 stated she might have said that, but it was not the truth. She was exhausted the day she was interviewed by the Administrator. Another interview on 02/06/24 at 3:34 P.M. with the Administrator and LPN #139 revealed the Administrator asked LPN #139 again if she notified the physician on 01/20/24 when the bruise was found. who was asked again if she had notified the on-call physician on 01/20/24 the day the bruise was found. LPN #139 verified she called the physician on 01/23/24 when she came back to work and did not notify the physician on 01/20/24 when the bruise was found. Review of the facility's policy titled Notification of Change of Condition dated 11/22/21 revealed the facility will immediately inform the resident; consult with the resident's physician, nurse practitioner or clinical nurse specialist when there is an accident involving the resident, which results in injury and has the potential for requiring physician intervention and a significant change in the resident's physical, mental, or psychosocial status This deficiency represents non-compliance investigated under Complaint Number OH00150641. 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 02/06/2024 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and observation, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer). This resulted in Actual Harm when Resident #11 who was a paraplegic (paralysis of the legs), was transferred using the mechanical lift and the resident 's legs were not secured, subsequently hitting her right leg on the Hoyer bar sustaining a right lower leg fracture. This affected one (Resident #11) of three residents reviewed for accidents. The facility census was 50. Findings include: Review of the medical record for Resident #11 revealed an admission date of 06/13/22. Diagnoses included paraplegia, type two diabetes mellitus, and idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was dependent on staff for bed mobility, toileting, dressing lower and upper body, transferring, and bathing. Review of the Activities of Daily Living (ADL) plan of care dated 06/20/22 revealed Resident #11 had an ADL self-care deficit. Interventions included Resident #11 was dependent on staff for transfers between surfaces and required a mechanical lift with two or more staff assistance with transfers. Review of the plan of care dated 06/23/22 revealed Resident #11 had paraplegia and bilateral lower extremities foot drop. Interventions included to protect the resident's feet per the ADL plan of care. Review of the weekly skin observation dated 01/16/24 revealed Resident #11's skin issues were on the right foot plantar and toe, and coccyx. No new skin issues found. Review of the facility's document titled Bath and Shower Sheet, dated 01/19/24 at 7:15 P.M., revealed Resident #11's right lower leg had a bruised large area. State Tested Nurse Aide (STNA) #383 and Licensed Practical Nurse (LPN) #139 signed the document. Review of the weekly skin observation dated 01/20/24 at 12:50 A.M. by LPN #139 documented there was a right lower leg bruise on Resident #11. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by LPN #139 noted the nurse was coming into Resident #11's room to complete treatment. The nurse pulled down covers to begin treatment and discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. Resident #11 has paralysis in both legs. The nurse asked Resident #11 if she recalled any instances where she would have hit or bumped her legs. Resident #11 stated, I cannot recall any time that may have happened. Nurse notified on-call Assisted Director of Nursing (ADON) #166. Review of the interdisciplinary team progress note dated 01/22/24 documented by the Director of Nursing (DON) noted Resident #11 was assessed and STNAs were interviewed for investigation. STNAs stated Resident #11 hit the shins on Hoyer bar during transfers. Resident #11 stated she was not able to (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 02/06/2024 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 - Actual harm feel when this happens because of her paraplegia. Resident #11 stated that it happens when the STNAs were not making sure her legs were pulled back enough during transfers. Resident #11 denies she was in any increased pain. The STNAs were educated on making sure the resident's legs were monitored and protected when the resident was being transferred by Hoyer lift. Residents Affected - Few On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician due to Resident #11's right lower extremity (RLE) showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern, possible injury. The nurse received a new order for an RLE x-ray. On 01/24/24 at 1:10 A.M., Resident #11 was sent to the emergency room for trouble related to swallowing and bounding pulse (a pulse that feels as though your heart is pounding or racing). Resident #11 returned to the facility on [DATE] at 6:09 A.M. with a new order for Nexium (can treat gastroesophageal reflux disease). On 01/25/24 at 7:50 P.M., the nurse followed up with the x-ray company to find out when they were coming to obtain x-rays of Resident #11's RLE. The x-ray was scheduled for 01/26/24. Subsequently, on 01/26/24 at 7:45 P.M. Resident #11 was sent to the hospital. The nurse asked Resident #11 if she wanted to go to the hospital to address her RLE issue. Resident #11 was found to have saliva and food drooling from her mouth. Resident #11 said she was in pain but could not explain where and she was groaning. Resident #11 returned to the facility on [DATE]. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Review of the self-reported incident dated 01/27/24 revealed the facility had filed a report about Resident #11's bruise and fracture. Review of LPN #139's statement, dated 01/30/24, indicated she was on duty on night shift of 01/19/24. LPN #139 stated she found Resident #11's right lower extremity to be bruised. LPN #139 asked questions to Resident #11 and investigated why this bruise was on her right leg. LPN #139 stated she notified ADON #166 regarding Resident #11's bruise and of concerns that it was possibly due to injury from Hoyer lift transfers. LPN #139 stated she returned to work on 01/23/24 and then called the on-call physician about Resident #11's bruise and obtained an x-ray order. On 01/23/24, LPN #139 stated that she received a call back from the physician giving directions to place an order for an x-ray to be performed. Interview on 02/06/24 at 10:00 A.M. with Resident #11 stated she was injured that she can remember at the facility. Resident #11 stated that a few times, the staff bumped her legs during transfer with the Hoyer lift in the room. During an interview and observation on 02/06/24 at 10:15 A.M. with Resident #11 and Registered Nurse (RN) #215, RN #215 opened the right leg brace at the Velcro to reveal Resident #11's right leg bruise. The bruise was located below the right knee and above the right ankle and had a large, faded tan-yellow appearance. Resident #11's leg had swelling. Resident #11 stated she does not feel anything below her waist, and she had no pain. (continued on next page) 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 02/06/2024 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 - Actual harm Interview on 02/06/24 at 2:11 P.M. with LPN #139 revealed she found the bruise after performing a treatment. LPN #139 stated she did sign the bath sheet dated 01/19/24 that had the right shin bruise documented. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00150641. 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 02/06/2024 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. 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 interview, the facility failed to timely obtain an x-ray of a resident's right lower extremity per physician orders. This affected one (Resident #11) of three residents reviewed for accidents. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 06/13/22. Diagnoses included paraplegia and type two diabetes mellitus. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by Licensed Practical Nurse (LPN) #139 stated the nurse discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician for Resident #11's right lower extremity (RLE) was showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern possible injury. The nurse received a new order for an RLE x-ray. There was no physician order written in the medical record for the RLE x-ray. On 01/24/24 at 1:10 A.M., Resident #11 was sent to the emergency room. Resident #11 returned to the facility on [DATE] at 6:09 A.M. On 01/25/24 at 7:50 P.M., the nurse followed up with the x-ray company to find out when they were coming to obtain x-rays of Resident #11's RLE. The x-ray was scheduled for 01/26/24. Subsequently on 01/26/24 at 7:45 P.M. Resident #11 was sent to the hospital. There was no x-ray obtained at the facility on 01/24/24 from the time Resident #11 returned back to the facility and when she went back ou to the hospital on [DATE] at 7:45 P.M. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Telephone interview with the Administrator on 02/08/24 at 2:59 P.M. stated they called the diagnostic company on 02/06/24 with the state surveyor. The diagnostic company verified the nurse didn't notify them of the physician order until 01/25/24 at 5:00 A.M. This was two days after the physician ordered the x-ray results. This deficiency represents non-compliance investigated under Complaint Number OH00150641. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366393 If continuation sheet Page 6 of 6