Health inspection·November 14, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to provide an Advanced Beneficiary Notice to Resident #142 and Resident #192 prior to skilled services being discontinued. This affected two residents (#142 and #192) of three residents reviewed for Beneficiary Notices. Residents Affected - Few Findings include: 1. Review of Resident #142's medical record revealed an admission date of 09/19/19 with diagnoses including generalized muscle weakness, heart failure, chronic obstructive pulmonary disease with acute exacerbation, major depressive disorder and anxiety. Review of Resident #142's Minimum Data Set (MDS) 3.0 assessment, dated 09/26/19 revealed the resident was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of eight. The MDS further revealed Resident #142 required the limited assistance of one person for bed mobility, transfers and hygiene and used a walker when ambulating. Review of Resident #142's Notice of Medicare Non-Coverage letter revealed that physical therapy services ended on 10/11/19 with a resident signature of 10/09/19. Review of Resident #142's Advanced Beneficiary Notice dated 11/06/19 revealed that physical therapy services were discontinued and notice was provided to the resident's Power of Attorney on 11/05/19 by telephone communication. Interview with the Director of Business Operations #150 on 11/13/19 at 4:40 P.M. confirmed that Resident #142's Advanced Beneficiary Notice was missed at that time services were ended and not issued until 11/06/19. Interview with the Director of Nursing (DON) on 11/13/19 at 05:48 P.M. revealed there was not a facility policy on beneficiary notices. The DON verified the Advanced Beneficiary Notice for Resident #142 was not issued until 11/06/19 and she had no explanation for the delay in the notice being sent out. 2. Review of Resident #192's medical record revealed an admission date of 09/25/19 with diagnoses including right tibia fracture, myelofibrosis(a bone marrow cancer that disrupts normal production of blood cells), morbid obesity, low back pain, right talus fracture, chronic pain, major depressive disorder, bronchiectasis (lung airways become damaged and difficult to clear mucus from) and other disorders of the lung. Review of Resident #192's Minimum Data Set (MDS) 3.0 assessment, 09/30/19 revealed the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS further revealed Resident #192 required extensive assistance of one person for bed mobility, dressing, and hygiene need , required the extensive assistance of two people for transfers and toileting, and that the resident used a walker when ambulating. Review of Resident #192's Notice of Medicare Non-Coverage letter revealed that physical therapy services ended on 10/27/19 with the resident signature of 10/25/19. There was not an Advanced Beneficiary Notice to Resident #192 available for review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 2 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Director of Business Operations #150 on 11/13/19 at 4:40 P.M. confirmed an Advanced Beneficiary Notice was not completed for Resident #192. Interview with the Director of Nursing (DON) on 11/13/19 at 5:48 P.M. confirmed there was not an Advanced Beneficiary Notice for Resident #192. The DON stated there was not was not a facility policy on beneficiary notices. Event ID: Facility ID: 366424 If continuation sheet Page 3 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure resident information was safeguarded when medication packets containing resident name and room numbers were thrown into the regular trash. This affected five residents, Resident #12, #16, 143, #144 and #146 and had the potential to affect all 43 residents receiving medication via the medication packets. One resident, Resident #34 did not receive medication via the medication packets. The facility census was 44. Residents Affected - Many Findings include; Observation on 11/12/19 at 10:25 A.M. revealed Licensed Practical Nurse (LPN) #156 disposed the empty medication packets, which contained the resident's name and room number, into the trash can on the side of the medication cart. Resident #16, #143, #144 and #146's medication packets were observed thrown into the trash by LPN #156. Interview on 11/12/19 at 10:50 A.M. with LPN #156, confirmed he had put the medication packets containing the resident's name and room number into the trash container on the side of the medication cart. LPN #156 confirmed that trash container was then emptied into the regular trash cans outside the facility. Observation on 11/13/19 at 10:39 A.M. revealed LPN #152 threw the medication packets for Resident #12, into the trash container on the side of the medication cart. Interview on 11/13/19 at 5:03 P.M. with LPN #152 confirmed she put the medications packets, which contained the resident's names and room numbers, for all the residents she administers medications to, into the trash on the side of the medication cart. She confirmed this trash then went into the regular trash. Interview with the Director of Nursing (DON) on 11/13/19 at 5:22 P.M. confirmed the medication packets were regularly disposed of into the regular trash. She also confirmed these medication packets did contain the resident's name and room number. The DON also confirmed all resident in the facility except one resident, Resident #34 received medication via the packets. Review of the facility policy titled De-Identifying Information Policy, dated 11/2013 revealed identifiers of the resident must be removed before disposal. Identifiers include among others, the resident's name and any unique identifying number, characteristic or code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 4 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to effectively implement their abuse policy and procedure by not investigating or reporting an incident of verbal intimidation involving Resident #37. This failed process resulted in the alleged perpetrator remaining in the resident's house, from the time of the initial incident through the date the facility started the abuse investigation. This affected one resident (#37) of one resident reviewed for abuse. Residents Affected - Few Findings include: Medical record review for Resident #37 revealed an admission date of 11/16/17. Diagnoses included infantile idiopathic scoliosis, Type II diabetes mellitus, muscle weakness, dislocation of the right shoulder, chronic pain, candidiasis of the skin and nails, adjustment disorder and morbid obesity. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #37 had intact cognition. She was also assessed to be totally dependent upon staff for her hygiene, toilet use and transfers. Review of Resident #37's plan of care revealed no documentation of false accusations toward staff. Review of the nursing progress notes for Resident #37 revealed on 08/16/19, Resident #37 had reported to Social Services she had concerns about the Activities director's (#145) daughter Aide #71, getting smart with her. Social service stated to Resident #37 if there was an issue about mistreatment, it would need to be reported and investigated. Aide #71 was later reported to be the Activities Director (AD)'s sister. Documentation dated 08/21/19 by Social services stated they met with Resident #37 on 08/15/19 and 08/16/19 and Resident #37 had verbalized issues concerning the staff. Resident #37 stated she wanted to keep the conversation confidential. Resident #37 was informed there could be no confidential secrets when it came to abuse and safety issues. Resident #37 reported she did not feel comfortable about relaying specific incidents which involved the AD's sister, Aide #71. Resident #37 was informed that all information had to be reported. No further documentation of safety or abuse concerns were documented. No documentation was found that that Social Services had reported any of Resident #37's concerns. In an interview with Resident #37 on 11/12/19 at 4:46 P.M., she stated AD #145 had witnessed her crying while setting up for Bingo, several months ago. AD #145 stated to Resident #37 that she was going to move her into the back of the home because she didn't want the resident's behavior to interrupt her Bingo. Resident #37 stated AD #145 then moved her wheelchair into the back hallway, where she left her alone. Resident #37 stated the Director of Nursing (DON) came into the building and saw the resident crying. Resident #37 stated she told the DON what AD #145 had said and stated she moved her to the back of the hall. She stated AD #145 continually spoke in a disrespectful manner to her and she had previously reported AD #145's verbal harassment to the Administrator. Resident #37 stated she had been told by the Administrator that AD #145 was not going to be assigned to her care and would not come into her room. In an interview with Resident #37 on 11/14/19 at 11:56 A.M. she alleged the AD #145 and her sister, Aide #71 were verbally intimidating and harassing her. She stated on 11/02/19, AD #145 and Aide #71 came into her room for resident care several times. She stated AD #145 had spoken to her in a nasty tone of voice and had yelled and threatened her. She stated AD #145 threatened her by telling her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 5 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she wasn't complying with State regulations. Resident #37 stated she was very frightened of AD #145, and afraid of retaliation from AD #145. On 11/14/19 at 12:15 P.M. interview with Husband #152 revealed he was present with Resident #37 on 11/02/19 when AD #145 was in the room and the verbal interaction between AD #145 and his wife had caused her to cry and shake. Husband #152 stated he had called the Administrator immediately when AD #145 had left his wife's room to report what had happened. Husband #152 stated the Administrator told him he had previously instructed Assistant Administrator (AAdm) #142 that AD #145 was not to care for Resident #37 or be in her room. He stated he also text the Administrator on 11/05/19 and expressed a concern involving the AD #145. He stated the Administrator text back and thank him for bringing these issues to his attention. On 11/14/19 at 12:22 P.M. Resident #37 stated that after her husband left on 11/02/19, AD #145 knocked on her door and came in before gaining permission from the resident. Resident #37 stated she told AD #145 that it was not a good time to come into her room. Resident #37 stated AD #145 entered the room anyway. The resident stated, AD #145 noticed I was upset and asked my why. I kept telling AD #145 that I wanted her to leave and didn't want to talk, but AD #145 wouldn't leave. She stated AD #145 kept asking her what the issue was and Resident #37 finally told her she was not supposed to be in her room according to the Administrator. Resident #37 stated AD #145 then got loud and stated what I said was not true. The resident continued by stating, I became very upset again and really started to cry and shake. AD #145 asked me if I wanted a nurse and I told her yes. AD #145 then opened my door and yelled out into the main common area that I was having some sort of episode. AD #145 kept telling me what I said was untrue and stayed in my room. The resident stated, she terrifies me. On 11/14/19 at 12:30 P.M. Resident #37 confirmed she felt she had been verbally abused by AD #145. Interview with the Administrator on 11/14/19 at 2:48 P.M. revealed Resident #37's husband had called him on 11/02/19 in the early afternoon. The Administrator stated the husband reported AD #145 and her sister, Aide #71 had been in his wife's room and had questioned her very aggressively about being changed. The Administrator stated he told Husband #152 he had given instructions to AAdm #142 to tell AD #145 on 11/01/19, she was not supposed to be in Resident #37's room or give her care. The Administrator indicated he told the husband there was apparently a miscommunication. Husband #152 called the Administrator a second time on 11/02/19, but the Administrator stated he was busy and didn't pick up the call. He stated he asked AAdm #142 on 11/02/19 if she had told AD #145 not to go into Resident #37's room or give her care and AAdm #142 confirmed she had done so. The Administrator stated AAdm #142 told him AD #145 had stated after she was told not to give care to Resident #37, everything was OK between me and the resident, it was OK for me to go in there. Administrator stated he had told AD #145 again on 11/02/19 she was not to go into Resident #37's room, and AD #145 had told him she had never been told not to do so. He confirmed he had talked with Resident #37 on 11/04/19 and Resident #37 stated to him she felt AD #145 was intimidating her and felt uncomfortable. The Administrator stated he didn't take this as abuse. Interview on 11/14/19 at 3:20 P.M. with the DON confirmed she had entered building number four a few months ago and found Resident #37 sitting in a wheelchair near the back-exit door alone and crying. The DON stated the resident told her she was crying over something AD #145 had said to her about Bingo. The DON stated she couldn't remember the details. The DON confirmed she had not looked further into the situation at that time. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 6 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0607 Property, dated 12/06/16 revealed all allegations of abuse should be reported to the Administrator. Abuse is the willful infliction of intimidation or mental anguish. Willful means the individual acted deliberately. 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: 366424 If continuation sheet Page 7 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of verbal abuse involving Resident #37 was immediately reported to the Administrator and reported to the State agency as required. This affected one resident (#37) of one resident reviewed for abuse. Findings include: Medical record review for Resident #37 revealed an admission date of 11/16/17. Diagnoses included infantile idiopathic scoliosis, Type II diabetes mellitus, muscle weakness, dislocation of the right shoulder, chronic pain, candidiasis of the skin and nails, adjustment disorder and morbid obesity. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #37 had intact cognition. She was also assessed to be totally dependent upon staff for her hygiene, toilet use and transfers. Review of Resident #37's plan of care revealed no documentation of false accusations toward staff. Review of the nursing progress notes for Resident #37 revealed on 08/16/19, Resident #37 had reported to Social Services she had concerns about the Activities director's (#145) daughter Aide #71, getting smart with her. Social service stated to Resident #37 if there was an issue about mistreatment, it would need to be reported and investigated. Aide #71 was later reported to be the Activities Director (AD)'s sister. Documentation dated 08/21/19 by Social services stated they met with Resident #37 on 08/15/19 and 08/16/19 and Resident #37 had verbalized issues concerning the staff. Resident #37 stated she wanted to keep the conversation confidential. Resident #37 was informed there could be no confidential secrets when it came to abuse and safety issues. Resident #37 reported she did not feel comfortable about relaying specific incidents which involved the AD's sister, Aide #71. Resident #37 was informed that all information had to be reported. No further documentation of safety or abuse concerns were documented. No documentation was found that that Social Services had reported any of Resident #37's concerns. There was no self reported incident to the State agency involving this incident. In an interview with Resident #37 on 11/12/19 at 4:46 P.M., she stated AD #145 had witnessed her crying while setting up for Bingo, several months ago. AD #145 stated to Resident #37 that she was going to move her into the back of the home because she didn't want the resident's behavior to interrupt her Bingo. Resident #37 stated AD #145 then moved her wheelchair into the back hallway, where she left her alone. Resident #37 stated the Director of Nursing (DON) came into the building and saw the resident crying. Resident #37 stated she told the DON what AD #145 had said and stated she moved her to the back of the hall. She stated AD #145 continually spoke in a disrespectful manner to her and she had previously reported AD #145's verbal harassment to the Administrator. Resident #37 stated she had been told by the Administrator that AD #145 was not going to be assigned to her care and would not come into her room. In an interview with Resident #37 on 11/14/19 at 11:56 A.M. she alleged the AD #145 and her sister, Aide #71 were verbally intimidating and harassing her. She stated on 11/02/19, AD #145 and Aide #71 came into her room for resident care several times. She stated AD #145 had spoken to her in a nasty tone of voice and had yelled and threatened her. She stated AD #145 threatened her by telling her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 8 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she wasn't complying with State regulations. Resident #37 stated she was very frightened of AD #145, and afraid of retaliation from AD #145. On 11/14/19 at 12:15 P.M. interview with Husband #152 revealed he was present with Resident #37 on 11/02/19 when AD #145 was in the room and the verbal interaction between AD #145 and his wife had caused her to cry and shake. Husband #152 stated he had called the Administrator immediately when AD #145 had left his wife's room to report what had happened. Husband #152 stated the Administrator told him he had previously instructed Assistant Administrator (AAdm) #142 that AD #145 was not to care for Resident #37 or be in her room. He stated he also text the Administrator on 11/05/19 and expressed a concern involving the AD #145. He stated the Administrator text back and thank him for bringing these issues to his attention. On 11/14/19 at 12:22 P.M. Resident #37 stated that after her husband left on 11/02/19, AD #145 knocked on her door and came in before gaining permission from the resident. Resident #37 stated she told AD #145 that it was not a good time to come into her room. Resident #37 stated AD #145 entered the room anyway. The resident stated, AD #145 noticed I was upset and asked my why. I kept telling AD #145 that I wanted her to leave and didn't want to talk, but AD #145 wouldn't leave. She stated AD #145 kept asking her what the issue was and Resident #37 finally told her she was not supposed to be in her room according to the Administrator. Resident #37 stated AD #145 then got loud and stated what I said was not true. The resident continued by stating, I became very upset again and really started to cry and shake. AD #145 asked me if I wanted a nurse and I told her yes. AD #145 then opened my door and yelled out into the main common area that I was having some sort of episode. AD #145 kept telling me what I said was untrue and stayed in my room. The resident stated, she terrifies me. On 11/14/19 at 12:30 P.M. Resident #37 confirmed she felt she had been verbally abused by AD #145. Record review revealed no facility self reported incidents to the State agency involving this incident at the time it occurred. Interview with the Administrator on 11/14/19 at 2:48 P.M. revealed Resident #37's husband had called him on 11/02/19 in the early afternoon. The Administrator stated the husband reported AD #145 and her sister, Aide #71 had been in his wife's room and had questioned her very aggressively about being changed. The Administrator stated he told Husband #152 he had given instructions to AAdm #142 to tell AD #145 on 11/01/19, she was not supposed to be in Resident #37's room or give her care. The Administrator indicated he told the husband there was apparently a miscommunication. Husband #152 called the Administrator a second time on 11/02/19, but the Administrator stated he was busy and didn't pick up the call. He stated he asked AAdm #142 on 11/02/19 if she had told AD #145 not to go into Resident #37's room or give her care and AAdm #142 confirmed she had done so. The Administrator stated AAdm #142 told him AD #145 had stated after she was told not to give care to Resident #37, everything was OK between me and the resident, it was OK for me to go in there. Administrator stated he had told AD #145 again on 11/02/19 she was not to go into Resident #37's room, and AD #145 had told him she had never been told not to do so. He confirmed he had talked with Resident #37 on 11/04/19 and Resident #37 stated to him she felt AD #145 was intimidating her and felt uncomfortable. The Administrator stated he didn't take this as abuse and did not report the allegation to the State agency. Interview on 11/14/19 at 3:20 P.M. with the DON confirmed she had entered building number four a few months ago and found Resident #37 sitting in a wheelchair near the back-exit door alone and crying. The DON stated the resident told her she was crying over something AD #145 had said to her about Bingo. The DON stated she couldn't remember the details. The DON confirmed she had not looked further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 9 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0609 into the situation at that time. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 12/06/16 revealed all allegations of abuse should be reported to the Administrator. Abuse is the willful infliction of intimidation or mental anguish. Willful means the individual acted deliberately. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 10 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview the facility failed to ensure notification of hospital transfers were completed as required for Resident #5. This affected one resident (#5) and had the potential to affect all 44 residents residing in the facility. Findings include: Review of Resident #5's medical record revealed an admission date of 03/07/19 with diagnoses including low back pain, major depressive disorder, dementia with Lewy bodies, major depressive disorder and diabetes mellitus type two. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 08/31/19 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further revealed Resident #5 required the extensive assistance of two people for bed mobility, toileting, and hygiene needs and required the extensive assistance of one person for dressing and transfers. Review of Resident #5's nursing progress notes revealed a note dated 06/30/19 that documented Resident #5 remained short of breath and rhonchi (lung sound that is low pitched and rattling and resembles snoring that is often caused by obstruction or airway secretions) were noted throughout, so the resident was sent to the Emergency Room. Review of a nursing note dated 07/06/19 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed there was not a transfer or bed hold notice documented in Resident #5's record regarding the 06/30/19 transfer to the hospital. Review of Resident #5's nursing progress notes revealed a note dated 07/17/19 that documented Resident #5 had increased confusion with hallucinations and was sent to the emergency room for an evaluation. Review of the nursing note dated 07/22/19 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed that a transfer notice was issued for the 07/17/19 hospitalization but was dated 09/18/19 and there was not a bed hold notice documented in Resident #5's medical record for the 07/17/19 hospital transfer. Review of Resident #5's nursing progress notes revealed a note dated 09/18/19 that documented Resident #5 had made suicidal statements and was sent to the emergency room for an evaluation. Review of the nursing note dated 09/29/10 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed there was not a transfer or bed hold notice documented in Resident #5's record regarding the 09/18/19 hospitalization. Interview with the Director of Nursing (DON) on 11/14/19 at 3:24 P.M. verified the transfer notice for the 07/17/19 hospital admission was dated 09/18/19. The DON stated she did not have an answer for why it was two months old and she was unable to locate any information regarding the transfer notifications for the 06/30/19 and 09/18/19 hospital admissions. Review of the facility policy titled Discharge/Transfer Policy and Procedure, dated 08/19/19 revealed the facility must notify the resident or resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The facility must send a copy of the notice of transfer or discharge to the Ombudsman and to the Ohio Department of health. Notice to the Ombudsman must occur before or as close as possible to the actual time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 11 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Potential for minimal harm transfer/discharge and must be documented in the medical record. The notice of transfer/discharge must include the reason for the transfer/discharge, effective date of the transfer/discharge, location of transfer/discharge destination, an explanation of appeal rights to State entity, name and address of State entity, information on to how to request an appeal, information on assistance with completing/submitting an appeal hearing request, and contact information for the Ombudsman. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 12 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record review and interview the facility failed to provide bed hold notification for Resident #5 as required. This affected one resident (#5) and had the potential to affect all 44 residents residing in the facility. Findings include: Review of Resident #5's medical record revealed an admission date of 03/07/19 with diagnoses including low back pain, major depressive disorder, dementia with Lewy bodies, major depressive disorder, and diabetes mellitus type two. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 08/31/19 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further revealed Resident #5 required the extensive assistance of two people for bed mobility, toileting, and hygiene needs and required the extensive assistance of one person for dressing and transfers. Review of Resident #5's nursing progress notes revealed a note dated 06/30/19 that documented Resident #5 remained short of breath and rhonchi (lung sound that is low pitched and rattling and resembles snoring that is often caused by obstruction or airway secretions) were noted throughout, so the resident was sent to the Emergency Room. Review of a nursing note dated 07/06/19 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed there was not a transfer or bed hold notice documented in Resident #5's record regarding the 06/30/19 transfer to the hospital. Review of Resident #5's nursing progress notes revealed a note dated 07/17/19 that documented Resident #5 had increased confusion with hallucinations and was sent to the emergency room for an evaluation. Review of the nursing note dated 07/22/19 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed that a transfer notice was issued for the 07/17/19 hospitalization but was dated 09/18/19 and there was not a bed hold notice documented in Resident #5's medical record for the 07/17/19 hospital transfer. Review of Resident #5's nursing progress notes revealed a note dated 09/18/19 that documented Resident #5 had made suicidal statements and was sent to the emergency room for an evaluation. Review of the nursing note dated 09/29/10 revealed Resident #5 returned from the hospital and was re-admitted to the facility. Further review of the medical record revealed there was not a transfer or bed hold notice documented in Resident #5's record regarding the 09/18/19 hospitalization. Interview with the Director of Nursing (DON) on 11/14/19 at 3:24 P.M. verified there was no documentation a bed hold notice was issued during the 06/30/19, 07/17/19 and 09/18/19 hospital admissions. Review of the facility policy titled Bed Hold Procedure, dated 11/14/17 revealed all residents would be issued the second notice of the bed hold policy at the time of transfer to the hospital or prior to leaving on the therapeutic leave. In the case of an emergency transfer, at the time of transfer means the resident/elder, an/or representative were provided with notification within 24 hours of the transfer. The social worker or designee should initiate contact with the resident/elder's representative by telephone once it has been established the resident/elder will be admitted to to the hospital to discuss the bed hold policy. Documentation of the telephone communication would be completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 13 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Potential for minimal harm in the social service progress notes in the medical record. If unable to reach the representative it was expected that multiple attempts to reach the representative were documented in the medical record. The social worker or designee would then complete the paperwork regarding the notification of the bed hold policy and send to the resident representative via certified mail. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 14 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment for Resident #43 was completed as required. This affected one resident (#43) of three residents reviewed for discharge. Findings include: Review of Resident #43's closed medical record revealed the resident was admitted to the facility 08/02/19 with a diagnosis of aftercare following a joint replacement surgery. Record review revealed the resident discharged home from the facility on 09/12/19. Review of Resident #43's care plan, dated 08/05/19 revealed she planned to discharge to her prior level of care. Interventions included assessing her cognitive ability prior to discharge and refer to additional services as indicated. Review of Resident #43's Minimum Data Set (MDS) 3.0 assessment, dated 09/01/19 revealed she had a moderate cognitive impairment. Review of Resident #43's Minimum Data Set (MDS) 3.0 assessment, dated 09/12/19 revealed it was a planned discharge and a return was not anticipated. She required extensive assistance from staff with all activities of daily living except for eating. Section C of the MDS, which assessed cognition, revealed Resident #43 had not been assessed prior to discharge. Review of Resident #43's progress notes revealed on 09/09/19, facility staff provided her with a Notice of Medicare Non-Coverage (NOMNC). During an interview on 11/14/19 at 11:27 A.M. the MDS Coordinator revealed the social worker was responsible for completing section C, but was on vacation. The MDS Coordinator confirmed the facility was aware of, and had planned the discharge, and that the cognition interview should have been completed prior to Resident #43's discharge. Review of a facility undated policy titled Resident Assessment (MDS) Policy and Procedure revealed the Minimum Data Set (MDS) would be completed according to the Medicare and OBRA guidelines. The facility would use the Long-Term Care Facility Resident Assessment Instrument User's Manual (current version) as the policy and procedure for the federal requirements of completing the MDS. The policy stated that each interdisciplinary team (IDT) member had access to and be knowledgeable to the MDS 3.0 RAI manual for ensuring accurate documentation for each resident. The MDS Registered Nurse was responsible for reviewing the MDS to assure it was completed, signed, and dated. The policy stated assessments required for Medicare guidelines/RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 15 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure Resident #15's Minimum Data Set (MDS) 3.0 assessment accurately reflected the resident's current activity level. This affected one resident (#15) of two residents reviewed for activities. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 12/18/17. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, adult failure to thrive, type II diabetes mellitus, spinal stenosis, peripheral vascular disease, acquired absence of bilateral legs, malignant neoplasm of the bladder. Review of the most recent Long-Term Care (LTC) Activities assessment, dated 03/12/18 revealed Resident #15 was listed that an interview for Daily and Activity preferences should not be performed. Review of Resident #15's plan of care, dated 04/02/19 revealed the resident had not been care planned for her likes or dislikes in activities. Review of the annual MDS 3.0 assessment, dated 09/24/19 revealed Resident #15 had no cognitive deficit. She was also assessed to need extensive assistance from staff for her activities of daily living (ADL). Review of section F activities revealed the resident was assessed as not being able to be interviewed. On 11/14/19 at 9:25 A.M interview with Activities Director (AD) #145 revealed she scheduled most activities in House Four. She confirmed she was responsible for completing the resident care plans for activities. On 11/14/19 at 9:28 A.M. interview with the Director of Nursing (DON) confirmed activity preferences should be included on the care plan. On 11/14/19 at 9:51 A.M. interview with Resident #15 revealed she would love to go to Bingo sometime, but no one was willing to take her to House Four for the activity. She also stated she would like to go to the poetry corner since she loved poetry. Observation of Resident #15 on 11/14/19 at 9:52 A.M. revealed the resident was alert and could carry on an intelligent conversation. The resident was observed to have no cognitive deficits. Interview with MDS Coordinator #143 on 11/14/19 at 11:22 A.M. confirmed an activity assessment, which was completed by AD #145, should be filled out upon admission and annually. She confirmed there was not an accurate annual assessment for activities completed for Resident #15. She also confirmed Resident #15 was cognitively competent to be interviewed. Interview with AD #145 on 11/14/19 at 11:34 A.M. verified she did not fill out Section F, activities, for Resident #15's annual MDS assessment. She confirmed her last activity assessment for Resident #15 was dated 03/12/19. AD #145 also confirmed she had marked Resident #15 as not being able to be interviewed. Interview on 11/14/19 at 11:46 A.M with MDS Coordinator #143 re-confirmed Resident #15 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 16 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0641 cognitively able to be interviewed and the first question in Section F on the MDS was marked incorrect. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Resident Assessment (MDS) Policy and Procedure, dated 12/06/16 revealed data was collected for the MDS assessments through observation, record review and resident interviews. It confirmed Activities staff were part of this process. Residents Affected - Few Review of the facility policy titled Activities Documentation Requirement Process Policy, dated 12/15/10 revealed an activity assessment was to be completed upon admission, with a change in condition and annually. The AD or designee would complete Section F of the MDS, and the AD or designee would be responsible for the activities care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 17 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop comprehensive and individualized care plans for Resident #15 related to activity preferences, for Resident #16 related to psychosocial needs and for Resident #192 related to oxygen use. This affected three residents (#15, #16 and #192) of 13 residents whose care plans were reviewed. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 12/18/17. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, adult failure to thrive, type II diabetes mellitus, spinal stenosis, peripheral vascular disease, acquired absence of bilateral legs and malignant neoplasm of the bladder. Review of the most recent Long-Term Care (LTC) activities assessment, dated 03/12/18 revealed Resident #15 was listed that an interview for Daily and Activity preferences should not be performed. Review of Resident #15's plan of care, dated 04/02/19, revealed the resident had not been care planned for her likes or dislikes in activities. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 09/24/19 revealed Resident #15 had no cognitive deficit. She was also assessed to need extensive assistance from staff for her activities of daily living (ADL). Review of section F activities revealed the resident was assessed as not being able to be interviewed. On 11/14/19 at 9:25 A.M interview with Activities Director (AD) #145 revealed she scheduled most activities in House Four. She confirmed she was responsible for completing the resident care plans for activities. She also confirmed the last activity assessment for Resident #15 was dated 03/12/19. On 11/14/19 at 9:28 A.M. interview with the Director of Nursing (DON) confirmed activity preferences should be on the care plan. On 11/14/19 at 9:51 A.M. interview with Resident #15 revealed she would love to go to Bingo sometime, but no one was willing to take her to House Four for the activity. She also stated she would like to go to the poetry corner since she loved poetry. Observation of Resident #15 on 11/14/19 at 9:52 A.M. revealed the resident was alert and could carry on an intelligent conversation. The resident was observed to have no cognitive deficits. Interview with MDS Coordinator #143 on 11/14/19 at 11:22 A.M. confirmed an activity assessment, which was completed by AD #145, should be filled out upon admission and annually. She also confirmed there was not an accurate annual assessment for activities completed for Resident #15. She also confirmed Resident #15 was cognitively competent to be interviewed. Interview with AD #145 on 11/14/19 at 11:34 A.M. confirmed an updated activity assessment should be completed with the annual comprehensive assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 18 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy titled Comprehensive Care Planning Procedure, dated 11/13/17 revealed the care plan for each resident should be updated on a quarterly basis and with any significant change in resident status. Review of the facility policy titled Activities Documentation Requirement Process Policy, dated 12/15/10 revealed an activity assessment was to be completed upon admission, with a change in condition and annually. The AD or designee would complete Section F of the MDS, and the AD or designee would be responsible for the activities care plan. 3. Review of Resident #192's medical record revealed an admission date of 09/25/19 with diagnoses including right tibia fracture, myelofibrosis (a bone marrow cancer that disrupts normal production of blood cells), morbid obesity, low back pain, right talus fracture, chronic pain, major depressive disorder, bronchiectasis (lung airways become damaged and difficult to clear mucus from) and other disorders of the lung. Review of Resident #192's physician's order revealed an order, dated 09/25/19 for Ipratropim-Albuterol 0.5-2.5 milligrams/3 milliliters to be administered one vial inhaled via nebulizer [NAME] six hours as need for shortness of breath ( a nebulizer is a piece of medical equipent that a person with a respiratory condition uses to admiister medication directly and quickly to the lungs). Review of Resident #192's physician orders revealed an order, dated 09/26/19 for oxygen administration at two to five liters per minute via nasal cannula inhalation as need for shortness of breath/comfort and an order, dated 09/26/19 for oxygen at at bed time for two liters via nasal cannula at night. Review of Resident #192's Minimum Data Set (MDS) 3.0 assessment, dated 09/30/19 revealed the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score a 15. The MDS further revealed Resident #192 required extensive assistance of one person for bed mobility, dressing and hygiene need and required the extensive assistance of two people for transfers and toileting and the resident used a walker when ambulating. Observation of Resident #192's room on 11/12/19 at 9:28 A.M. revealed the resident had an oxygen concentrator in her room for oxygen delivery via nasal cannula tubing and a nebulizer for breathing treatment delivery at bedside. Review of Resident #192's care plan revealed no documentation of a focus area or interventions for oxygen administration or utilization of a nebulizer. Interview with the Director of Nursing (DON) on 11/13/19 at 5:54 P.M. revealed that Resident #192 was one of four residents in the facility on oxygen (Resident #20, Resident #24, Resident #142 and Resident #192). The DON verified there was not a a care plan relating to oxygen administration in Resident #192's medical record. Review of the facility policy titled Comprehensive Care Planning Procedure, dated 11/13/17 revealed a comprehensive care plan was developed for each resident with 21 days of admission by qualified persons and the care plan was updated on a quarterly basis and with any significant change in resident status. The policy further revealed the comprehensive care plan included measurable objectives and timeframes to meet a resident's medical, nursing, and mental/psychological needs that were identified in the comprehensive assessment. Each care plan focus also listed specific interventions and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 19 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 approaches utilized for the focus listed. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #16's medical record revealed the resident was admitted to the facility 09/12/19 with diagnoses including major depressive disorder and anxiety. Residents Affected - Few Review of the physician's orders revealed an order, dated 09/12/19 for an anti-anxiety medication 5 milligrams (mg), three times a day for anxiety and an order for 60 mg of an antidepressant medication for depression. Review of Resident #16's care plan, initiated 09/12/19 revealed her major depressive disorder, anxiety, and use of antidepressant and antianxiety medication were not care planned Resident #16's MDS 3.0 assessment, dated 09/18/19 revealed the resident was cognitively intact and required supervision to limited assistance from staff for all activities of daily living. During an interview on 11/14/19 at 2:50 P.M. the DON confirmed Resident #16's care plan, initiated 09/12/19 did not address her major depressive disorder, anxiety or use of her antidepressant and antianxiety medication. Review of a facility policy titled Comprehensive Care Planning Procedure, dated 11/13/17 revealed the interdisciplinary team (IDT) was responsible for developing, implementing and evaluating the comprehensive person-centered plan of care. The policy stated the care plan would be updated on a quarterly basis and with any significant change in resident status. Further review of the policy revealed the care plan would include measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that were identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 20 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, record review and interview the facility failed to ensure care plans were updated for Resident #19 related to a pureed diet and for Resident #9 related to fall prevention interventions. In addition, the facility failed to conduct care conferences for Resident #5. This had the potential to affect one resident (#19) of one resident reviewed for nutrition, one resident (#9) of one resident reviewed for accident hazards and one resident (#5) of 13 residents whose care plans were reviewed for care planning. Findings include: 1. Review of medical record for Resident #19 revealed an admission date of 10/01/15 with diagnoses including Alzheimer's disease, major depressive disorder, oropharyngeal dysphagia and heart failure. Review of the Minimum Data Set (MDS) 3.0 dated, 10/01/19 revealed the resident required one to two person physical assist with activities of daily living. Review of Resident #19's physician's orders revealed an order, dated 06/13/19 for a pureed textured diet at a thin liquid consistency with 1/2 portion desserts. Review of Speech Therapist's documentation, dated 06/24/19 revealed staff were being trained regarding the resident's specified diet. Resident #19 was being seen by the speech therapist for a dysphasia evaluation and to develop a plan of care for skilled treatment recommended for oropharyngeal dysphagia. Review of Resident #19's nutritional screening, dated 10/21/19 confirmed Resident #19 was receiving a diet of pureed food. Review of Resident #19's plan of care, last updated 10/21/19 revealed the plan did not reflect the resident was to receive a pureed textured diet at a thin liquid consistency with 1/2 portion desserts. On 11/14/19 at 10:00 A.M. interview with the Director of Nursing (DON) confirmed Resident #19's plan of care did not include her need for a pureed textured diet at a thin liquid consistency with 1/2 portion desserts. Review of the facility Diets Policy, dated 01/01/2009 revealed a pureed diet was a regular diet texture altered to accommodate those who have difficulty swallowing and/or chewing. Texture varies from thin (applesauce) to thick (mashed potatoes). 2. Review of medical record for Resident #9 revealed an admission date of 12/19/14 with diagnoses including dementia, major depressive disorder, generalized anxiety and Alzheimer's disease. The Minimum Data Set (MDS) 3.0 assessment, dated 09/10/19 revealed the resident required one to two person physical assist with activities of daily living. Review of Resident #9's nursing progress notes contained in her medical record revealed she had two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 21 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 falls in August of 2019, one when ambulating in the den and one when trying to get out of bed. Level of Harm - Minimal harm or potential for actual harm On 11/13/19 at 9:00 A.M. observation of Resident #9 revealed a bed assist bar connected to the right side of her bed. Residents Affected - Few Review of Resident #9's care plan, last updated 08/28/19 revealed the plan did not include a new ordered fall intervention of an assist bar attached to her bed. On 11/13/19 at 10:41 A.M. interview with the administrator revealed he purchased the enabler (assist bar) for Resident #9's bed around the first week of September of 2019. On 11/14/19 at 10:00 A.M. interview with the Director of Nursing (DON) confirmed Resident #9's care plan did not include an assist bar connected to Resident #9's bed as a fall intervention. 3. Review of Resident #5's medical record revealed an admission date of 03/07/19 with diagnoses including low back pain, major depressive disorder, dementia with Lewy bodies, major depressive disorder and diabetes mellitus type two. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 08/31/19 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further revealed Resident #5 required the extensive assistance of two people for bed mobility, toileting, and hygiene needs and required the extensive assistance of one person for dressing and transfers. Review of Resident #5's medical record revealed the initial care conference was documented as completed on 03/15/19. Further review of the record revealed there was no documentation of any other care conferences conducted in the resident's chart. Interview with Resident #5 on 11/12/19 at 3:55 P.M. revealed the resident stated she had not been invited to any conferences. Interview with Social Worker #144 on 11/13/19 at 1:00 P.M. revealed care conference were completed quarterly for each resident and she was responsible for sending the invitation letters to the resident to inform them of the date and time of the conference. Social Worker #144 confirmed Resident #5 would have been due to have a care conference in June and September 2019 based on the initial conference date of 03/15/19. Social Worker #144 revealed she began to work for the facility on 07/22/19 and Resident #5 was on the list of care conference that were overdue and needed to be completed in July. Social Worker #144 stated Resident #5 was not invited to the July care conference due to the resident's 07/18/19 to 07/22/19 hospitalization, as Social Worker #144 felt the conference may have been overwhelming for the resident. Social Worker #144 confirmed there was no documentation of a June or July 2019 care conference or attempts for a care conference in the medical record. Further interview with Social Worker #144 revealed Resident #5 was not on the September 2019 calendar for a care conference. Social Worker #144 stated Resident #5 was not on the September care conference calendar due to the 09/18/19 to 09/20/19 hospitalization and she felt the care conference would be overwhelming. Social Worker #144 verified there was no documentation of care conferences conducted after 03/15/19 and no documentation of care conference invitation letters in Resident #5's medical record. Review of the facility undated policy titled Care Conference Process revealed care conferences were held within 7 days of admission/readmission, quarterly, anytime there is a significant change in the elder's condition, and at the request of an elder or family member. The team leader in each house contacted the elder and family and determined a date within a two week time span that was convenient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 22 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for the care conference. After the conference, the care card was returned and the care conference summary was completed. The MDS nurse within 24 hours documented in the progress notes for any skilled elder that the care conference was held and briefly describes any issues. Review of the facility policy titled Comprehensive Care Planning Procedure, dated 11/13/17 revealed care conferences were held to discuss a resident's care plan and both the resident and representative were to be invited to all care conferences. The policy further revealed if the participation of the resident or representative was determined to not be practicable for the development of the care plan, then a written explanation was provided in the medical record. The 11/13/17 policy revealed care conferences were held to discuss the current plan of care, any quarterly updates and any significant changes in the resident status. Event ID: Facility ID: 366424 If continuation sheet Page 23 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure all required information was present in the discharge summary for Resident #43. This affected one resident (#43) of three residents reviewed for discharge summaries. Findings include: Review of Resident #43's closed medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis including aftercare following a joint replacement surgery. The resident was discharged home from the facility on 09/12/19. Review of Resident #43's Minimum Data Set (MDS) 3.0 assessment, dated 09/01/19 revealed the resident had moderate cognitive impairment. Review of Resident #43's Minimum Data Set (MDS) 3.0 assessment, dated 09/12/19 revealed it was a planned discharge and a return was not anticipated. The resident required extensive assistance from staff with all activities of daily living except for eating. Section C of the MDS, which assessed cognition, revealed Resident #43 had not been assessed prior to discharge. Review of Resident #43's Discharge summary, dated [DATE], lacked individual care instructions, primary care physician information including follow-up appointments and phone number, what services were to be provided by home health, required durable medical equipment and pharmacy information. During an interview on 11/14/19 at 11:43 A.M. the Director of Nursing (DON) confirmed Resident #43's discharge summary lacked individual care instructions, primary care physician information including follow-up appointments and phone number, what services were to be provided by home health, required durable medical equipment, and pharmacy information. Review of the facility undated Discharge Guide revealed the facility should provide a list of follow-up appointments, with dates and times, or that needed to be scheduled as well as complete the Discharge Summary form in the electronic Medical Record. Review of the facility undated Discharge Planning Procedure revealed the facility would develop and implement a discharge plan that would prepare the resident to be an active partner and effectively transition the resident to post-discharge care. The policy stated the facility would develop a discharge summary that indicated where the resident planned to reside, any arrangements that had been made for the resident's follow-up care and any post-discharge medical and non-medical services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 24 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 Based on record review and interview the facility failed to follow physician orders regarding peripherally inserted central catheter (PICC) line dressing changes for Resident #192. This affected one resident (#192) of one resident the facility identified as having a PICC line. Residents Affected - Few Findings include: Review of Resident #192's medical record revealed an admission date of 09/25/19 with diagnoses including right tibia fracture, myelofibrosis(a bone marrow cancer that disrupts normal production of blood cells), morbid obesity, low back pain, right talus fracture, chronic pain, major depressive disorder, bronchiectasis (lung airways become damaged and difficult to clear mucus from),and other disorders of the lung. Review of Resident #192's physician orders revealed an order, dated 09/27/19 to change dressing to the central line weekly and apply a transparent dressing one time a day on Friday of each week. Review of Resident #192's Minimum Data Set (MDS) 3.0 assessment, dated 09/30/19 revealed the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS further revealed Resident #192 required extensive assistance of one person for bed mobility, dressing and hygiene needs, required the extensive assistance of two people for transfers and toileting, and the resident utilized a walker when ambulating. Review of Resident #192's care plan, dated 09/30/19 revealed a focus of intravenous (IV) therapy/chemotherapy received outside of the facility and interventions to change IV tubing per protocol, flush peripheral, PICC or midline IV per protocols, monitor the IV site for edema, swelling and redness, and to perform dressing changes per protocol. (A PICC line is a long thin hollow flexible tube (catheter) that is inserted above the bend of your arm and runs to a large vein near the heart. A PICC line is used for long term intravenous (IV) access for delivery of medications such as antibiotics or chemotherapy). Review of Resident #192's physician orders revealed the order (dated 09/27/19) for central line dressing changes on Friday was discontinued on 11/11/19 and a new order dated 11/11/19 for central line dressing change and apply a transparent dressing one time a day on Monday of each week. Review of Resident #192's October 2019 Treatment Administration Record (TAR) revealed the central line dressing changes had not been documented as being completed as ordered on 10/4/19 and 10/11/9. The TAR revealed the central line dressing was not documented as being changed until 10/19/19 (21 days after the commencement of the 09/27/19 order). Review of Resident #192's progress notes revealed no documentation regarding the status of the 10/04/19 and 10/11/19 central line changes. Interview with Resident #192 on 11/12/19 at 9:21 A.M. revealed that resident went out for a medical appointment at an outside facility about three weeks ago and she was informed by the nurse at the outside facility that the PICC line dressing was dated for over two weeks ago. The resident stated she did not know why the nurse at the facility had not been changing her PICC line dressing and that she purchased her own supplies (dressings, caps, masks and gauze) to assist with dressing changes and care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 25 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 Residents Affected - Few Interview with the Director of Nursing (DON) on 11/13/19 at 12:35 P.M. confirmed Resident #192's PICC line dressing changes should have been done on 10/04/19 and 10/11/19 but were not signed off on the TAR. The DON further verified there was no documentation or progress note that the dressing change had been completed in the resident record. During the interview with the DON on 11/13/19 she stated the TAR should be marked and initialed after the completion of each task or that a progress note should document why the treatment was not completed. The DON revealed Resident 192's daughter purchased and brought in specific supplies she wanted staff to use when performing the PICC line dressing changes. Review of the facility policy titled Peripherally inserted central catheter (PICC) dressing change, dated 06/14/19 revealed a transparent dressing over a PICC line should be changed every five to seven days to assess, clean and disinfect the site and observe for signs of infection. The policy further stated PICC line dressing changes required sterile technique to reduce the risk of vascular catheter-associated infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 26 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement a comprehensive and individualized pain management program for Resident #5 to include the use of non-pharmacological interventions for pain. This affected one resident (#5) of one resident reviewed for pain management care. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 03/07/19 with diagnoses including low back pain, major depressive disorder, dementia with Lewy bodies, major depressive disorder and diabetes mellitus type two. Review of Resident #5's care plan, dated 06/14/19 revealed a focus area of chronic low back pain related to spinal stenosis, chronic shoulder pain, and knee pain related to osteoarthritis with the intervention to offer non-pharmacological interventions prior to the administration of as needed pain medications (relaxation, repositioning, and distraction). Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 08/31/19 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further revealed Resident #5 required the extensive assistance of two people for bed mobility, toileting, and hygiene needs and required the extensive assistance of one person for dressing and transfers. Review of Resident #5's physician orders revealed an order, dated 09/17/19 to administer one table of Oxycodone- Acetaminophen 7.25-325 milligrams (mg) every four hours as needed (PRN) for pain. (Oxycodone-Acetaminophen is the generic form of the brand named narcotic pain reliever Percocet. This medication is classified as a schedule two controlled substance due to the high potential for abuse increased potential for physical or psychological dependence). Review of Resident #5's Medication Administration Record (MAR) dated October 2019 revealed the PRN pain medication, Oxycodone Acetaminophen was administered 69 times in a 31 day review period of 10/01/19 thorough 10/31/19 with no documentation of non-pharmacological interventions in the record. Review of the November 2019 MAR revealed Oxycodone Acetaminophen was administered 30 times in the thirteen day review period of 11/01/19 through 11/13/19. Additionally there was no documentation of non-pharmacological interventions attempted in Resident #5's medical record. Interview with Resident #5 on 11/12/19 at 3:53 P.M. revealed the resident had chronic pain in her back, shoulder and arms and that she did not recall any non-pharmacological interventions for pain relief being offered but stated she would be willing to try them in addition to taking pain medication. Resident #5 further stated her pain level would reach a ten out of ten if she waited up to twelve hours before she asked for pain medication. The resident stated she did not ask for the medication sooner because she did not want to bother the nurse. Resident #5 stated the pain medications did not always help like they should and thought other interventions would be beneficial. Interview with the Director of Nursing (DON) on 11/03/19 at 12:35 P.M. revealed non-pharmacological interventions for Resident #5 were to be documented in the progress notes under the electronic medication administration record. The DON stated the non-pharmacological interventions were not documented on a grid or flowsheet of any type. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 27 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #5's progress notes from 10/01/19 to 11/13/19 revealed no documentation of any non-pharmacological interventions for pain in the electronic medication administration record. Interview with Admissions Coordination #203 on 11/14/19 at 1:40 P.M. confirmed Resident #5's non-pharmacological interventions were not documented in the medical record and the DON was rewriting the orders. Review of the facility policy titled Pain Management, dated September 2007 revealed each resident would be assessed upon admission, quarterly, with significant change, and any time pain is suspect, for the presence or absence of pain and non-pharmacological forms of interventions would be considered whenever appropriate. The resident's care plan was to be updated as needed to reflect the interventions used to manage pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 28 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 - Some 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. Based on observation, record review and interview the facility failed to follow the daily dietary menus for Resident #2, #26, #36 and #143. This affected four residents (#2, #26, #36 and #143) and had the potential to affect all 20 residents who resided in House One and House Three. Findings include: 1. Review of House One Week at a Glance Menu revealed on Wednesday 11/13/19, the lunch to be served was cottage cheese with peaches, cheese and crackers (1 each) country vegetable soup and peanut butter and jelly sandwiches (1 each). On 11/13/19 at 12:15 P.M. observation of the kitchen in House One revealed 10 small white bowls sitting on the counter filled with fruit cocktail. Interview with Elder Assistant (EA) #51 at the time of the observation revealed they were not serving cottage cheese because they did not have any. Observations from 12:15 P.M. to 12:30 P.M. revealed Resident #2, #26 and #36 were sitting at the dining table eating their soup. Each resident received a bowl of crackers and a bowl of soup. The residents did not have a peanut butter and jelly sandwich or one cracker with cheese. On 11/13/19 at 3:26 P.M. interview with dietary tech #148 revealed the house menus were different in each house. They are approved by a registered, licensed dietician. Dietary tech #148 revealed the EA staff were to follow the menus created weekly unless otherwise directed. 2. Review of the medical record for Resident #143 revealed an admission date of 11/02/19 with diagnoses including infectious gastroenteritis and colitis, Alzheimer's disease, dehydration, history of falling, post-traumatic stress disorder, heart disease, Type II Diabetes Mellitus, dysphagia, and muscle weakness. Further review of the medical record revealed Resident #143 had severe cognitive deficit. Review of the physician's current orders for Resident #143 identified an order, dated 11/05/19 for a regular diet, pureed texture and thin consistency. Review of Resident #143's plan of care revealed he was at risk for changes in nutrition and hydration related to recent illness, diabetes and dysphagia and needed a mechanical altered diet with adequate calorie and protein intake. Interventions included encourage resident to drink all fluids, encourage to eat snacks, encourage to eat offered foods, encourage to eat calorically dense foods and plenty of protein and offer the diet ordered by the doctor. Review of the menu dated 11/12/19 revealed the scheduled lunch should have consisted of four ounces of salmon, four ounces of rice pilaf, four ounces of asparagus with cashews, eight ounces of milk and four ounces of fresh strawberries with whipped topping. Observation on 11/12/19 at 12:55 P.M. revealed Aide #52 retrieved a frozen Stouffer's meatloaf meal from the freezer and placed it into the microwave to heat the meal up. At 12:58 P.M. Aide #52 took the meat patty from the Stouffer's tray and placed it into a blender. She then blended the meat patty to a rough consistency. Aide #52 placed the blended meatloaf patty, which was approximately one-fourth cup and the heated mashed potatoes onto a plate for Resident #143's lunch. She was also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 29 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 observed to put Ensure into a cup for Resident #143. Level of Harm - Minimal harm or potential for actual harm Interview on 11/12/19 at 1:07 P.M. with Aide #52 confirmed she had given Resident #143 a Stouffer's frozen meal. She stated the facility purchased several Stouffer's meals for Resident #143 to eat. Residents Affected - Some Review of the Ohio Revised Code for nutrition, it stated menus must be prepared in advance and must be followed to meet the nutritional needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 30 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. 2. Review of medical record for Resident #19 revealed an admission date of 10/01/15 with diagnoses including Alzheimer's disease, major depressive disorder, oropharyngeal dysphagia and heart failure. Residents Affected - Few The Minimum Data Set (MDS) 3.0 assessment, dated 10/01/19 revealed the resident required one to two person physical assist with activities of daily living. Review of Resident #19's orders revealed an order dated 06/13/19 for a pureed textured diet at a thin liquid consistency with 1/2 portion desserts. Review of Resident #19's nutritional screening, dated 10/21/19 confirmed Resident #19 was receiving a diet of pureed food. On 11/12/19 from 11:30 A.M. to 12:30 P.M. observation of the kitchen of House Three revealed Elder Assistant (EA) #64 using a small electronic food chopper to make a pureed salad for Resident #19. She explained, she always pureed Resident #9's food, no matter what it was. The EA reported she had given Resident #19 pureed salad in the past. EA placed a teaspoon of the pureed salad in a bowl. After completing the process, the surveyor requested a sample of the food item to taste for texture and palatability. The test revealed a texture of small pieces of lettuce, carrots and tomatoes with no taste. The salad was not of pureed consistency as per physician order or the facility policy and procedures. Review of the Facility Diets Policy, dated 1/01/2009 revealed a pureed diet was a regular diet texture altered to accommodate those who have difficulty swallowing and/or chewing. Texture varies from thin (applesauce) to thick (mashed potatoes). Based on observation, record review and interview the facility failed to ensure staff followed recipes and prepared pureed meals to the proper consistency. This affected two residents (#19 and #143) of two residents reviewed for pureed diets. Findings include: 1. Review of the medical record for Resident #143 revealed an admission date of 11/02/19 with diagnoses including infectious gastroenteritis and colitis, Alzheimer's disease, dehydration, history of falling, post-traumatic stress disorder, heart disease, Type II diabetes mellitus, dysphagia, and muscle weakness. Further review of the medical record revealed Resident #143 had severe cognitive deficit. Review of the physician's current orders for Resident #143 identified an order dated 11/05/19 for a regular diet, pureed texture and thin consistency. Review of Resident #143's plan of care revealed he was at risk for changes in nutrition and hydration related to recent illness, diabetes and dysphagia and needed a mechanical altered diet with adequate calorie and protein intake. Interventions included encourage to drink all fluids, encourage to eat snacks, encourage to eat offered foods, encourage to eat calorically dense foods and plenty of protein and offer me the diet my doctor has ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 31 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the menu dated 11/12/19 revealed the scheduled lunch should have consisted of four ounces of salmon, four ounces of rice pilaf, four ounces of asparagus with cashews, eight ounces of milk and four ounces of fresh strawberries with whipped topping. Observation on 11/12/19 at 12:55 P.M. revealed Aide #52 retrieved a frozen Stouffer's meatloaf meal from the freezer and placed it into the microwave to heat the meal up. At 12:58 P.M. Aide #52 took the meat patty from the Stouffer's tray and placed it into a blender. She then blended the meat patty to a rough consistency. Aide #52 placed the blended meatloaf patty, which was approximately one-fourth cup and the heated mashed potatoes onto a plate for Resident #143's lunch. She was also observed to put Ensure into a cup for Resident #143. Interview on 11/12/19 at 1:07 P.M. with Aide #52 confirmed she had given Resident #143 a Stouffer's frozen meal. She stated the facility purchased several Stouffer's meals for Resident #143 to eat. Aide #52 revealed she had not yet taken her State certification test to become a State Tested Nursing Assistant (STNA) and revealed she had not received very much education in the area of pureed foods. Aide #52 confirmed the consistency of the meat loaf was very grainy. Interview on 11/13/19 at 10:56 A.M. with STNA #71 revealed she did not really know how to puree foods and indicated she used Google on the internet to find instructions on how to do so. She denied knowing what the consistency of a pureed item was supposed to be. Observation on 11/13/19 at 12:51 P.M. of the pureed preparation for Resident #143's lunch revealed STNA #210 added an unmeasured amount of shredded chicken into the blender and then she added a small amount of that day's cauliflower soup. The STNA then proceeded to blend the chicken. The blended chicken was placed into a bowl and was observed to have a grainy consistency. The amount was approximately one-fourth cup. STNA #210 then placed some of the cauliflower and broccoli soup into a bowl for the resident. Observation of the soup revealed it contained whole pieces of cauliflower, broccoli and shreds of chicken. STNA #210 then proceeded to feed Resident #143 the meal. Interview on 11/13/19 at 12:55 P.M. with STNA #210 confirmed she had not measured any of Resident #143's food prior to serving and confirmed she had not pureed the soup. Interview on 11/13/19 at 2:12 P.M. with Dietitian Aide #148 revealed the consistency of pureed items should be that of mashed potatoes. It should be smooth with no particles observed. Interview on 11/13/19 at 2:43 P.M. with Speech Therapist #136 confirmed the consistency of a pureed item should fully processed with no food particle felt or seen, like yogurt or applesauce. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 32 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to ensure food items were properly stored including proper labeling and dating to prevent contamination and/or food borne illness and failed to ensure food temperatures were properly taken. This had the potential to affect all residents who resided in House One, Three, Four and Five. The facility census was 44. Findings include: 1. On 11/12/19 from 9:45 A.M. to 11:05 A.M. a tour of House One, Three, Four and Five kitchens revealed the following: a. Observations in House One, which were confirmed by Elder Assistant (EA) #64 at the time of the observation included: A bag of uncooked pasted not sealed with no date on the bag. A sealed glass jar of flour sitting on the counter with a scoop sitting inside the jar. The refrigerator contained a block of American cheese in a sealed plastic bag with no date. Cereal in a plastic container with no date. b. Observations in House Three, which were confirmed by EA #51 at the time of the observation included: A package of salami open in the refrigerator and sitting on the shelf not in a sealed container. A box of corn bread mixes open and with no date and not in a sealed container. A box of saltines opened with 3 bags of crackers in the box with one bag open with no date or in a sealed container. The bottom of the refrigerator beneath the lowest plastic drawer on the right had a red substance under it c. Observations in House Four, which were confirmed by EA # 71 at the time of the observation included: One package of English muffins and two packages of hot dog buns with expiration dates of 11/06/19. One bag of bagels with a hand-written date of 10/30/19. Ham slices in a sealed container with no date. A jar of applesauce has a purchased date on it, but not an open date on it. One bag of English muffins dated 11/04/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 33 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 An opened bag of flour tortillas, undated. Level of Harm - Minimal harm or potential for actual harm Observation of the refrigerator in the storage room revealed an opened package of ham slices, a package of turkey lunch meat and an opened bag of hard salami, all three packages were dated 11/03/19. Residents Affected - Many An opened box containing a half a cheese cake, with no open date on it A half empty container of Spicy pickle chips, no open date documented Interview on 11/13/19 at 11:30 A.M. with EA #71 in House Four confirmed all the dates on the food items were the date the food item was purchased, and food was only kept for three days after it gets open; however, no one knew when the food was opened so the food was kept until it was used. d. Observations in House Five, which were confirmed by EA #79 at the time of the observation included: The main kitchen refrigerator contained one-quart container of Half and Half, with no open date. One opened container of sour cream with no open date on it. A squeeze bottle of olive oil mayonnaise with no date. A large bowl with several pieces of cooked chicken covered in loose plastic wrap with a date of 11/10/19. Interview on 11/13/19 at 11:46 A.M. with STNA #77 confirmed the dates on all the food items were the date the item was purchased. Review of the Food Storage Policy and Procedure, dated 09/24/09 revealed prepared food was covered, dated, labeled with the month and day on which it was prepared. The label also indicated the use by date which was four to seven days after the food was prepared. Condiments such as mayonnaise, salad dressings, single serve cottage cheese, sour cream were left in their original container, marked and dated with month and day refrigerated. Prepackaged food or baking goods were marked with month and day and placed in a covered container and completely sealed. 2. Interview and observation on 11/12/19 with EA #64 revealed she was serving pizza for lunch. She was observed removing the pizza from the oven. She removed a food thermometer sitting in a cup of water on the counter. She dried it with a paper towel and inserted into a slice of pizza. The temperature of the pizza was 116 degrees Fahrenheit. She confirmed she did not use an alcohol wipe to cleanse the thermometer prior to using it. On 11/13/19 from 12:13 P.M. to 12:40 P.M. EA # 77 was observed in the kitchen of House Five. EA #77 was observed to take a thermometer out of the drawer and placed it in a cup of cold water trying to get the thermometer to read zero. Then she removed the thermometer and began to temp the food. The EA made no attempt to clean the thermometer with alcohol before using it to test the food temperatures. The EA revealed she does not use an alcohol prep pad to clean it prior to using the thermometer nor did she know what the temp of the food should be when serving. She explained, I do everything like I do it at home. She added, I do not use measuring utensils to measure the food being served or know how much each serving should be. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 34 of 35 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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 Review of the Food Thermometer policy and Procedure, dated 05/2015 revealed the method to measure food temperature was to sanitize the thermometer before use with an alcohol swab to sanitize the stem as well as the holding clip. After each use remove the thermometer from the food and wipe away food excess with a paper towel and sanitize the stem of the thermometer as indicated. Repeat for each food being sure to sanitize between food types. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 35 of 35