Inspection·July 25, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was confirmed on 07/20/22 at 2:41 P.M. by Elderly Assistant (EA) #301 who revealed she was unsure if the facility had urinary coverage bag available. Observation on 07/20/22 at 10:09 AM revealed Elderly Assistant #700 assisted Resident #5 with incontinence care, with the residents window blinds open. The residents window faced a residential house and part of the facility's parking lot. The observation was confirmed immediately following the care with EA #700. Review of the facility policy titled, Ohio Resident Rights & Facility Responsibilities revised 01/22/20 revealed the resident had the right to privacy during medical examination or treatment and in the care of personal or bodily needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 2 of 36 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 07/25/2022 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observations, medical record review, and facility policy review, the facility failed to ensure resident call lights/pendants were within reach. This affected five residents (Resident #4, #24, #17, #52, and #203) of five reviewed for accomodation of needs. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 10/24/17 with diagnoses including fracture of the right tibia shaft, protein-calorie malnutrition, Alzheimer's disease, osteoarthritis, lumbar region intervertebral disc degeneration, dementia, need for assistance with personal care, unsteadiness on her feet, mood disorder, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/26/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 (severe cognitive impairment). The resident required extensive to total assistance of one to two staff members for all Activities of daily Living (ADL's) including eating. Review of the plan of care dated 07/19/22 revealed the resident had an ADL/mobility dysfunction related to Alzheimer's disease, dementia, chronic pain, rheumatoid arthritis (RA), emphysema, bilateral hand contractures, and muscle weakness. Further review of the care plan revealed at baseline the resident needed oversight to extensive assistance with her ADLs. She slept in her recliner at times, did not participate in her personal hygiene, varied from oversight to extensive assist, needed limited to extensive assistance with dressing, required extensive assistance with bathing, fed herself after meal tray was setup but needed help at times. had functional limitations to her bilateral hands with contracture formation related to RA, had episodes of both urinary and fecal incontinence, and was likely to vary/fluctuate in her needed due to her diagnosis. As of 04/15/22 the resident had a fall with a right tibial fracture, transferred with the assistance of two staff members and the mechanical Hoyer lift, was non ambulatory and required limited to extensive assistance with eating. Interventions included assistance as needed. Observation on 07/19/22 at 10:26 A.M. revealed Resident #17 was in bed sleeping when the nurse entered to administer medications, her call pendant was to the right of her bed, in front of her recliner, on the over the bedside table and no within reach. The observation was confirmed at 07/19/22 at 10:33 A.M. with Registered Nurse (RN) #703. 2. Review of the medical record for Resident #52 revealed an admission date of 05/05/22 with diagnoses including dementia, restlessness, agitation, and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/03/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). His behaviors included inattention. The resident required extensive assistance of one staff for all Activities of daily Living (ADL's). Observation on 07/20/22 at 09:46 A.M. with Resident #52 revealed he was sitting at the dining room table eating breakfast, no call light or pendant within reach, and observation of his room revealed no visible call light. Observation on 07/20/22 at 01:45 P.M. revealed no staff in dining room when Resident #52 stood up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 3 of 36 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 07/25/2022 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and began walking independently from the table, without his walker. He was directed by another resident, to come to the sound of his voice, when Elder Assistant (EA) #700 exited a residents room and began assisting Resident #52 who verbalized his need to use the toilet. EA #700 confirmed Resident #52 did not have a call light within reach on 07/20/22 at 01:45 PM. 3. Review of the medical record for Resident #24 revealed an admission date of 08/31/16 with diagnoses including but not limited to Parkinson's disease, epilepsy, psychotic disorder with delusions, constipation, angina pectoris, flaccid neuropathic bladder, right sided hemiplegia and hemiparesis following a cerebral infarction. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/04/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of seven out of 15 (severe impairment). The resident required extensive assistance of one to two or more staff for all Activities of daily Living (ADL's) except eating which he required supervision and one person assistance. Review of the plan of care dated 05/18/22 revealed the resident had a self-care and physical mobility deficit related to a-fib, aphasia, chronic pain, cognitive communication deficit, right sided hemiplegia, contractures, epilepsy, gout, hypertension, insomnia, lack of coordination, Parkinson's disease, and cerebral vascular accident (CVA). He required extensive assistance to turn and reposition in bed and was non-weight bearing for all surface transfers requiring a Hoyer lift. He required physical assist with bathing, personal hygiene, and dressing. He could feed himself after his meal tray was setup/arranged but needed assist at times when fatigued. He was incontinent of bowel and bladder and given his diagnosis, his status was likely to fluctuate throughout the course of the day and vary from day to day. He refused splinting/maintenance plan for contractures and getting out of bed (OOB) daily. He also refused the bedpan, urinal, and nail care. Interventions included assistance as needed. Further review of the care plan revealed the resident was at risk for falls due to a-fib, aphasia, chronic pain, cognitive communication deficit, right sided hemiplegia, contractures, epilepsy, gout, hypertension, insomnia, lack of coordination, Parkinson's disease, and cerebral vascular accident (CVA). Interventions included ensuring the residents call light was within reach and encourage him to use it for assistance as needed. Interview and observation on 07/18/22 at 08:53 A.M. revealed Resident #24 stated poop poop poop when asked if he needed cleaned up he responded yes, no visible call light within reach, and the resident was unsure where his call light was located. Interview on 07/18/22 at 8:54 A.M. with EA #301 revealed residents called for help with the call pendant which was to be around the residents neck or on the residents tray which alarms the EA's pagers. The Surveyor informed the EA of the Resident #24's need for assistance. Interview and observation on 07/18/22 at 8:58 A.M. revealed Resident #24's call pendent was observed to the left of the resident out of reach, on the residents table, inside a green bowl, where the resident stated he was unable to reach it. The observation was confirmed on 07/18/22 at 8:59 A.M. with EA #301 4. Review of the medical record for Resident #4 revealed an initial admission date of 08/18/15 and a re-entry date of 03/23/20 with diagnoses included anemia and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 4 of 36 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 07/25/2022 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was rarely/never understood, had long and short-term memory problems, and was moderately cognitively impaired. The resident required extensive assistance of two or more staff for all Activities of daily Living (ADL's). Observation on 07/18/22 at 9:01 A.M, 10:55 A.M., and 12:16 P.M. of Resident #4 revealed no call button was within reach, it was laying on the night stand across from the residents bed. Interview and observation on 07/18/22 at 12:23 P.M. with Coach #237 confirmed Resident #4 did not have a call light within reach since it was laying on her night stand. 5. Observation on 07/19/22 at 09:34 A.M. of Resident #203 revealed his family member was at bedside and reported being upset the resident had to yell out for help last night after his call light was not answered timely. She arrived at 6:30 A.M, on 07/19/22 to find his call light out of reach and no staff members had come to check on the resident the whole time since she arrived until the nurse entered the room with the residents morning medications . Observation at the time of the family member's complaint revealed the residents call pendant was laying on his nightstand to the left of his bed and was out of the resident reach. The observation and residents family member complaint was not disputed by RN #703 who was present during the reported allegation and observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 5 of 36 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 07/25/2022 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to notify the physician of a change in condition for Resident #46. The deficient practice affected one resident (Resident #46) of one reviewed for change of condition. The facility census was 58. Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22. The resident was hospitalized on [DATE] and had a readmission date on 06/20/22. Medical diagnoses included benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis (06/20/22), Type II Diabetes Mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. Review of the nurse's notes in May 2022 revealed on 05/22/22 at 6:35 P.M., Resident #46 was noted with right side facial swelling and upon palpitation it was hard and warm. Lungs were not clear and sounded congested. Vital signs were: blood pressure 162/95, pulse 104, temperature 97.2 degrees, and oxygen saturation was 94%. The Certified Nurse Practitioner (CNP) and Director of Nursing (DON) were notified via text message and the resident's daughter was contacted and promised to be at the facility in about 25 minutes. On 05/23/22 at 2:43 P.M., Resident #46 was seen by Physician #302. The physician indicated the staff noted patient had redness and swelling on right side of her face. Blood pressure was slightly elevated but no fever. Patient was seen by CNP who spoke with family who wanted patient managed at hospital if possible and also started Keflex (an antibiotic) last night. Skin was swelling at right side of face and right eye. Had tenderness to palpitation with swelling along right parotid as well as some upper airway congestion. Assessment/Plan included right facial swelling likely related to parotitis-seems to have some difficulty clearing secretions. Will send to hospital for further treatment. On 05/23/22 at 6:01 P.M., Registered Nurse (RN) #230 noted facial swelling worsening and airway sounds compromised. Resident #46's daughter and sister agreed that the resident should go to the hospital. Patient transferred to the hospital. Review of the hospital records dated 05/23/22 at 5:56 P.M. revealed Resident #46 was admitted with severe sepsis mostly due to right parotiditis and right facial cellulitis. CT images suggestive of right parotiditis as well as right facial cellulitis. Also showed vague supraglottic edema with airway narrowing and mild epiglottic edema (swelling in throat). Resident #46 was admitted to Intensive Care Unit (ICU) for close monitoring. Review of Resident #46's physician orders revealed the resident completed Keflex 500 milligrams (mg) via gastrostomy tube (G-tube) four times a day for infection until 05/30/22 with a start date on 05/23/22. Review of the current physician orders for July 2022 revealed Resident #46 had an order to change peripherally inserted central catheter (PICC) dressing weekly dated 06/21/22. Additionally, Resident #46 had completed orders for Cefazolin Sodium Solution Reconstituted (an antibiotic) two grams (gm) with instructions to give two gm intravenously every eight hours for sepsis until 07/11/22 with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 6 of 36 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 07/25/2022 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 0580 start date on 06/23/22. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was rarely or never understood. Per the staff assessment, the resident had severely impaired cognition. Resident #46 required total dependence on two staff to complete Activities of Daily Living (ADLs). Residents Affected - Few Interview on 07/20/22 at 3:51 P.M. with the Assistant Director of Nursing (ADON) revealed Resident #46 started showing signs of facial swelling and redness on 05/22/22. The resident's daughter (who was a nurse) was notified and was not in agreement to having the resident sent to the hospital at that time and wanted to assess the resident herself. Resident #46 was stable at that time. Physician #302 assessed Resident #46 on 05/23/22 and wanted the resident to be sent out to the hospital. Resident #46's daughter was notified again and agreed to have the resident transported to the hospital. Resident #46 was sent out that same evening on 05/23/22. The ADON did not know if Resident #46's condition worsened after Physician #302 assessed her. Interview on 07/21/22 at 10:44 A.M. with Physician #302 revealed he recalled Resident #46's parotid infection case. The physician stated, usually we don't want to wait on that and would have the patient sent to the hospital but with Resident #46, the daughter was a nurse and was very involved with making healthcare decisions for the resident. The resident's daughter wanted to see the resident before she agreed to have the resident sent to the hospital. Physician #302 stated Resident #46's face was swollen and tender on 05/22/22. The CNP visited the resident that day and the physician's understanding was that the swelling had worsened a little bit and she did have some congestion but was stable and started on an antibiotic. When Physician #302 assessed Resident #46 on 05/23/22, the resident's face was pretty swollen and red and he felt the resident needed to go to the hospital for treatment but did not feel it was an emergent (911) situation. Physician #302 stated at that time the resident's daughter was notified that Resident #46's condition had worsened and the daughter agreed to have the resident sent to the hospital at that time. Physician #302 was not notified again of any additional changes in condition or that Resident #46's airway had become compromised prior to the resident being sent to the hospital. Interview via telephone on 07/21/22 at 12:27 P.M. with RN #230 revealed Physician #302 informed her he felt Resident #46 had a parotid infection and should be transferred to the hospital. RN #230 stated the resident had a low grade fever, swelling, and redness to her face. RN #230 was reminded of her note that she entered on 05/23/22 at 6:01 P.M. that noted Resident #46's airway appeared compromised. RN #230 stated she did not recall all of the details of the incident as it was a couple of months ago. RN #230 first indicated she was pretty sure she had called 911 to have the resident transported to the hospital but after being informed according to the nurse's notes, the resident was not transported for approximately three hours after being seen by the physician, the nurse stated she must have called the contracted transportation company to transport the resident. RN #230 confirmed she did not notify the physician of any changes in condition after she was told by the physician that the resident should go to the hospital. Review of the facility policy,Notification Of Change Of Condition, dated 11/22/21, revealed the policy stated, the facility will immediately inform the resident, consult with the resident's physician, nurse practitioner or clinical nurse specialist; and if known, notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status, a need to altar treatment significantly, and when a decision to transfer or discharge the resident from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 7 of 36 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 07/25/2022 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 Based on staff interview and facility policy review, the facility failed ensure newly hired employees had a criminal background check prior to beginning to work in the facility. This had the potential to affect all 56 residents residing in the facility. Residents Affected - Some Findings include: Review of personnel files with Human Resource #265 on 07/21/22 at approximately 3:00 P.M. revealed Maintenance #238 was hired on 06/09/22, Assistant Director of Nursing (ADON) #239 was hired on 07/14/21, Temporary Nurse Aide (TNA) #235 was hired on 05/05/22, and TPN #256 was hired on 03/25/22. He also confirmed the facility did not have documented evidence a criminal back ground check was completed for those identified employees. Interview on 07/21/22 at approximately 3:11 P.M. with Director of Nursing revealed if the personnel files did not contain the criminal background checks, the facility was not able to provide evidence the checks were completed. Review of the facility policy titled,Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 12/06/16, revealed the policy of the facility was to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. Further review of the policy revealed the facility was to do the following prior to hiring a new employee: conduct a criminal background check in accordance with Ohio law and the facility's policy. Review of the facility policy titled,Employment Process, dated 06/01/00, revealed 10 steps labeled with letters in the hiring process. Step B in the process included verification of personal and professional references. Step F in the process included a criminal convictions check. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 8 of 36 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 07/25/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #55 was admitted to the facility on [DATE]. Her diagnoses were senile degeneration, osteoarthritis, dementia, hypertension, hyperlipidemia, hearing loss, osteoporosis, and urinary incontinence. Residents Affected - Few Review of Resident #55 medical records revealed she was discharged from the facility on 05/17/22 to the community. This was confirmed via electronic progress notes dated 05/17/22 and 05/18/22. Review of her Minimum Data Set (MDS) assessment, dated 05/17/22, revealed the facility documented she was discharged to an acute hospital; which was not accurate. Interview with Registered Nurse (RN) #239 on 07/20/22 at 11:36 A.M. and 12:02 P.M. confirmed Resident #55 did discharge to the community and her MDS, dated [DATE], was not correct. Review of facility Resident Assessment (MDS) Policy and Procedures, dated 12/06/16, revealed data collected through observation, record review, resident interviews, and director care staff interviews on all shifts. The MDS RN is responsible for reviewing the MDS to assure it is completed, signed, and dated. Based on record review, review of minimum data set (MDS) assessments, staff interview, and facility policy review, the facility failed to ensure MDS assessments were completed accurately for two residents (Residents #2 and #55). The deficient practice affected two (Residents #2 and #55) of two residents reviewed for accurate assessments. Findings Include: 1. Review of the medical record for Resident #2 revealed an admission date on 01/15/22 with medical diagnoses including dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, and anxiety disorder. Review of the the physician orders for July 2022 revealed Resident #2 had orders for Seroquel (an antipsychotic) 50 milligrams (mg) daily dated 02/10/22 and Seroquel 100 mg daily at night dated 02/09/22. Review of the Medication Administration Record (MAR) for May, June, and July 2022 revealed Resident #2 was administered Seroquel twice daily as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under the medications section, Resident #2 received daily antipsychotic medication however, under the Gradual Dose Reduction (GDR) section, it was indicated no antipsychotic medications were received. Interview on 07/20/22 at 1:21 P.M. with the Assistant Director of Nursing (ADON)/MDS coordinator confirmed the medication section was not completed accurately. The MDS coordinator agreed to correct the assessment immediately. Review of the facility policy, Resident Assessment (MDS) Policy and Procedure, dated 12/06/16, revealed the policy stated, A MDS assessment will be completed according to the Medicare and OBRA guidelines. Each interdisciplinary team (IDT) member has access to the MDS 3.0 RAI manual. Each IDT member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 9 of 36 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 07/25/2022 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 is expected to be knowledgeable of this manual for ensuring accurate documentation on each resident. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #2 revealed an admission date on 01/15/22 with medical diagnoses including dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, and anxiety disorder. Residents Affected - Few Review of the nurse's notes dated from March 2022 to current revealed Resident #2 had a fall without any injuries on 03/17/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under the health conditions section, no falls were reported since admission. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under the health conditions section, no falls were reported since admission. Interview on 07/20/22 at 1:21 P.M. with the Assistant Director of Nursing (ADON)/MDS Coordinator confirmed the falls section of the assessment was not completed accurately. The MDS coordinator agreed to correct the assessment dated [DATE] immediately to reflect a fall had occurred without any injuries. Review of the facility policy, Resident Assessment (MDS) Policy and Procedure, dated 12/06/16, revealed the policy stated, A MDS assessment will be completed according to the Medicare and OBRA guidelines. Each interdisciplinary team (IDT) member has access to the MDS 3.0 RAI manual. Each IDT member is expected to be knowledgeable of this manual for ensuring accurate documentation on each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 10 of 36 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 07/25/2022 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, resident interviews, staff interviews, facility policy review, and resident council minutes review, the facility failed to offer activities to meet the residents needs and preferences. This affected one resident (Resident #5) of three residents reviewed for activities. The census was 56. Residents Affected - Few Findings Include: Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF) and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). Review of the physician orders for July revealed an order dated 04/09/22 for permission for the resident to participate in on and off campus activities. Review of the plan of care dated 04/09/22 revealed the resident's preferences were left blank but were identified and listed under approaches. Interventions included the resident and family being aware she can personalize her room, she preferred to assist in choosing her own clothing, and she preferred activities such as visiting with family, listening to the radio, and watching television. Review of the residents short stay activity screening dated 04/14/22 revealed the resident family stated she most likely will not get out of bed and was content being in her room listening to the radio and watching tv. Further review of the interview for activity preferences revealed the only very important thing to the resident were keeping up with the news, listening to music she liked was somewhat important to her, but doing things with groups of people were not important at all to the resident. Further review of the assessment revealed the resident did not wish to attend any activities. Review of Resident #5's activity participation notes revealed only three notes dated 06/10/22, 06/16/22, and 07/12/22 by a Chaplain who confirmed he had a personal and pastoral care visits with the resident on the listed dates. Review of the task titled, Activity/Leisure (A)Enjoys listening to the radio, listening to TV and visiting with family dated 06/21/22 through 07/19/22 revealed the only activity marked for Resident #5 was watching television. Review of the task titled, Activity/Leisure (A)PRN Document from 06/21/22 through 07/19/22 revealed documentation only on 06/28/22 stating Resident #5 watched television/movies. Interview on 07/18/22 at 9:21 A.M. with Resident #5 revealed she was unaware of any facility provided activities, denied staff providing her with things to do in her room, and stated she was almost blind so she was unable to watch television. Observations from 07/18/22 through 07/21/22 of house three revealed no activities provided to Resident #5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 11 of 36 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 07/25/2022 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/20/22 at 10:48 A.M. and 12:56 P.M. with Activities Coordinator #232 revealed the facility was a home like environment, so activities were offered as much as possible. He confirmed the facility had one big activity per day out side of Monday which was the day one on one visits occurred and BINGO occurred twice per month. He revealed outings occurred weekly, weather permitting, and there were two or three entertainers per month. He revealed the elderly assistants (EA), himself, and management invited residents to the activities and he confirmed they kept track of who was invited. He also revealed the EA's were responsible for daily activities within each house and examples of activities were walking the residents to the dining room for meals and listening to music in the dining room. He also confirmed the facility had an activities calendar and they were given to the EA's who were to distribute them as they see fit. Interview and observation on 07/20/22 at 12:54 P.M. with Resident #5 revealed no visible activities calendar or radio. She stated activities were never offered and she did not receive an activities calendar. Interview on 07/20/22 at 2:12 PM with EA #301 revealed EA's were responsible for activities in house and did painting, clay, and other things at the table to entertain residents but none to her knowledge were completed on 07/18/22 or 07/20/22 during her shift. She confirmed each house had a paper calendar of activities in the kitchen and a wall calendar of activities but did not recall seeing calendars in residents rooms. Interview on 07/20/22 at 2:42 PM with EA #700 revealed EA's were not responsible for activities but Activities Coordinator #232 was and therefore she did not provide activities for house three during her shifts on 07/19/22 and 07/20/22. Review of the resident council meeting minutes for 10/2021 revealed resident concerns for exercise activities. Review of the concern form dated 10/28/21 revealed the resolution was for more activities to be scheduled indoors and outdoor activities and outings were planned depending on weather conditions. Review of the resident council meeting minutes dated 11/2021 revealed the residents request for exercise added into the activity calendar as well as music sessions with staff. Review of the concern form dated 11/29/21 revealed the resolution was activities scheduled additional indoor activities, invited entertainers, as well as dining out activities were scheduled. Review of the resident council meeting minutes dated 01/2022 revealed residents wished for more frequent activities. Review of the concern form dated 01/2022 revealed the resolution was due to severe weather more indoor activities were scheduled. Review of the resident council meeting minutes dated 02/2022 revealed residents wanted more outings and bowling activities. Review of the concern form dated 02/24/22 revealed indoor activities were increased due to winter weather conditions and outings were scheduled weekly using the facility's transportation. Review of the resident council meeting minutes dated 03/2022 revealed residents wanted more outings (which the activity department was aware of and due to inclement weather the outings were cancelled). Review of the concern form dated 03/30/22 revealed the resolution was indoor activities were increased due to winter weather conditions and weekly outings were scheduled. Review of the resident council meeting minutes dated 04/2022 revealed the residents request for more outside activities and bowling. Review of the concern form dated 04/29/22 revealed the resolution was scheduled outings weekly. Review of the resident council meeting minutes dated 05/03/22 revealed residents request for more outside activities. Review of the concern form dated 05/25/22 revealed the resolution was due to COVID-19, activities scheduled additional indoor activities and some dining out. Review of the resident council meeting minutes dated 06/15/22 revealed residents requesting more outside activities (which was noted, the activity department was aware of and due to inclement weather were keeping residents inside). Review of the concern form dated 06/28/22 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 12 of 36 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 07/25/2022 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 0679 resolution was unchanged. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titledEngagement and Activity dated 11/26/19 revealed residents were to be offered activities to enhance her/his sense of well-being and to promote physical, cognitive, and emotional health. The activities included but were not limited to a monthly calendar of scheduled activities, on admission using information gathered on the MDS to determine activities of interest, resident would be engaged by all staff members for either one on one activities, group activities, or activities in which the elder showed interest, and the quality of life coordinator would provide materials for self-directed activities. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 13 of 36 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 07/25/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to monitor bruising on Resident #46's bilateral legs. The deficient practice affected one resident (Resident #46) of one resident reviewed for bruising/skin. Residents Affected - Few Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22 and readmission date on 06/20/22 with medical diagnoses including benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis, type II diabetes mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. Review of the readmission skin assessment dated [DATE] revealed Resident #46 did not have any bruising on her legs noted on the assessment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was rarely or never understood. Per the staff assessment, the resident had severely impaired cognition. Resident #46 required total dependence on two staff to complete Activities of Daily Living (ADLs). The resident did not have any skin bruising noted. Review of the current physician orders dated July 2022 revealed there were no orders for monitoring any bruising. Review of the skin assessment dated [DATE] revealed Resident #46 was not noted to have any bruising to her legs. There were no additional skin assessments included in the resident's medical record. Review of wound clinic notes dated from 06/20/22 to 07/19/22 revealed Resident #46 was not seen for any bruising on her legs. Review of the nurse's notes from readmission on [DATE] to current revealed there was no indication of bruising on Resident #46's legs was identified or being monitored. Review of the plan of care dated 07/09/22 revealed there was no indication that Resident #46 had bruising or that bruising of the resident's skin should be monitored. Observation on 07/18/22 at 1:21 P.M. of Resident #46 in her room. Resident #46 was non-verbal and bed bound. The resident was covered by a sheet and blanket. Upon looking under the covers, Resident #46's legs were observed to have scattered bruising on both lower legs and shins. The resident's left shin had a large purple-reddish area stretching from just above the ankle to below the knee. Both legs had several smaller round bruises ranging in color from purple to green to yellow scattered on both sides of her lower legs. Interview on 07/20/22 at 1:29 P.M. with the Director of Nursing (DON) revealed bruising on residents should be monitored by the nurse. If a cause was not able to be determined then an incident report was completed. Any bruising should be included on weekly skin assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 14 of 36 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 07/25/2022 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 on 07/20/22 at 2:08 P.M. with Registered Nurse (RN) #276 revealed she was familiar and had cared for Resident #46 regularly. RN #276 stated the resident had fragile and thin skin. The nurse stated any bruising should be monitored. The nurse stated the staff completed both daily and weekly skin assessments and any bruising should be noted on the assessments. RN #276 stated the assessments were completed by the Elderly Assistants (EA) and were documented on either paper or in the electronic medical record. RN #276 stated she was aware Resident #46 had skin tears on each elbow and on the back of her hand but was not aware of any skin issues, including bruising, to the resident's legs. Interview and observation on 07/20/22 at 2:17 P.M. with RN #276 of Resident #46 in the resident's room confirmed Resident #46 had scattered bruising on both lower legs and shins. RN #276 confirmed there had not been any bruising documented on any of the skin assessments and she had not been monitoring the bruising because she was not aware of the areas. Review of the facility policy, Skin Care Management, dated 11/02/18, revealed the policy stated, implement, monitor, and modify if needed appropriate strategies to attain or maintain intact skin, prevent complications, promptly identify and manage complications, and involve resident and caregiver in skin management. This deficiency is a recite from the survey dated 06/23/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 15 of 36 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 07/25/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy review, the facility failed to timely investigate a fall with major injury and failed to complete neurochecks per facility protocol for Resident #2. The deficient practice affected one resident (Resident #2) of two residents reviewed for accidents. Findings Include: Review of the medical record for Resident #2 revealed an admission date on 01/15/22. Medical diagnoses included dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, and shortness of breath (SOB). Review of the fall risk assessments dated 01/15/22, 03/31/22, and 06/24/22 revealed the resident was at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was rarely or never understood. Per staff assessment, Resident #2 had severely impaired cognition. Resident #2 required extensive assistance from one staff for most Activities of Daily Living (ADLs) including bed mobility, transfers, dressing and toileting but only requires supervision with set up help only with locomotion. The resident had not had any falls with injury since admission. Review of the nurse's notes dated from admission on [DATE] to current revealed Resident #2 displayed wandering and exit seeking behaviors. Resident #2 had a fall on 03/17/22 without any injuries. There were not any notes related to a fall with major injury included in the medical record. Review of the facility matrix form completed on 07/18/22 revealed Resident #2 had a fall with major injury. Review of Medication Administration Record (MAR) for July 2022 revealed Resident #2 did not report any pain until 07/16/22 where a pain level of five was documented. Resident #2 was administered Tramadol Hydrochloride (HCl) 50 milligrams (mg) as needed for pain twice on 07/16/22 and once on 07/17/22. Review of the plan of care revised 07/01/22 revealed Resident #2 was at risk for falls with a fall with nasal fracture noted on 07/15/22 that was added to the care plan on 07/17/22. Interventions included keep call light in reach, educated the resident related to safety, wear appropriate footwear when ambulating or in wheelchair, keep area clutter free, keep needed items within reach, keep phone close to chair if possible, remind to use rollator, and staff to offer toileting and/or pericare upon rising, before and after meals, at night and as needed. Review of the incident report dated 07/14/22 at 11 19 P.M. revealed Resident #2 had an unwitnessed fall in his room. At 11:25 P.M., the aide notified the nurse Resident #2 had fallen while trying to leave his room and go to church. The resident was noted to be confused and alert. The resident had a small open cut in the middle of his head as well as bleeding from his nose. The resident denied having any pain. 911 was called and Resident #2 was transported to the hospital. The physician, family, and hospice was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 16 of 36 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 07/25/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of hospital records dated 07/15/22 revealed Resident #2 was seen in the emergency room following a fall. X-rays were completed and revealed the resident had nasal bone fractures as well as a cut to his forehead that required three stitches and a cut to the bridge of his nose that required two stitches. Review of neurological checks dated 07/15/22 revealed Resident #2 received the neurological checks upon returning from hospital at 7:00 A.M. and 9:00 P.M. on 07/15/22, 8:21 A.M. and 11:30 P.M. on 07/16/22, and 8:30 A.M. on 07/17/22. A fall investigation report was not included in the medical record or provided by the facility as requested. Review of the facility matrix form completed on 07/18/22 revealed Resident #2 had a fall with major injury. Observation on 07/18/22 at 2:27 P.M. of Resident #2 sitting at the dining room table revealed the resident had bruising under both eyes as well as stitches placed in the middle of his forehead and on the bridge of his nose. Interview on 07/20/22 at 8:54 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #2 had a fall on 07/14/22 just before midnight. The resident fell on his face and x-rays confirmed he suffered a broken nose as well as needed a total of five stitches to close two facial lacerations. The resident returned to the facility the same day, a few hours after being sent out for treatment. The ADON confirmed there was no documentation of the fall in the nurse's notes and a fall investigation was not been completed on the fall until surveyor requested the information. An email from the Director of Nursing (DON) on 07/20/22 at 3:21 P.M. revealed neurological checks should be completed every 15 minutes for one hour, every 30 minutes for one hour, every four hours for one day, and every shift for one day. When a resident was sent to the hospital for treatment but required neurological checks to be completed that the checks should start according to how long the resident was out of the building and should be completed per protocol until the appropriate amount time has been completed. Interview on 07/20/22 at 3:41 P.M. with the ADON confirmed Resident #2 should have had neurological checks completed every four hours for one day, then every shift for one day when he returned from the hospital. The ADON confirmed according to the documentation, staff only completed the neurological checks on each shift. Review of the facility policy, Falls Management, dated 12/03/19, revealed the policy stated, the documentation in the progress notes in the resident's medical record should be written to include a complete account of the events surrounding the fall, include notification of the family and physician and what interventions were instituted to prevent further falls. Remember if there is evidence of head trauma or if it is an unwitnessed fall, neurochecks must be completed per protocol. The interdisciplinary team will meet to review the fall to determine if any additional interventions are needed. The Director of Nursing or designee will add the IDT summation note to the medical record in the progress note following the IDT meeting being held. The DON will then review the accident and incident form in the medical record, add the summation of the investigation to this form and close the report in the electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 17 of 36 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 07/25/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and Resident #17 received nutritional supplements as ordered. This affected two Residents (#4 and #17) of two residents reviewed for nutrition. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed an initial admission date of 08/18/15 and a re-entry date of 03/23/20 with diagnoses including anemia and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident was rarely/never understood, had long and short-term memory problems, and was moderately cognitively impaired. The resident required extensive assistance of two or more staff for all Activities of daily Living (ADL's). Review of the plan of care dated 07/07/22 revealed the resident had congestive heart failure with a risk for breathing issues, edema, and weight fluctuations. Interventions included monitoring cardiac status, check breath sounds, and monitor/document labored breathing and/or the use of accessory muscles while breathing. Observation on 07/19/22 at 12:41 P.M. and 07/20/22 at 1:10 P.M. revealed Resident #4 independently eating lunch. Interview on 07/21/22 at 11:42 A.M. with Resident #4 revealed she had not had any ensure yet for the day. Interview on 07/20/22 at 2:12 P.M. with Elder Assistant (EA) #301 revealed as of Monday (07/18/22) she was not sure who received ensures since the residents information was not readily available in the stock room where their diets and supplements were supposed to be noted for the agency staff. She revealed the residents did not receive supplements as ordered on Monday. Interview on 07/20/22 3:49 P.M. with Dietician #300 confirmed the lack of ensure intake documentation for Residents #4. He stated he could not defend the gaps in documentation and could not provide evidence of the supplement being provided per orders. Interview on 07/21/22 at 11:37 A.M. with Assistant Director of Nursing (ADON) confirmed ensure intakes for Resident #4 were documented in tasks and if it was not documented it had to be assumed it was not provided per orders. Interview on 07/21/22 at 11:42 A.M. with Elderly Assistant #223 revealed she had not provided any ensure to any residents and she did not know which residents were to get ensures. 2. Review of the medical record for Resident #17 revealed an admission date of 10/24/17 with diagnoses including fracture of the right tibia shaft, protein-calorie malnutrition, Alzheimer's disease, osteoarthritis, lumbar region intervertebral disc degeneration, dementia, need for assistance with personal care, unsteadiness on her feet, mood disorder, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/26/22, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 18 of 36 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 07/25/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 (severe cognitive impairment). The resident required extensive to total assistance of one to two staff members for all Activities of daily Living (ADL's) including eating. Review of Resident #17's care plan dated 11/28/18 revealed the resident was at possible nutrition risk due to the use of a mechanically altered diet, low body mass index, poor oral intake, and significant weight change in June 2022. Interventions included assist her with eating as needed, if she did not like the food being served or did not eat more than 50% offer her a substitution, monitor ensure intake, offer the diet order by her physician, and if her oral intake decreased, encourage her family to bring in foods she liked. Review of the physician orders revealed an order dated 12/23/21 for an ensure supplement, three times per day. The order was discontinued on 06/06/22 when ensure enlive advanced therapeutic nutrition shake was ordered three times per day. The resident also had orders for a regular diet, mechanical soft texture, nectar consistency and remeron 7.5 mg (appetite stimulant). Review of Resident #17's progress note dated 6/6/2022 at 2:04 P.M. by Dietetic Technician #203 revealed the resident had a significant weight loss of 10.8 pounds, 11.7% in one month. The resident received Ensure Original three times a day (TID) for additional 660 kcalories (kcals) and 27 grams (g) of protein. T he resident received assistance with eating and was recommend switching her from Ensure Original to Ensure Enlive TID to better meet her needs. The ensure enlive (eight ounces (oz)) would provide 350 kcals and 20 g of protein. Review of Resident #17's Nutritional Supplement-Ensure Enlive three times per day, with meals (likes chocolate) task documentation from 06/21/22 through 07/19/22 revealed the resident drank 75% on 06/21/22 one time a day documented, on 06/22/22 she drank 50 to 75% all three times, on 06/23/22 she drank 100% one time a day intake was documented, she drank 50% all three times on 06/24/22, 50 to 75% on 06/26/22 through 06/27/22 when intake was documented once per day, 50 and 75% on 06/28/22 the two times it was documented, 06/29/22 the resident consumed 50% the one time intake was documented, 100% on 06/30/22 the one time intake was documented, intake was documented once on 07/02/22 as 100%, 07/05/22 her intake was 25% the one time it was documented, 07/06/22 she drank between 0 and 50% all three times, 07/08/22 the resident had one intake documented as 100%, 07/10/22 the resident had one intake documented as 50%, 07/13/22 the resident consumed between 0 to 50% all three times, 07/16/22 the resident consumed 75-100% all three times, and 07/18/22 the resident had one intake documented as 100%. Review of the Nutrition/Snacks (offer snacks between meals) document if accepted task from 06/22/22 through 07/19/22 revealed there was only four days the resident accepted a snack (06/22/22, 06/24/22, 07/13/22, and 07/16/22). Review of the task titled, ADL/Eating:(Needs assist with feeding all meals) from 06/21/22 through 07/19/22 revealed Resident #17 was marked as independent for 12 of the 29 documented meals (not all meals were documented each day), required supervision for seven, meals and limited to total assistance for the remaining meals. Review of the task titled, Nutrition/Amount Eaten: (Regular diet, mechanical soft texture, nectar thickened liquids). Document percent (%) consumed. Likes McDonalds, ice cream and pies dated 06/21/22 through 07/19/22 revealed Resident #17 usually ate between 51% to 75% of her meal, but ate 26 to 50% on three occasions, and ate 76%-100% on two occasions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 19 of 36 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 07/25/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #17's progress note dated 7/6/2022 at 4:38 P.M. by Dietetic Technician #203 revealed the resident had a significant weight loss of 11.7 pounds (#), and 12.2% loss in 6 months. The resident had a leg fracture (fx) and was hospitalized , her weight was trending up, recently, with a 2.6 # gain in 1 month. The resident received Ensure Enlive three times per day (TID) and Remeron 7.5 mg for appetite. Observations on 07/18/22 through 07/21/22 revealed only one observation of an ensure being provided to another resident, which was not Resident #17. Observation on 07/19/22 at 12:53 P.M. and 1:31 P.M. and 07/20/22 01:40 P.M. revealed Resident #17 was eating independently. Interview on 07/20/22 at 2:12 P.M. with EA #301 revealed as of Monday (07/18/22) she was not sure who received ensures since the residents information was not readily available in the stock room where their diets and supplements were supposed to be noted for the agency staff. She revealed the residents did not receive supplements as ordered on Monday. Interview on 07/20/22 at 3:49 P.M. with Dietician #300 confirmed the lack of ensure intake documentation for Residents #17. He stated he could not defend the gaps in documentation and could not provide evidence of the supplement being provided per orders. Interview on 07/21/22 at 11:37 A.M. with ADON confirmed ensure intakes for Resident #17 were documented in tasks and if it was not documented it had to be assumed it was not provided per orders. Interview on 07/21/22 at 11:42 A.M. with EA #223 revealed she had not provided any ensure to any residents and she did not know which residents were to get ensures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 20 of 36 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 07/25/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure oxygen (O2) was administered, stored, labeled, and dated properly. This affected three residents (Resident #4, #5, and #52) of three residents reviewed for respiratory care. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF) and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). Further review of the MDS revealed the resident received oxygen therapy. Review of the plan of care dated 04/09/22 revealed Resident #5 had alteration in her respiratory status related to acute/chronic respiratory failure. Interventions included administration of humidified oxygen as ordered. Review of the residents oxygen (O2) saturation (sat) documentation from 04/22/22 (when her continuous O2 was ordered) through 07/19/22 revealed the residents O2 sat was documented on O2 per nasal cannula 12 out of the 43 recorded O2 sats. The remaining O2 sats were documented as the resident being on room air despite the resident having continuous O2 ordered. Review of physician orders for July 2022 identified orders to change oxygen tubing weekly every Sunday on night shift and oxygen at two to five liters per minute (L/min) via nasal cannula (NC). Both orders were ordered on 04/22/22. Review of the Electronic Treatment Administration Record (ETAR) for July 2022 revealed the oxygen tubing was signed off as changed on 07/03/22, 07/10/22, and 07/17/22. Interview and observation on 07/18/22 at 9:23 A.M. with Resident #5 revealed she believed her oxygen tubing was changed within the last week but was not sure the exact date. Interview and observation on 07/18/22 at 9:24 A.M. with Elderly Assistant (EA) #301 revealed Resident #5's O2 and breathing treatment tubing were not dated and the residents breathing treatment mask was stored in her recliner. She confirmed the facility's policy was for the tubing to be dated and mask to be stored in a plastic bag when it was not in use. 2. Review of the medical record for Resident #52 revealed an admission date of 05/05/22 with diagnoses including dementia and Parkinson's Disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of 15 (severe cognitive impairment). The resident required up to extensive assistance of two or more staff for all Activities of daily Living (ADL's). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 21 of 36 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 07/25/2022 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 0695 Review of the plan of care dated 06/30/22 revealed no respiratory care plan. Level of Harm - Minimal harm or potential for actual harm Review of Resident #52's vital signs revealed on 07/01/22 the residents oxygen saturation (O2 sat) was 96 percent (%) on oxygen per nasal cannula. Residents Affected - Few Review of physician orders for July 2022 and all discontinued orders identified no orders for oxygen or oxygen tubing. Observation on 07/18/22 at 09:46 A.M. revealed Resident #52 had an oxygen (O2) concentrator, next to his bed, that was turned off, and with tubing that was undated and laying on the floor. The observation as confirmed on 07/18/22 at 11:00 AM with Coach #237 who revealed O2 tubing should be stored in a bag when not in use and she was not sure if O2 tubing had to be labeled and dated but she revealed staff used the EMAR to know when the tubing was last changed. She also revealed the resident was on O2 as needed and did not require continuous O2. Interview on 07/18/22 at 11:02 A.M. with Licensed Practical Nurse (LPN) #202 confirmed O2 tubing was to be labeled, dated, and stored in a bag when not in use. Interview on 07/18/22 at 11:17 A.M. with EA #301 revealed she believed Resident #52 only used oxygen at night. Interview on 07/18/22 at approximately 11:30 A.M. with Resident #52 confirmed he only used oxygen when he needed it at bedtime. Interview on 07/19/22 at 9:49 A.M., 10:03 A.M., 10:18 A.M., and 12:35 P.M. with Director of Nursing (DON) confirmed Resident #52 did not have orders for oxygen, and was unsure why the resident had oxygen (O2) concentrators in their room. DON revealed Resident #52 was readmitted to the facility with O2, the nurses trialed him on and off the oxygen, determined the resident did not need oxygen, and the concentrator was not removed from his room. 3. Review of the medical record for Resident #4 revealed an initial admission date of 08/18/15 and a re-entry date of 03/23/20 with diagnoses including anemia and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident was rarely/never understood, had long and short-term memory problems, and was moderately cognitively impaired. The resident required up to extensive assistance of two or more staff for all Activities of daily Living (ADL's). Review of Resident #4's vital signs revealed on 04/18/22 and 06/04/22 the residents oxygen saturation (O2 sat) was 99% and 97.3% on oxygen per mask and nasal cannula. Review of the plan of care dated 07/07/22 revealed the resident had congestive heart failure with a risk for breathing issues, edema, and weight fluctuations. Interventions included monitoring cardiac status, check breath sounds, and monitor/document labored breathing and/or the use of accessory muscles while breathing. Review of physician orders for July 2022 and all discontinued orders identified no orders for oxygen or oxygen tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 22 of 36 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 07/25/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 07/18/22 at 09:01 A.M., 10:55 A.M., and 12:16 P.M. revealed Resident #4 had an oxygen concentrator next to her bed. The concentrator was turned off and the tubing was laying on top of the machine. The tubing was undated. The observation was confirmed on 07/18/22 at 12:23 PM with Coach #237 who confirmed the residents O2 tubing was not labeled, dated, or stored per facility policy. Interview on 07/19/22 at 9:49 A.M., 10:03 A.M., 10:18 A.M., and 12:35 P.M. with the DON revealed Resident #4 did not have orders for oxygen and was unsure why the resident had an oxygen (O2) concentrator in their rooms. DON revealed Resident #4 used O2 on 07/09/22 during an emergent episode and an order was never placed. Review of the facility policy titled, Oxygen administration, long-term care undated revealed the oxygen order was to be verified prior to providing Oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 23 of 36 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 07/25/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on staff interview, resident interview, observations, and facility policy review, the facility failed to sufficiently staff house three to meet the needs of residents. This affected all 12 residents (Resident #4, #5, #6, #9, #17, #24, #30, #36, #38, #52, #203, and #204) of 12 residents residing in House Three. Findings include: Review of the facility assessment revised 01/01/22 revealed the general staffing plan to ensure the facility had sufficient staff to meet the needs of the residents at any given time, consider if and how the degree of fluctuation in the census, and acuity levels impact staffing needs. The staffing plan included one director of nursing (DON), one assistant director of nursing (ADON), one minimum data set (MDS) nurse, who were all full time on days, two floor nurses on days and on nights, 10 elder assistants (EA) on days and evenings and five EA's on nightshift, a business office Manger (BOM), quality of life coordinator full time on days, housing coordinator full time on days, maintenance full time on days, a coach full time on days, and a guide full time on days. Review of the MDS assessments for residents in House Three revealed eight of the 12 resident residing in the house needed at least extensive assistance of two staff members for bed mobility and/or transfers. Further review of the MDS for the residents residing in House Three revealed four residents required supervision of one staff member, one resident required limited assistance of one staff member, and four resident required extensive assistance of one staff member. Review of the Alarm Average Response Time Report dated 06/20/22 through 07/20/22 for House Three (containing the 300 rooms) revealed the average call light wait time was 25 minutes and 10 seconds. Review of the resident council meeting minutes for 10/2021 revealed resident concerns regarding long call light/pendant wait times. Review of the concern form dated 10/28/21 revealed the resolution including scheduling staff so agency was not working alone, providing agency a schedule to follow when they were filling a position, and agency to work along side permanent staff to ensure the needs of residents were being met. Review of the resident council meeting minutes for 11/2021 revealed the residents concern for long call light wait times. Review of the concern form dated 11/29/21 revealed the resolution was the staff schedule was changed to ensure agency personnel were not working alone and were working with permanent staff. Review of the resident council meeting minutes for 01/2022 revealed residents concerns for long call light wait times. Review of the concern form dated 01/2022 revealed the resolution was pendant and pagers batteries were check and ensured proper functioning. Review of the resident council meeting minutes for 02/2022 revealed residents concerns for long call light wait times. Review of the concern form dated 02/24/22 revealed the resolution included pendant and pagers batteries were check and ensured proper functioning. Review of the resident council meeting minutes for 03/2022 revealed resident concerns regarding long call light wait times. Review of the concern form dated 03/30/22 revealed there was no resolution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 24 of 36 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 07/25/2022 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 0725 for the concern of long call light wait times. Level of Harm - Minimal harm or potential for actual harm Review of the resident council meeting minutes for 04/2022 resident concerns for weekend staff to improve long call light wait times. Review of the concern form dated 04/29/22 revealed pendant and pagers batteries were check and ensured proper functioning. Residents Affected - Some Review of the resident council meeting minutes for 05/03/22 revealed residents concerns of long call light wait times. Review of the concern form dated 05/25/22 revealed the resolution consisted of the staffing schedule being changed to ensure agency personnel were not working alone and were working with permanent staff to ensure cleaning and care of the residents were met and the expectation was that agency would better understand the facility call light policy using pendants. Review of the resident council meeting minutes for 06/15/22 revealed residents were concerned for long call light wait times. Review of the concern form dated 06/28/22 revealed the resolution included staffing schedule being changed to ensure agency personnel were not working alone and were working with permanent staff to ensure cleaning and care of the residents were met and pendant and pagers batteries were checked and replaced, pendants and pagers were properly working. Interview and observation on 07/18/22 at 8:53 A.M. revealed Resident #24 stated poop poop poop when asked if he needed cleaned up he responded yes, with no visible call light within reach, and the resident was unsure where his call light was located. Interview on 07/18/22 08:54 A.M. with EA #301 revealed the residents called for help with the call pendant which was to be around the residents neck or on the residents tray which alarms the EA's pagers The surveyor informed the EA of the Resident #24's need for assistance. At 07/18/22 08:58 A.M. Resident #24's call pendent was observed to the left of the resident, on the residents table, inside a green bowl, where the resident stated he was unable to reach it. Interview on 07/18/22 08:59 AM with EA #301 confirmed Resident #24 was not able to reach his call light, the resident told the aide poop poop poop and the aide confirmed the residents need for incontinence care, stating your a two person assist, let me get some assistance. The care was provided approximately 10 minutes later. The observation was confirmed immediately following the observation with EA #301. Interview on 07/18/22 at 9:02 A.M. with Resident #203 and his Family Member revealed call lights are not answered timely. Interview on 07/18/22 at 09:16 A.M. with Resident #6 revealed call lights were not answered timely. Interview on 07/20/22 at 11:07 A.M. during the resident council meeting with Resident #19 and Resident #21 revealed call lights were not answered timely. Observation and Interview on 07/20/22 at 9:42 A.M. revealed Resident #5 stated she needed assistance with incontinence care and she initiated her call light. Interview 10 minutes later on 07/20/22 at 9:52 AM with Elderly Assistant (EA) #700 revealed there were no call lights going off, there was no pager in House Three to receive call lights, but the laptop on the kitchen counter would announce call lights. She stated she was the only EA in the house from 9:30 A.M. until the EA was scheduled to arrive back at 11:30 A.M. After informing the EA Resident #5 needed assistance with incontinence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 25 of 36 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 07/25/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care and pressed her call pendant approximately 10 minutes prior to the interview, Licensed Practical Nurse (LPN) #202 revealed the staff had not logged into the call light system, therefore were not being notified of call lights going off. Twelve minutes after initiating her call light for assistance, EA #700 entered the residents room to provide assistance. The resident reminded the EA she was supposed to be getting her coffee and informed her of her need for incontinence care. The EA did not dispute the residents statement of requesting coffee previously. At 10:00 A.M., EA #700 entered the residents room, provided the coffee, and informed the resident she would return to provide incontinence care. She exited the residents room and resumed serving breakfast, while LPN #202 administered medication, and EA #223 revealed it was her first day and she was observing. Observation on 07/20/22 at 10:03 A.M. revealed Coach #237 fixed the pager so the EA could receive call light notifications. Observation on 07/20/22 at 10:09 A.M. with EA #700 revealed she entered Resident #5's room (27 minutes after initiating her call light and surveyor intervention) to provide incontinence care. After providing incontinence care the resident requested to be pulled up in bed but was informed by the STNA there was no additional staff member to assist her. Interview on 07/20/22 at 10:40 A.M. with EA #700 revealed due to staffing she was unable to answer call lights timely, provide resident care immediately, and was unable to pull the resident up in bed resulting in the resident verbalizing she was uncomfortable in bed but would lay in that position until the EA had help to pull her up in bed. Interview on 07/20/22 at 1:07 P.M. with Administrator revealed resident council concern forms & appearance of the same interventions being implemented for multiple months for the same concerns without any effectiveness was discussed. The Administrator did not seem to understand the concern and indicated when it came to call lights, when there is a problem with the call light, the staff kept extra batteries and checked the resident pendants. The Administrator indicated call light audits were not needed because the houses are so small, all of rooms could be seen. The Administrator did not address response times and what the facility had implemented to try to resolve this concern. During the same interview the DON and ADON revealed they had done other things to address reoccurring concerns as well that are not listed on the concern forms such as education, stimulation, reminders, weekend/evening observations, and regular contact with the IT department. Interview on 07/20/22 at 2:12 P.M. with EA #301 revealed she was unable to get all her job duties completed, often times work was left undone, and care unprovided as well as long call light wait times as a result of not having sufficient staff. She revealed most of the time the nurses do not help when needed and management outside of Coach #237 did not help. She also revealed EA's were responsible for activities in the house, cooking, cleaning (housekeeping), laundry, accuchecks, and resident care amongst some of their job duties. Interview on 7/20/22 at 4:27 P.M. with Coach #237 stated she would expect staff to answer call lights within 15 minutes at the most. She confirmed an average response of 25 minutes was not good and she was not happy with that. She stated they are having some issues with some of the resident's pendants not resetting when answered by staff but stated it was scattered and should not have affected the average call light wait time significantly. Interview on 07/21/22 at 10:48 A.M. with Coach #237 revealed normal staffing consisted of two aides for each house, occasionally a call off occurred or an agency member did not show up so the coach, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 26 of 36 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 07/25/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scheduler, or another EA from another building would fill in while the scheduler attempted to find coverage. She revealed long call light wait times were occasionally a concern and as a resolution the facility first checked pendant batteries and functioning, then provided education to the aides. She confirmed another resolution consisted of staffing each house with one permanent staff member and one agency aide but confirmed House Three had two agency staff members all week as a result of other EA's not working well in other houses. She confirmed the agency staff scheduled in the building during the week were not strong which caused delay in care for residents. Review of the facility provided long call light wait time interventions/resolutions, undated, revealed the facility always started out with changing the batteries to the pendant and pager if needed, contact the nurses and EA's to see if there was an issue, run a simulation which consisted of initiating the call light and ensuring the call light was relayed to the pager, remind staff to reset the pendants, the administrator made weekend and evening observations but could provide no documented evidence of the observation, and staff kept in contact with the IT department regularly when there was an issue. Review of the facility policy titled, Call System/Overhead Paging revised 05/28/14 revealed the call system was initiated by pressing the emergency pendant or by pulling a bath cord. Review of the facility policy titled,Emergency Staffing Plan revised 01/22/22 revealed the facility understood the normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances. Further review of the policy revealed qualified partners could be re-deployed into different roles with the facility, staff who were not affected would be contacted and asked to pick up shifts, and temporary staffing agency(s) would be used to assist with staffing needs. The policy revealed maintaining appropriate staffing in healthcare facilities was essential to providing a safe work environment for healthcare personnel (HCP) and for safe patient care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 27 of 36 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 07/25/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to timely and adequately review pharmacy recommendations. This affected one (Resident #48) of five residents reviewed for unnecessary medications. Findings Include: Resident #48 was admitted to the facility on [DATE] with diagnoses including pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of Resident #48's Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a pharmacy recommendation made on 09/07/21 to review Duloxetine 60 milligrams (mg) for a gradual dose reduction (GDR). Physician disagreed with the recommendation with the justification of follows psych. It was signed by the physician on 09/09/21. Facility psychiatrist made a progress note entry on 10/23/21, which did not discuss the recommendation for a GDR regarding Duloxetine. Also, another pharmacy recommendation made on 03/04/22 to review Duloxetine 60 mg for a GDR. Physician disagreed with the recommendation with the justification of follows psych. It was signed by the physician on 03/10/22. Facility psychiatrist made a progress note entry on 05/29/22, which did not discuss the recommendation for a GDR regarding Duloxetine. Interview with Assistant Director of Nursing (ADON) #239 on 07/21/22 at 10:46 A.M. and 11:38 A.M., confirmed the pharmacy recommendations made for Resident #48 were not thoroughly and timely reviewed by the psychiatrist. She confirmed the facility physician reviewed each pharmacy recommendation, but the justification for the psychotropic medication GDRs were that Resident #48 follows psych. Review of facility Medical Regimen Review policy, dated 11/13/17, revealed the pharmacist must report any irregularities to the attending physician, the community's medical director, and the director of nursing (DON) and these reports must be acted upon in a manner that meets the needs of the residents. If the attending physician declines or otherwise rejects the consulting pharmacist's recommendation, and explanation as to the rationale for the rejection shall be documented in the resident's medical record or on the pharmacy recommendation itself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 28 of 36 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 07/25/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two residents (Resident #2, and Resident #48) of five residents reviewed for unnecessary medications. The census was 56. Findings Include: 1. Resident #48 was admitted to the facility on [DATE]. Her diagnoses were pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a physician order for Zyprexa (antipsychotic medication) 2.5 milligrams (mg). The justification documented for this medication was dementia with psychosis. Review of Resident #48 diagnoses list and medical record, revealed she did not have a documented diagnosis of psychosis. Also, Resident #48 had a physician order for Depakote Sprinkles (anticonvulsant medication) 125 mg with the documented justification as Alzheimer's disease. Interview with Assistant Director of Nursing (ADON) #239 on 07/21/22 at 11:38 A.M. confirmed the justification documented for Resident #48 Zyprexa and Depakote Sprinkles were were not appropriate for the medications ordered. 2. Review of the medical record for Resident #2 revealed an admission date on 01/15/22 with diagnoses including dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, and shortness of breath (SOB). Review of the current physician orders for July 2022 revealed Resident #2 had orders for Seroquel (an antipsychotic) 50 milligrams (mg) daily and 100 mg at night daily related to dementia without behavioral disturbance dated 02/09/22 and 02/10/22. Review of the Medication Administration Record (MAR) for May, June, and July 2022 revealed Resident #2 received the antipsychotic medication twice daily as ordered. Interview on 07/21/22 at 11:43 A.M. with the Director of Nursing (DON) confirmed Resident #2 was ordered an antipsychotic (Seroquel) without an appropriate medical diagnosis/justification. The DON stated the hospice physician ordered the medication and would not change the diagnosis. The DON confirmed she was aware dementia was not an appropriate diagnosis for the antipsychotic medication. A facility policy was requested related to appropriate justification for the use of antipsychotics during the survey period. The only policy provided was, Gradual Dose Reduction (GDR) Policy and Procedure, dated 11/29/17, that does not address the deficient practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 29 of 36 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 07/25/2022 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, resident interview, staff interviews, and facility meal schedule review, the facility failed to provide an adequate number of dietary staff to ensure food was delivered/served in a palatable and appetizing manner. This had the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed for meal service. Findings Include: Observations on 07/20/22 from 11:45 A.M. to 12:55 P.M., revealed Elder Assistant (EA) #301 was only staff preparing and cooking all the food items for residents in the 300 house. During the food preparation and cooking period, no residents were being served food, because she was responsible for continuing to cook all the resident food and prepare side dishes, including beginning stages of cutting a watermelon. At 12:25 P.M., Dietitian #300 stepped in and assisted EA #301 with cutting the watermelon so she could finish preparing and cooking the hamburgers, baked beans and french fries. At 11:55 A.M., 12:24 P.M., and 12:46 P.M., Resident #301 told staff that was walking around her that she was hungry. She was offered (and ate) watermelon at approximately 12:16 P.M. After eating that, she was asked if the watermelon was good. Her response was, yes, but I'm not satisfied. I won't be satisfied until the food is in my mouth. The first plate was served to the residents, who had been sitting in the dining room since 11:50 A.M., at 12:55 P.M. At 1:28 P.M., a test tray was completed, which revealed the following temperatures for the food: hamburger was 89 degrees, french fries were 84 degrees, and the baked beans were 101 degrees. Surveyor ate portions of each food, and all were cold. Interview with EA #301 on 07/20/22 at 1:30 P.M. confirmed food is constantly cold when sent to the rooms. This is due to her having to cook/prepare everything, and then trying to serve all residents at the same time. She confirmed residents have complained about cold food and the timeliness of being served. They will heat up the food if a resident requests it. The schedule they have required the aides to prepare, cook, and serve all meals, but at the same time, still provide resident care during that time. She confirmed she is only one person and can't do everything. On 07/20/22, she confirmed they had one aide (who was feeding a resident), another aide in training who was told she was not able to physically help anyone in the homes yet, and her in the facility to assist the residents and complete meal service. During meals times, she stated there was not enough staff because she was responsible for everything. Interview with Resident #5 on 07/20/22 at 1:47 P.M. confirmed food is constantly cold when brought to her room. She stated she does not know why it takes so long for meals to get to her; which contributes to her meals being cold. Review of facility Meal Times policy, dated 06/29/09, revealed lunch is a family style meal served between 11:30 A.M. and 2:00 P.M. as determined by the activities in the house each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 30 of 36 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 07/25/2022 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on Observations, resident interview, staff interviews, and facility policy review, the facility failed to serve food at a safe and appetizing temperature. This had to the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed as being served meals. Residents Affected - Some Findings Include: Observations on 07/20/22, starting at 11:45 A.M., revealed Elder Assistant (EA) #301 started to cook lunch, which included hamburgers, baked beans, and french fries. At 12:12 P.M., the first seven hamburgers were completed and the cooking temperatures were between 172 and 187 degrees Fahrenheit. The hamburgers were placed on a dinner plate and put into the microwave. At 12:34 P.M., seven more hamburgers were cooked, with cooking temperatures being between 164 and 180 degrees. They were placed on top of the already cooked hamburgers that were on the dinner plate. All of them were then covered with aluminum foil and placed on the kitchen counter. At 12:43 P.M., the french fries were taken out of the oven and placed on the stove and kitchen counter; no cooking temperature was taken but there was a sizzling sound made from the fries on the pan. At 12:46 P.M., baked beans were taken out of the microwave after being cooked/warmed up. The cooking temperature was not taken, but aluminum foil was placed on top of the bowl and placed on the counter. At 12:50 P.M., the last two hamburgers were cooked and the cooking temperature was 152 and 162 degrees. At 12:55 P.M., the first resident was served food in the dining room. Progressively, until 1:25 P.M., EA #301 plated and served each of the 12 residents that ate lunch that day. At 1:28 P.M., a test tray was completed, which revealed the following temperatures for the food: hamburger was 89 degrees, french fries were 84 degrees, and the baked beans were 101 degrees. Surveyor ate portions of each food, and all were cold. Interview with EA #301 on 07/20/22 at 1:30 P.M. confirmed food is constantly cold when sent out to be eaten. This is due to her having to cook/prepare everything, and then trying to serve all residents at the same time. She confirmed residents have complained about cold food, and the timeliness of being served. Interview with Resident #5 on 07/20/22 at 1:47 P.M. confirmed food is constantly cold when brought to her room. Interview with Dietitian #300 on 07/20/22 at 3:32 P.M. revealed the aides are supposed to serve meals to those in the dining room as the food is cooked. He stated they should not have held all the food until it was all cooked and then served. He confirmed the temped food at the end of service was too low, based on the temperatures that were reported to him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 31 of 36 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 07/25/2022 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. Observations of the 300 and 400 houses on 07/18/22 from 8:20 A.M. to 8:45 A.M. revealed multiple items within the refrigerators that were opened an undated. In the 300 house, there were five packages of lunch meat and two bags of shredded cheese that were opened and did not have an opened or used by date listed on them. Also, in the 400 house, there were four packages of lunch meat, a package of hot dogs, and a package of pepperoni that were opened and did not have an opened or used by date listed on them. Interview with Elder Assistant (EA) #301 on 07/18/22 at 8:40 A.M. confirmed there were no dates on the lunch meat and shredded cheese packages that were opened. She confirmed there should be dates on them as to when they were opened. She also confirmed they are to discard any opened items after seven days. Interview with Diet Tech #203 on 07/18/22 at 10:12 A.M. confirmed the items that were opened in the refrigerator, did not have a date on them as to when they were opened or when they should be used by. She confirmed they should have a date. Review of facility Food Storage Policy, dated 10/01/09, revealed the purpose of the policy was to assure all food is stored, labeled, and dated properly to assure stock rotation and prevent food illnesses. Prepackaged food or baking goods are marked with month and day and placed in a covered container, completed sealed and placed in dry storage. Based on observations, staff interview, and facility policy review, the facility failed to properly store and date foods and failed to use appropriate hand hygiene while serving a lunch meal. The deficient practices had the potential to affect all 24 residents who resided in the 200 and 300 houses (Residents #4, 6, 7, 8, 9, 10, 15, 17, 21, 24, 26, 30, 34, 36, 38, 41, 43, 44, 49, 52, 103, 203, 204, and 312) and nine residents (Residents #45, 46, 153, 154, 155, 156, 157, 158, and 159) who resided in 500 house. One resident (Resident #39) in 500 house was on a nothing by mouth (NPO) diet. Findings Include: Observation of Elder Assistant (EA) #249 on 07/18/22 from 12:06 P.M. to 12:14 P.M. serving lunch in the 500 house showed EA #249 wearing gloves. The EA opened the plastic bag of submarine buns with her gloved hands, reached into the bag, and grabbed a bun from the bag. The EA placed the bun on a plate with her gloved hands. The EA was then observed touching the handle on the pot holding the meatballs and marinara sauce and the serving spoon. The EA picked up the plate with the meatball sub on it and placed it on a serving tray. EA #249 doffed her gloves and threw them away but without washing her hands, donned another pair of clean gloves. The EA then touched the outside of the plastic bag of submarine buns, grabbed another bun out of the bag, opened a sealed bag of shredded cheese, grabbed a handful of shredded cheese out of the bag and placed the cheese on top of the meatball sub sandwich, pressing the cheese down on to the meatballs with her gloved hands. EA #249 did not change her gloves or complete any hand hygiene during the rest of the observation and touched multiple other items including: a dessert cup from the pantry, another sub bun, the serving spoon handle, more shredded cheese, a plastic cup for salad dressing, the Ranch dressing bottle, and the lid to the Ranch dressing bottle with the same gloves on. Interview on 07/18/22 at 12:15 P.M. with EA #249 confirmed the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 32 of 36 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 07/25/2022 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 facility policy, Hand Hygiene, dated 11/05/21, revealed the policy stated, hand hygiene should occur at the beginning of a shift, returning from break, after using the restroom and during routine patient care as indicated below: before cooking, assisting with meal, and eating and after removing PPE. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 33 of 36 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 07/25/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observations, medical record review, and facility policy review, the facility failed to implement infection control practices to prevent the potential spread of illness, related to hand hygiene, glove use, personal protective equipment, and tuberculosis screening. This had the potential to affect all 12 residents in House Two (Resident #7, #8, #10, #15, #21, #26, #34, #41, #43, #44, #49, and #103), four residents (Resident #5, #17, #36, and #52) of four residents reviewed for infection control, with the potential to affect all 56 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF), type 2 diabetes (DM2), acute myocardial infarction (MI), atrial fibrillation (a-fib), hypertension (HTN), hyperlipidemia (HLD), and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). Further review of the MDS confirmed the resident received oxygen therapy. Observation on 07/18/22 at approximately 12:07 P.M. revealed Elder Assistant (EA) #702 used gloved hands to assist and set up Resident #36 with eating, then assisted Resident #52 to sit at the dining room table with the same gloved hands, then provided Resident #5 a drink in her room with the same gloved hands. The observation was confirmed at 07/18/22 at 12:11 P.M. with EA #702. 2. Review of the medical record for Resident #52 revealed an admission date of 05/05/22 with diagnoses including dementia, major depressive disorder (MDD), hypertension (HTN), seizures, hyperlipidemia (HLD), progressive supranuclear ophthalmoplegia, and Parkinson's disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of 15 (severe cognitive impairment). The resident required up to extensive assistance of two or more staff for all Activities of daily Living (ADL's). Observation on 07/18/22 at approximately 12:07 P.M. revealed EA #702 used gloved hands to assist and set up Resident #36 with eating, then assisted Resident #52 to sit at the dining room table with the same gloved hands, then provided Resident #5 a drink in her room with the same gloved hands. The observation was confirmed at 07/18/22 at 12:11 P.M. with EA #702. 3. Review of the medical record for Resident #36 revealed an admission date of 09/29/20 with diagnoses included type 2 diabetes (DM2), cerebral infarction, hypertension (HTN), hyperlipidemia (HLD), vascular Dementia, and major depressive disorder (MDD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). The resident required supervision to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 34 of 36 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 07/25/2022 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 0880 Review of the plan of care dated 07/01/22 revealed no care plan related to infection. Level of Harm - Minimal harm or potential for actual harm Review of physician orders for July and the discontinued orders revealed no orders for antibiotics. Residents Affected - Many Observation on 07/18/22 at 11:56 A.M. revealed Elder Assistant (EA) #301 prinked Resident #36's finger with gloved hands, did not get a sufficient sample of blood, then used her gloved hands to get another strip from the plastic container (holding the shared bottle of test strips and lancets). A new strip was applied to the glucometer, the resident's blood sugar was checked, her gloves were removed, and new gloves were applied without performing hand hygiene. The EA used her new gloved hands to disinfect the glucometer and hand hygiene was completed when she was finished. Interview on 07/21/22 at 11:30 A.M. with DON revealed there was no glove policy but hand hygiene was to be performed between changing gloves. 4. Review of the medical record for Resident #17 revealed an admission date of 10/24/17 with diagnoses including fracture of the right tibia shaft, protein-calorie malnutrition, Alzheimer's disease, osteoarthritis, lumbar region intervertebral disc degeneration, dementia, need for assistance with personal care, unsteadiness on her feet, mood disorder, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/26/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 (severe cognitive impairment). The resident required extensive to total assistance of one to two staff members for all Activities of daily Living (ADL's) including eating. Review of the plan of care dated 04/05/21 revealed the resident had impaired immunity related to rheumatoid arthritis (RA) and prednisone use. Interventions included encouraging fluids and adequate rest to bolster her immune system. Observation on 07/19/22 at 9:51 A.M. revealed EA #700 walked out of room Resident #17's room with gloves, walked to the kitchen, turned around pulled her mask up with her gloved hand, and reentered the room with the same gloves. Interview on 07/21/22 at 11:30 A.M. with DON revealed there was no glove policy but hand hygiene was to be performed between changing gloves. Review of the facility policy titled, Hand Hygiene Procedure revised 11/05/21 revealed hand hygiene was to occur before and after having direct contact with a residents intact skin, after contact with an inanimate objects in the immediate vicinity of the resident, before assisting with meals, and after removing personal protective equipment (PPE). Review of the facility policy titled, Infection Prevention and Control Program revised 11/05/21 revealed the staff were to implement practices consistent with accepted standards that would help to reduce the spread of infections and prevent cross contamination. 5. Observation on 07/21/22 at 11:59 A.M. with EA #701 in House Two, revealed she was not wearing her mask over her nose. The mask was under her chin, while she was in the kitchen, with several residents in the dining room nearby. EA #701 confirmed the observation on 07/21/22 at 12:00 P.M. that she did not have her mask covering her mouth and nose stating she was hot after coming back in from her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 35 of 36 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 07/25/2022 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 0880 break. Level of Harm - Minimal harm or potential for actual harm Review of the facility census revealed Resident #7, #8, #10, #15, #21, #26, #34, #41, #43, #44, #49, and #103 resided in House Two. Residents Affected - Many Review of the facility policy titled, Infection Prevention and Control Program revised 11/05/21 revealed the staff were to implement practices consistent with accepted standards that would help to reduce the spread of infections and prevent cross contamination. 6. Review of personnel files with Human Resource #265 on 07/21/22 at approximately 3:00 P.M. revealed Maintenance #238, Temporary Nurse Aide (TNA) #256, Diet Technician #203 did not have a two step tuberculosis (TB) test upon hire. Interview on 07/21/22 at approximately 3:11 P.M. with the DON revealed TB two steps series were done upon hire and then annual screenings thereafter, if the screenings were not in the employee files then she was unsure what happen or why it was not available. Review of the facility policy titled,TB Screening for Partners Policy dated 06/01/17 revealed upon hire, partners were to have a two-step Mantoux test completed. If new partners had a previous positive reaction or a history of treatment for TB disease, they will be assessed for TB symptoms, if they do not have symptoms, the assessment will become part of their file. Partners were to complete a TB assessment annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366424 If continuation sheet Page 36 of 36