Inspection visit

Health inspectionMay 26, 2023

OTTERBEIN GAHANNACMS #36643026 citations on this visit

26 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 26 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #19's advanced directives were in the electronic medical record and failed to ensure Resident #12 and #29's advanced directives matched the signed documents. This affected three residents (#12, #19, and #29) of seven reviewed for advanced directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 11/07/22 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, depression, hypertension, fibromyalgia, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed cognition was not assessed but staff interview revealed Resident #19 had no memory concerns and no delirium. She was independent for cognitive skills for daily decision making. Review of the physician's orders and care plan on 05/15/23 revealed no mention of Resident #19's code status. Review of Resident #19's physician's order dated 05/16/23 revealed an order for full code. Interview on 05/17/23 at 9:00 A.M. with the Director of Nursing (DON) verified Resident #19's code status had not been in the physician's orders and care plan, until an audit had been completed the previous day. 2. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 had severely impaired cognition. Review of the Do Not Resuscitate (DNR) identification form dated 04/08/22 revealed Resident #12's code status was a DNR comfort care (CC) -Arrest, meaning the DNRCC protocol was to be implemented in (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 71 Event ID: 366430 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0578 the event of a cardiac arrest or respiratory arrest. Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 05/31/22 revealed an order for DNRCC. Residents Affected - Few Review of the plan of care dated 04/07/22 revealed Resident #12 had a code status of DNRCC. Interventions included educating the family on code status, offering to provide and review educational materials, and reviewing overall goals for care and the importance of quality of life. Interview on 05/16/23 at 2:14 P.M. with Registered Nurse (RN) #208 verified the signed form in the medical record did not match what was in the electronic medical record. She was unsure which was correct. 3. Review of the medical record revealed Resident #29 had an admission date of 12/22/21 with diagnoses including Parkinson's disease, paranoid personality disorder, essential tremor, anxiety disorder, dementia, depression, dysphagia, and delusional disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had impaired cognition. Review of the Do Not Resuscitate (DNR) identification form dated 11/23/22 revealed Resident #12's code status was DNRCC. Review of Resident #29's physician order dated 02/10/23 revealed an order for DNRCC-Arrest. Review of Resident #29's plan of care dated 03/23/23 revealed an order for DNRCCA. Interventions included educating family and resident on code status, offer to provide and review educational materials, and reviewing overall goals for care and the importance of quality of life. Interview on 05/16/23 at 2:53 P.M. with Assistant [NAME] President (VP) of Clinical #273 verified the physician's order and care plan did not match the signed form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 2 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some 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** 2. Review of the medical record for Resident #1 revealed an initial admission date of 03/19/21 with the latest readmission of 11/11/22 with the diagnoses including cerebrovascular infarct with left sided hemiplegia, diabetes mellitus, dysphagia, major depressive disorder, neuromuscular dysfunction, hyperlipidemia, right above the knee amputation, hypertension, gastro-esophageal reflux disease, constipation and retention of urine. Review of the plan of care dated 03/19/21 revealed the resident was at possible nutritional risk due to diabetes mellitus. Interventions included diet as ordered, medications as ordered and monthly weight. Review of the plan of care dated 07/02/21 revealed the resident was at nutritional risk due to health status, history of significant weight change, dysphagia, diabetes mellitus, hyperlipidemia, chronic obstruction pulmonary disease, hypertension, constipation, use of therapeutic diet and hemiplegia. Interventions included educate the resident on importance of adequate calorie and protein intake as appropriate, offer substitutes if resident does not like what is being served, monitor skin and wound reports, address any negative findings, offer the supplement the physician ordered and review weights, skin , labs and intakes routinely and as available and report changes as needed. Review of the resident's quarterly MDS assessment dated [DATE] revealed had no cognitive deficit. The resident required extensive assistance of two for bed mobility, transfers and was dependent on two staff for toilet use. The assessment indicated the resident had a significant weight loss, not on a prescribed weight loss regimen and receives a therapeutic diet. Review of the monthly physician's orders for May 2023 identified orders dated 03/19/21 weights monthly, 04/30/21 regular one-half portion dessert diet, regular texture, thin liquids and 05/15/23 Glucerna Thera shake three times a day. Review of the resident's weights revealed on 02/01/23 the resident weighted 160.4 pounds, on 03/04/23 the resident weighed 149.5 pounds, on 04/05/23 the resident weighed 159.5 pounds and on 05/05/23 the resident weighed 142.5 pounds indicating the resident had an 11.16% weight loss in 90 days and a 10.66% weight loss in 30 days. Review of the medical record revealed no evidence the resident's family and physician were notified of the significant weight loss. On 05/17/23 at 10:50 A.M., interview with Registered Dietician (RD) verified the resident's physician or family had not been notified of the significant weight loss. Based on record review, staff interviews, and facility policy review, the facility failed to notify the physician and resident representatives of a significant weight change for three residents (Residents #1, #12, and #45), a new skin condition for one resident (Resident #12), and one cognitively impaired resident's (Resident #53) continued refusals for intravenous hydration and hospitalization with a critically high potassium level. The deficient practice affected four residents (Residents #1, #12, #45, and #53) of four residents reviewed for notification of change. The facility census was 56. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 3 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 Findings Include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, diabetic chronic kidney disease Stage III, and aphasia following stroke. Residents Affected - Some Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident displayed physical behaviors towards others one to three days during the review period. No other behaviors were noted, including rejection of care. Resident #53 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of the laboratory test results reported on 04/18/23 at 6:13 P.M. revealed Resident #53 had a critically high potassium level of 6.1. The normal range was 3.5 to 5.3. Review of progress notes dated from 03/30/23 to 05/18/23 revealed on 04/17/23 at 7:30 A.M., Rehabilitation Physician (RP) #402 noted Resident #53 had a fall a few days ago with no injuries and this morning, Resident #53 was sitting on the toilet and he had an episode of syncope. Resident #53 aroused again but has been more confused, weaker than usual, had some tinting of the skin of his upper extremity and seemed a little bit dry. RP #402 stated Resident #53 was likely dehydrated and noted would give intravenous (IV) fluids now. On 04/17/23 at 9:43 A.M., a nurse noted Resident #53's spouse, nurse practitioner, and the Director of Nursing (DON) were notified of Resident #53 passing out. A late entry was entered for 04/17/23 at 10:00 A.M., revealed Resident #53 refused IV and to be sent out to the hospital for treatment. There was no indication the family or the physician were notified of Resident #53's refusals of treatment. A late entry was entered for 04/17/23 at 11:06 A.M., revealed Resident #53 refused IV fluids three times. The physician and family were notified. There were no additional notes entered related to Resident #53's status from 04/17/23 at 11:06 A.M. until 04/19/23 at 4:00 A.M. when Resident #53's lab results showed a potassium level of 6.1. and the Nurse Practitioner and family were notified. Resident #53 was sent out to the hospital on [DATE] at 12:28 P.M. and remained in the hospital until 04/26/23. Interview on 05/22/23 at 3:25 P.M. with the Director of Nursing (DON) confirmed there was not any documentation related to Resident #53's status from 04/17/23 at 11:06 A.M. until 04/19/23 at 4:00 A.M. The DON stated the facility staff continued to offer IV fluids and Resident #53 continued to refuse treatment and to go to the hospital on [DATE] and 04/18/23. The DON stated Resident #53 did drink some fluids by mouth during that timeframe. The DON confirmed there was not any documentation of Resident #53's physician or family notifications of the continued refusals on 04/17/23 and 04/18/23. 3. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed severely impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 4 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some Review of Resident #12's weights revealed on 09/06/22 she weighed 233.5 pounds, on 10/12/22 she weighed 221.0 pounds (a 5.4% weight loss over 36 days), on 10/22/22 pounds she weighed 190.5 pounds (18.4 % over 46 days and 13.8% over 10 days), on 11/01/22 she was 190.5 pounds, on 12/01/22 she was 190.5 pounds, on 01/09/23 she weighed 184.2 pounds, on 02/09/23 she weighed 175 pounds, on 03/03/23 she weighed 175.4 pounds, on 04/05/23 she weighed 173.6, and on 05/01/23 she weighed 152 pounds (12.4% over 30 days and 20.2% over 180 days). Review of the progress notes dated 10/25/22, 10/26/22, 01/18/23, 03/03/23, 03/10/23, and 04/29/23, revealed Diet Technician #440 addressed Resident #12's significant weight loss. There was no evidence he informed the family or the physician of Resident #12's significant weight changes. Interview on 05/18/23 at 10:59 A.M. with Dietitian #269 verified there was no evidence of notification of weight change in the medical record. On 05/23/23 at 11:10 A.M., observation of Resident #12's perineal area revealed the resident's groins and labia were red with scattered red rash. The resident's inner labia was red and excoriated. Review of Resident #12's physician order dated 05/16/23 revealed an order for panniculus skin tears between thigh folds to cleanse with soap water, pat dry, and apply antifungal powder every night shift for a skin tear. Review of the progress notes 05/16/23 to 05/22/23 revealed no documentation related to skin tears. Interview on 05/23/23 at 12:45 P.M. with Assistant [NAME] President (VP) of Clinical #273 verified there was no evidence the family or physician was noted of the new skin concern. 4. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the progress notes dated 01/18/23, 02/01/23, 02/07/23, 02/24/23, and 04/05/23, revealed Diet Technician #440 noted Resident #45 as having significant weight loss. There was no evidence the physician or family was notified of the weight change. Interview on 05/18/23 at 10:59 A.M. with Dietitian #269 verified there was no evidence of notification of weight change in the medical record. Review of the policy Notification of Change of Condition last revised 11/22/21 revealed the facility should immediately inform the resident, consult with the physician or nurse practitioner, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. Additionally they were to notify when there was a need to alter treatment significantly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 5 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #33 revealed an initial admission date of 09/26/22 with diagnoses including Alzheimer's disease, osteoporosis, hypothyroidism, hypertension, anxiety and major depressive disorder. Review of the bowel and bladder screen dated 01/13/23 revealed the resident was now occasionally incontinent of both bowel and bladder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident required supervision with transfers, ambulation and toilet use. The assessment indicated the resident was occasionally incontinent of both bowel and bladder and was not on a toileting program. Review of the bowel and bladder assessment dated [DATE] revealed the resident was occasionally incontinent of both bowel and bladder. Review of the monthly physician orders identified orders dated 09/27/22 peri-guard barrier cream may be kept in resident's room and applied by State Tested Nursing Assistant (STNA), no orders for toileting program or incontinence care. On 05/23/23 at 9:45 A.M., interview with Assistant [NAME] President of Clinical Services (AVPCS) verified Resident #33 lacked a care plan addressing incontinence of bowel and bladder. 6. Review of the medical record for Resident #39 revealed an initial admission date of 12/27/21 with the admitting diagnoses of end stage renal disease, hypertension, diabetes mellitus, congestive heart failure, anemia, aortic valve insufficiency, cardiomegaly, dysphagia, gastro-esophageal reflux disease, dependence on renal dialysis, constipation, hyperlipidemia, chronic respiratory failure and alcohol abuse in remission. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the medical record identified no activity assessment for the resident's preferences for activities. Review of the resident's plan of care revealed no care plan addressing the resident's activity preferences. On 05/22/23 at 1:34 P.M., interview with Activity Coordinator (AC) #220 verified the resident had no plan of care addressing the resident's activity preferences. Review of the facility policy, Comprehensive Care Planning Procedure, dated 11/13/17, revealed the facility policy stated, an interdisciplinary team is responsible for developing, implementing and evaluating the comprehensive, person-centered plan of care. The resident comprehensive care plan will include measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. This will include services to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 6 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. A comprehensive person centered plan of care is developed for each resident within 21 days of admission by qualified persons. And updated quarterly and with any significant changes. Each care plan focus was to list individualized specific interventions and approaches to be utilized for the focus listed. 3. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating. The resident required limited assistance from one staff for eating. Resident #3 was on oxygen. Review of the physician orders dated for May 2023 revealed Resident #3 had the following order: change oxygen tubing weekly every night shift every Sunday dated 04/09/23. Observations on 05/15/23 at 2:31 P.M. and 05/18/23 at 5:47 P.M. revealed Resident #3 utilized oxygen via nasal cannula. Review of care plan dated 04/03/23 revealed Resident #3 had an altered respiratory status. Interventions did not address oxygen use. Resident #3 had a self-care and/or physical mobility performance deficit. Interventions included, oxygen as ordered for me. Interview on 05/23/23 at 9:51 A.M. with Assistant [NAME] President of Clinical (AVPC) #273 confirmed Resident #3's comprehensive care plan did not adequately address oxygen use. 4. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following stroke, Type II Diabetes Mellitus, diabetic chronic kidney disease Stage III, and major depressive disorder-recurrent. Review of physician orders revealed Resident #53 had the following orders: Sodium Chloride 0.9% use 60 milliliters (mL) per hour intravenously (IV) for hydration for one day dated 04/18/23, send to the emergency room (ER) due to abnormal labs and dehydration dated 04/19/23. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #53 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of progress notes dated 04/17/23 through 04/19/23 revealed Resident #53 had a syncope episode on 04/17/23. Rehabilitation Physician (RP) #402 noted Resident #53's episode was likely due to dehydration and would administer IV fluids. Resident #53 refused IV fluids on 04/17/23 and 04/18/23. The lab results for Resident #53 on 04/19/23 showed a critically high potassium level. RP #402 noted concern for acute kidney injury and dehydration and ordered for Resident #53 to be sent to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 7 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 hospital for treatment. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 03/30/23 revealed Resident #53's risk for dehydration was not addressed in the comprehensive care plan. Residents Affected - Some Interview on 05/23/23 at 9:51 A.M. with the AVPC #273 confirmed Resident #53's care plan did not address the resident's risk for dehydration. Based on interview and record review the facility failed to develop comprehensive care plans that included activities, bladder and bowel, nutrition, hydration, respiratory care, position, mobility, and behaviors. This affected six residents (#3, #12, #33, #39, #45, and #53) of 27 records reviewed. The facility census was 56. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 03/10/23 revealed the resident was at risk for dehydration due to low fluid balance. Interventions included encouraging fluids. Review of the plan of care dated 04/07/23 revealed Resident #12 was at possible nutrition risk due to health status, use of therapeutic diet, and diagnoses. Interventions included providing diet as ordered, medications as ordered, monitoring oral intake, and monitoring skin and wound reports. Review of Resident #12's weights revealed a history of significant weight change since October 2022. Interview on 05/18/23 at 11:17 A.M. with Dietitian #269 verified Resident #12's care plans were not comprehensive. Care plans should address specific resident concerns and interventions including therapeutic diets, significant weight changes, thickened liquids, supplements, feeding ability, and anything that would affect eating and hydration. 2. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the plan of care dated 01/18/23 revealed Resident #45 was at nutritional risk related to her health status. Interventions included encouraging to eat calorically dense foods and encouraging to participate in menu planning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 8 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of Resident #45's weights revealed a history of weight fluctuations and weight loss. Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/23 at 11:17 A.M. with Dietitian #269 verified Resident #45's care plan was not comprehensive. Care plans should address specific resident concerns and interventions including therapeutic diets, significant weight changes, thickened liquids, supplements, feeding ability, and anything that would affect eating and hydration. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 9 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #13 revealed an initial admission date of 12/21/15 with the latest readmission of 12/27/18 with the diagnoses including multiple sclerosis (MS), major depressive disorder, thiamine deficiency, hyperlipidemia, hypertension, nonpsychotic mental disorder, irritable bowel syndrome, dysphagia, contracture to left hand, contracture to right hand, constipation, dry eye syndrome and stage IV pressure ulcer to sacral region. Review of the plan of care dated 01/04/23 revealed the resident had an open pressure wound of such depth a wound vac is indicated. Interventions included enhanced barrier precautions, change wound vac dressing per scheduled order, position resident at all times to avoid prolonged pressure at wound site, monitor character and volume of drainage, monitor wound vac pressure, assure it is set/maintained per order, check dressing integrity for air leaks, notify physician/family immediately of signs/symptoms of infection, assess appropriateness of wound vac dressing and measure wound progress. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers and dependent on two staff for toilet use. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one Stage IV pressure ulcer not present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care and application of ointments/medications other than to feet. Review of the monthly physician orders for May 2023 identified orders dated 05/04/23 cleanse wound to sacrum with normal saline (NS), pat dry, apply collagen, then alginate and cover with bordered island gauze daily. On 05/23/23 at 09:47 A.M., interview with [NAME] President of Clinical Services (VPCS) #273 verified the lack of revision to care plan for the discontinuation of the wound vac to the Stage IV pressure ulcer to the coccyx. Review of the facility policy, Comprehensive Care Planning Procedure, dated 11/13/17, revealed the facility policy stated, an interdisciplinary team is responsible for developing, implementing and evaluating the comprehensive, person-centered plan of care. The resident comprehensive care plan will include measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. This will include services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Based on record review, staff interview, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Resident #3 and #13) to address changes in status, including the need for supervision with all meals and discontinuation of a wound vac. The deficient practice affected two residents (Resident #3 and #12) of 23 residents reviewed in the final sample for care plans. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 10 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating. The resident required limited assistance from one staff for eating. Review of the physician orders dated May 2023 revealed Resident #3 had the following order in place: No Added Salt diet, pureed texture, thin consistency; supervised with each meal, patient is not to eat alone in room dated 04/08/23. Review of the care plan dated 04/03/23 revealed Resident #3 was at risk for changes to her nutrition and hydration. Interventions did not address the resident's physician order to be supervised with all meals. Interview on 05/23/23 at 9:51 A.M. with Assistant [NAME] President Clinical (AVPC) #273 confirmed Resident #3's care plan did not include supervision with all meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 11 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and facility policy review, the facility failed to ensure personal hygiene was completed for six residents (#7,#13, #24, #31, #33, #41), who were dependent on staff. Additionally the facility failed to ensure two residents (#8, #21) received scheduled showers. This affected eight of ten residents reviewed for activities of daily living (ADLs). The facility census was 56. Residents Affected - Some Findings Included: 1. Review of the medical record for Resident #7 revealed an initial admission date of 05/03/21 with the latest readmission of 11/30/22 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, chronic peripheral venous insufficiency, diabetes mellitus, hypertension, hyperlipidemia, right knee contracture, left knee contracture, gout, gastro-esophageal reflux disease and pain. Review of the plan of care dated 05/06/21 revealed the resident had a self-care deficit and/or physical mobility performance deficit related to COPD, cardiac conditions, pain, dementia and bilateral knee contractures. Interventions included encourage to use call pendent for assistance, apply heel/ankle protector to bilateral heels every shift for protection as tolerated, bed against the wall to allow more space in room, monitor/document/report as needed any symptoms of immobility, pressure reducing devices as ordered, therapy as ordered, vital signs as directed and the resident required one extensive staff assistance with personal hygiene and oral care. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required extensive assistance of two staff for personal hygiene. On 05/15/23 at 11:43 A.M., observation of Resident #7 revealed she had long, curly chin hair. On 05/18/23 at 11:05 A.M., observation of Resident #7 revealed the long, curly chin hair remained. On 05/18/23 at 11:08 A.M., interview with Licensed Practical Nurse (LPN) #227 verified the resident had long curly chin hair. The LPN revealed she was unsure who removed female facial hair. On 05/22/23 at 12:10 P.M., observation of Resident #7 revealed the long, curly chin hair remained. 2. Review of the medical record for Resident #13 revealed an initial admission date of 12/21/15 with the latest readmission of 12/27/18 with the diagnoses including multiple sclerosis (MS), major depressive disorder, thiamine deficiency, hyperlipidemia, hypertension, nonpsychotic mental disorder, irritable bowel syndrome, dysphagia, contracture to left hand, contracture to right hand, constipation, dry eye syndrome and stage IV pressure ulcer to sacral region. Review of the plan of care dated 03/01/18 revealed the resident had a self-care deficit related to bilateral hand contractures, bowel/bladder incontinence, dysphagia, feeding difficulties, hearing loss, hypertension, hyperlipidemia, impaired gait/balance, impaired vision, insomnia, multiple sclerosis, muscle weakness and nonpsychotic mental disorder. Interventions included bilateral enabler bar for mobility, encourage to use call pendant for assistance, assist with meals, head of bed up during meals, bilateral palm protectors on in the morning and remove at night, resident will ask for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 12 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some palm protectors to be removed at times, therapy as ordered, vital signs as ordered, the resident requires one extensive assist for bed mobility and personal hygiene. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the mood and behavior revealed the resident displayed no behaviors, including rejection of care. The resident required extensive assistance of two staff for personal hygiene. Review of the monthly physician orders for May 2023 identified no orders related to nail care. On 05/15/23 at 10:40 A.M., observation of Resident #13 revealed the resident had bilateral hand contractures. Further observation revealed the resident's nails were long, jagged and dug into the resident palms causing indents and red marks. On 05/15/23 at 10:50 A.M., interview with State Tested Nursing Assistant (STNA) #300 verified the resident's nails were long, jagged and making red indentions in the resident's palm of her hand. 3. Review of the medical record for Resident #24 revealed an initial admission date of 07/05/22 with the diagnoses including senile degeneration of brain, dementia, severe protein calorie malnutrition, dysphagia, hyperlipidemia, osteoarthritis, hypertension, bipolar disorder, diverticulosis of intestine, retention of urine and disorders of bladder. Review of the plan of care dated 07/18/22 revealed the resident had an ADL self-care and/or physical mobility performance deficit related to dementia, bipolar disorder, anxiety and osteoarthritis. Interventions included the resident required extensive assist of one for personal care. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required extensive assistance of one staff for personal hygiene. On 05/15/23 at 11:53 A.M., observation of Resident #24 revealed the resident had long white chin hairs. On 05/16/23 at 9:30 A.M., observation of Resident #24 revealed the resident had long white chin hairs. On 05/18/23 at 11:02 A.M., observation of Resident #24 revealed the resident had long white chin hairs. On 05/18/23 at 11:07 A.M., interview with LPN #227 verified the resident had long curly chin hair. The LPN revealed she was unsure who removed female facial hair. 4. Review of the medical record for Resident #33 revealed an initial admission date of 09/26/22 with diagnoses including Alzheimer's disease, osteoporosis, hypothyroidism, hypertension, anxiety and major depressive disorder. Review of the plan of care dated 10/06/22 revealed the resident had a self-care deficit and/or physical mobility performance deficit related to weakness. Interventions included requires supervision to limited assistance of one staff with walking, uses walker with walking, encourage to use call pendant for assistance, requires one extensive assist with dressing, requires supervision to limited assistance of one staff with toileting and monitor/document/report as needed any changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 13 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the had delusions and wandered. The resident required extensive assistance with personal hygiene. On 05/15/23 at 12:01 P.M., observation of Resident #33 revealed the resident had several days of white chin hairs. On 05/18/23 at 11:04 A.M., observation of Resident #33 revealed the resident had several days of white chin hairs. The resident stated, that would be nice, when asked if she would like the chin hair removed. On 05/18/23 at 11:07 A.M., interview with LPN #227 verified the resident had long curly chin hair. The LPN revealed she was unsure who removed female facial hair. 5. Review of the medical record for Resident #41 revealed an initial admission date of 03/08/22 with the diagnoses including Alzheimer's disease, heart failure, anxiety disorder, chronic obstructive pulmonary disease (COPD), dementia, major depressive disorder, hyperlipidemia, hypertension, history of COVID-19, atrial fibrillation, osteoporosis, seasonal allergic rhinitis, and sexual dysfunction. Review of the plan of care dated 03/08/23 revealed the resident had an impaired self-care deficit. Interventions included assist as needed to complete activities of daily living (ADL) and encourage independence, encourage to perform self care with ADL at the level indicated by physician and therapy, encourage to use call pendent for assistance, monitor/document/report as needed any changes, potential for improvement, praise all efforts at self care, therapies as ordered. Review of the plan of care dated 03/30/22 revealed the resident had an ADL self-care and/or physical mobility performance deficit related to Alzheimer's, confusion and dementia. Interventions included encourage to use call pendent for assistance and resident requires supervision to limited assistance of one staff for personal hygiene and oral care. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and wandering. The assessment indicated the resident required extensive assistance of one for personal hygiene. On 05/15/23 at 10:39 A.M., observation of Resident #41 revealed the resident's facial hair was long and scruffy. On 05/16/23 at 2:35 P.M., observation of Resident #41 revealed the resident's facial hair was long and scruffy. On 05/17/23 at 11:15 A.M., observation of Resident #41 revealed the resident's facial hair was long and scruffy. On 05/17/23 at 11:38 A.M. interview with STNA #267 verified the resident had long scruffy facial hair. 8. Review of the medical record for Resident #21 revealed an admission date on 04/06/23. Medical diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 14 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 end stage renal disease with dependence on renal dialysis. Level of Harm - Minimal harm or potential for actual harm Review of the Medicare 5-Day MDS 3.0 assessment dated [DATE] revealed Resident #21 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #21 required limited to extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Bathing activity did not occur during the review period. Resident #21's functional goals for shower or bathing indicated substantial to maximal assistance was required upon admission. Residents Affected - Some Review of the Social Services Screen dated 04/07/23 revealed Resident #21 preferred showers for bathing. Review of the bathing task for the last 30 days revealed there was no documented showers or bathing completed. Review of the shower schedule for Resident #21 revealed the resident was scheduled to receive showers on Sundays and Thursdays during first shift. Review of the care plan dated 04/06/23 revealed Resident #21 had an impaired ability to perform or complete activities of daily living such as feeding, dressing, bathing, and toileting. Interventions included assist as needed to complete ADLs and encourage independence. Interview on 05/15/23 at 2:48 P.M. with Resident #21 revealed she had been receiving bed baths but would prefer a shower. The resident stated her physician indicated she could start receiving showers effective 05/04/23 but still had not received one or had her hair washed. Resident #21 stated she would require two person assist for shower due to fear of falling and there was usually only one aide scheduled to care for the residents in the house. Resident #21 stated she was supposed to receive showers on non-dialysis days so she was not so tired. Review of shower sheets dated from 04/06/23 to 05/23/23 revealed none of the shower sheets indicated what kind of care was provided during the shower bath (shaved, nail care, hair washed, etc.). The shower sheets dated 05/03/23 and 05/07/23 did not indicate whether Resident #21 received a shower or a bed bath and the sheet dated 05/07/23 was not signed by the aide or the nurse. There were no shower sheets provided from 05/08/23 through 05/23/23 (15 days). Interview on 05/22/23 at 4:42 P.M. with the Director of Nursing (DON) confirmed there was not any shower documentation for Resident #21 from 05/08/23 through 05/22/23. Review of the facility policy titled, Shaving, last revised 05/22/23 revealed shaving may be part of a resident's usual daily routine. Shaving promotes resident comfort by removing facial hair that can itch and irritate the skin and produce an unkempt appearance. Review of the policy, Tub baths and showers, revised 05/20/23, revealed the policy stated, tub baths and showers provide personal hygiene, stimulate circulation, and reduce tension for a patient. They also allow observation of the condition of the patient's skin and assessment of joint mobility and muscle strength. The policy did not address the frequency of showers or providing showers as scheduled. 6. Review of the medical record for Resident #31 revealed an admission date of 06/27/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 15 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some side, chronic kidney disease stage three, type two diabetes mellitus, epilepsy, adjustment disorder with depressed mood, left and right knee contractures, cognitive communication deficit, dysphagia, and vascular dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed impaired cognition. He was totally dependent for bed mobility, transfers, and personal hygiene. Review of the plan of care dated 09/21/20 revealed an activity of daily living self-care deficit and physical mobility performance deficit related to diagnoses. Interventions included encouraging him to sit in his chair for a few hours a day, medications as ordered, monitoring for signs of immobility, checking nail length, trimming, and cleaning them on bath day and as necessary, assisting with oral hygiene, and monitoring for any changes. Observation on 05/15/23 at 5:14 P.M. revealed Resident #31 had long fingernails with visible dirt underneath. Observation on 05/22/23 at 8:55 A.M. revealed Resident #31's fingernails remained long with visible dirt underneath. Interview on 05/22/23 at 8:55 A.M. with STNA #264 verified the observation. She reported because the resident was diabetic, the nurse needed to clip his nails. Interview on 05/22/23 at 8:57 A.M. with Registered Nurse (RN) #229 revealed she did not know who would clip fingernails for a resident with diabetes. Interview on 05/22/23 at 11:11 A.M. with the Director of Nursing (DON) verified nurses should be clipping fingernails for residents with diabetes, however, the aides should be notifying them when it needs done. 7. Review of the medical record for Resident #8 revealed an admission date of 03/02/23 with diagnoses including Parkinson's disease, chronic respiratory failure, rheumatoid arthritis, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 required the extensive assistance of one person for personal hygiene and bathing did not occur ding the lookback period. Review of the plan of care dated 03/03/23 revealed Resident #8 had an activity of daily living self-care and physical mobility performance deficit related to Parkinson's disease. Interventions included requiring extensive assistance of one person for walking, pressure reducing devices to wheelchair, and assistance of one person for bathing and showering. Review of the electronic medical record revealed no documented bath or showers in the previous 30 days. Review of the body audit forms for April and May 2023 revealed six body audit forms that did not indicate if a bath or shower was completed, these forms were dated 04/12/23, 04/23/23, 04/30/23, 05/04/23, 05/17/23, and one that was for April 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 16 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 05/15/23 at 2:40 P.M. with Resident #8 revealed she had not gotten a shower in over four weeks. Interview on 05/22/23 at 1:38 P.M. with the DON verified the documentation was unclear if a bath or shower was completed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 17 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #7 revealed an initial admission date of 05/03/21 with the latest readmission of 11/30/22 with diagnoses including dementia, chronic obstructive pulmonary disease, heart failure, atrial fibrillation, chronic peripheral venous insufficiency, diabetes mellitus, hypertension, hyperlipidemia, right knee contracture, left knee contracture, gout, gastro-esophageal reflux disease and pain. Residents Affected - Some Review of the plan of care dated 02/09/22 revealed the resident had little to no activity involvement related to dementia and inability to communicate interests. Interventions included establish prior level of activity involvement and interests by talking with the resident/caregivers and/or family on admission and as necessary, provide a variety of activity types and locations to maintain interests, monitor/document for impact of medical problems on the residents activity level, remind the resident she is able to the activity at anytime and is not required to stay for the entire activity. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required extensive assistance of two staff for bed mobility, transfers and locomotion on/off the unit. The assessment indicated the enjoyed listening to music, religious activities or practices and family involvement in care discussions. Review of the medical record revealed no activity assessment for the resident. Review of the medical record revealed the following documented activities occurring on 05/25/21, 05/26/21 and 03/30/23. Further review of the medical record revealed no other documented activities were provided to the resident. On 05/16/23 at 1:45 P.M., observation of Resident #7 revealed the resident was sitting at the dining room table playing with her hair. No activities were observed in the house. Review of the activity calender for May 2023 revealed bingo was scheduled for 1:30 P.M. in house 402, where the resident resides. On 05/17/23 at 1:30 P.M., observation of Resident #7 revealed the resident was sitting in Broda chair at the dining room table picking her clothing. No activities were observed in the house. Review of the activity calender for May 2023 revealed Bible study was scheduled for 1:30 P.M. in house 401. On 05/18/23 at 2:00 P.M., observation of Resident #7 revealed the resident was sitting in Broda chair with feet elevated at the dining room table. No activities were observed in the house. Review of the activity calendar for for May 2023 revealed bible study was scheduled at 1:30 P.M. in house 404, trivia in house 401 and popsicles on the porch and patio. On 05/18/23 at 1:50 P.M., observation of Resident #7 revealed the resident was sitting in Broda chair at the dining room table. No activities were observed in the house. 4. Review of the medical record for Resident #39 revealed an initial admission date of 12/27/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 18 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 with the admitting diagnoses of end stage renal disease, hypertension, diabetes mellitus, congestive heart failure, anemia, aortic valve insufficiency, cardiomegaly, dysphagia, gastro-esophageal reflux disease, dependence on renal dialysis, constipation, hyperlipidemia, chronic respiratory failure and alcohol abuse in remission. Residents Affected - Some Review of the resident's plan of care revealed no care plan addressing the resident's activity preferences. Review of the medical record identified no activity assessment for the resident's preferences for activities. Review of the medical record revealed the only documented activities by the facility chaplain 03/22/22, 05/26/22, 11/03/22 and 05/16/23. On 05/16/23 at 8:21 A.M., interview with Resident #39 revealed the facility provides no activities and she would like to have daily scheduled activities. On 05/22/23 at 1:34 P.M., interview with Activity Coordinator (AC) #220 revealed activities are scheduled in one house of the five houses each day. AC #220 revealed residents from the other four houses can attend the scheduled activities in the house activities are scheduled in. AC #220 revealed she was the only activity staff employed by the facility. Review of the activities calendar for May 2023 revealed during the weekdays no activities were scheduled after 2:30 P.M. Review of the weekends revealed on 05/13/23 there was a Mother's Day event scheduled, however, for every other Saturday the schedule included movie matinee and every Sunday for the month included coffee and chat. Interview on 05/22/23 at 3:52 P.M. with Activities Coordinator #220 verified she was the only employee and coordinated activities on the weekdays when she was present. She reported during the evenings and weekends the nurse aides should be doing activities with the residents. Activities indicated she did not know if the nurse aides were completing activities or if they were documenting them like they should. Interview on 05/22/23 at 4:40 P.M. with Scheduler #266 revealed if the aides completed activities, they would be documented in the task section of the medical record. A policy was requested but none was provided. Based on observation, interview, record review, and review of the activities calendar, the facility failed to provide activities in the evening and on the weekends, which had the potential to affect cognitively impaired residents, additionally, the facility failed to develop an individualized activity plan for Resident's #7, #39, and #210, and provide independent activities for Resident #12 and #210. This affected four residents (#7, #12, #39, and #210) of four reviewed for activities and had the potential to affect all cognitively impaired residents in the facility. The facility census was 56. Findings include: 1. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 19 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. Residents Affected - Some Review of Resident #210's plan of care revealed it was absent for activities. Review of Resident #210's short stay activities screen dated 05/08/23 revealed it was incomplete. It did not include staff interviews for daily and activity preferences, past activity interests, spiritual activities, current activity participation, and limitations or special needs. Review of Resident #210's task activity documentation for 04/30/23 to 05/15/23 revealed the only non-independent activity documented was one on one or family visits on 05/05/23, 05/08/23, 05/09/23, and 05/10/23. Review of Resident #210's progress notes 04/30/23 to 05/15/23 revealed no activity documentation. Observation on 05/15/23, 05/16/23, 05/17/23, 05/18/23, and 05/22/23, revealed Resident #12 could be heard yelling almost continuously, Resident #12's room was close to Resident #210. Observation on 05/15/23 at 9:40 A.M., 10:40 A.M., 11:04 A.M., 2:15 P.M., and 3:50 P.M. revealed Resident #210 in his room, with the lights off and with no source of entertainment. There was no television or music. Observation on 05/16/23 at 1:22 P.M. and 3:41 P.M. revealed Resident #210 in his room with the lights off and with no source of entertainment. Interview on 05/16/23 at 3:54 P.M. with State Tested Nursing Aide (STNA) #241 verified the above observation. They reported Resident #210's sister told them he did not like the television. STNA #241 verified another resident could be heard yelling throughout the building on most occasions. Interview on 05/16/23 at 4:39 P.M. with Resident #210's responsible party revealed Resident #210 liked jazz music and was deeply religious and may benefit from hearing the Quran since he could no longer read it. She reported he was always in a quiet room when she visited. She reported she had been aware prior to him moving in that Resident #12 yelled out continuously, however, she thought he would have some sort of entertainment to drown out the noise. Observation on 05/17/23 at 10:05 A.M., 11:14 A.M. and 11:48 A.M., on 05/18/23 at 2:38 P.M., and on 05/22/23 at 9:45 A.M. and 4:43 P.M. revealed Resident #210 in his room, awake and with no source of entertainment. Interview on 05/18/23 at 2:39 P.M. with Activities Coordinator #220 revealed the aides should be turning on things like television and music for residents daily depending on preference. Activities Coordinator #220 verified Resident #210's assessment had not been completed. She was not aware of his favorite activities but reported jazz music and listening to the Quran was something they could arrange for him. 2. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 20 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of Resident #12's quarterly MDS 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 04/14/23 revealed Resident #12 had little or no activity involvement related to cognitive decline. Interventions included assistance to activity functions and residents preferred activities included watching television, listening to music, and one on one visits with family and staff. Review of Resident #12's Activity screening dated 04/26/23 revealed it was somewhat important to watch or listen to television and listen to music. Her favorite hobbies were listening to music and one on one visits with family and staff. Review of Resident #12's task activity documentation for the 30 days leading up to 05/18/23 reveled no activity documentation Review of the activities log for April 2023 and May 2023 revealed activity participation on 04/03/23, 04/05/23, 04/24/23, 04/25/23, 04/26/23, 04/27/23, 05/03/23, 05/04/23, 05/08/23, 05/10/23, and 05/11/23. Observation on 05/15/23 at 9:42 A.M., 11:04 A.M., 2:30 P.M., 3:52 P.M., and 4:12 P.M., and on 05/16/23 at 1:22 P.M., 2:55 P.M., and 3:41 P.M. revealed Resident #12 was in her room with no entertainment, television or music, and with her remote positioned in front of her television. Interview on 05/16/23 at 3:54 P.M. with State Tested Nursing Aide (STNA) #241 verified Resident #12 had been in the room without music or television. STNA #241 reported Resident #12 would throw the remote, however, she verified it had been in front of the television. STNA #241 went to turn the television on and Resident #12 revealed she wanted to watch a movie. Interview on 05/18/23 at 2:39 P.M. with Activities Coordinator #220 verified Resident #12 had been sitting in a silent room on 05/15/23 and 05/16/23. She reported Resident #12's preferred activities included television and music. Activities Coordinator #220 was asked to provide evidence of activities between 04/05/23 and 04/24/23, and no additional activities were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 21 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 observation, interview, and record review, the facility failed to assess and document on new skin concerns for Resident #10 and Resident #12, and failed to ensure hospice documentation in facility for Resident #210. The facility census was 56. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 06/11/16 with diagnoses including cerebral infarction, multiple sclerosis, paraplegia, anxiety disorder, contracture's of left and right hand, unspecified dementia, peripheral vascular disease, and as of 03/24/23 fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. Review of the plan of care dated 05/16/23 revealed Resident #10 had a skin tear to the left ankle and interventions included identifying potential causative factors and eliminating and resolving when possible, treat according to facility protocol and notify physician, monitoring location, size and treatment of skin tear and report abnormalities, failure to health and signs of infection, to be seen weekly by wound doctor until healed, and using caution during transfers and bed mobility. Review of the progress note dated 05/13/23 revealed Resident #10 had drainage from a left ankle wound. The wound was cleaned, dressed, and wrapped with an ace bandage. Review of Resident #10's weekly skin observation tools revealed there was none completed on 05/13/23. Review of Resident #10's weekly skin observation tool dated 05/15/23 revealed the wound measured 2.5 centimeters (cm) by 2.0 cm with no depth. Observation on 05/16/23 at 10:27 A.M. revealed Resident #10 had a skin tear to her left anterior ankle. Interview on 05/22/23 at 10:58 A.M. with the Director of Nursing (DON) verified Resident #10's wound was not measured or described upon discovery on 05/13/23, she confirmed this should have been done at that time. 2. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #12's physician order dated 05/16/23 revealed an order for panniculus skin tears between thigh folds to cleanse with soap water, pat dry, and apply antifungal powder every night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 22 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 shift for a skin tear. Level of Harm - Minimal harm or potential for actual harm Review of Resident #12's weekly skin observation tool dated 05/20/23 revealed no skin impairments were documented. Residents Affected - Few Review of the progress notes 05/16/23 to 05/22/23 revealed no documentation related to skin tears. On 05/23/23 at 11:10 A.M., observation of Resident #12's perineal area revealed the resident's groins and labia were red with scattered red rash. The resident's inner labia was red and excoriated. Interview on 05/23/23 at 12:45 P.M. with Assistant [NAME] President (VP) of Clinical #273 verified there was no assessment, measurements, or description of the Resident #12's skin area. Review of the policy 'Skin Care Management Procedure' dated 12/09/22 revealed staff should be alert to potential changes in the skin condition and evaluate and document identified changes. 3. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. Review of the physician order dated 04/30/23 revealed Resident #210 was admitted to hospice. Review of an electronic message on 05/17/23 at 5:16 P.M. sent to the Administrator revealed hospice documentation for Resident #210 was requested to be available on 05/18/23. Interview on 05/18/23 at 4:37 P.M. with the Director of Nursing (DON) revealed she had called and requested documents from hospice but had not received any. The DON verified they had no documents in the facility at that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 23 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to provide timely and necessary treatment and services to residents with pressure ulcers to prevent, promote healing and decrease the risk of decline of pressure ulcers. This affected three residents (#13, #52, and #159) of four residents reviewed for pressure ulcers. The facility census was 56. Residents Affected - Few Findings Include : 1. Review of the medical record for Resident #159 revealed an admission date on 05/01/23. Medical diagnoses included nondisplaced fracture of right femur, displaced fracture of olecranon process of right ulna (forearm), congestive heart failure (CHF), hypotension (low blood pressure), anemia (low iron level), and hypertension (high blood pressure). Although there was no indication Resident #159 had a sacral wound on the diagnosis list at the time of admission, review of the hospital records from Resident #159's hospital admission from 04/19/23 to 05/01/23 revealed Resident #159 had a sacral wound that was present upon admission to the hospital. The records noted the wound was treated with a Mepilex bordered foam dressing (a multilayer foam dressing designed for use on the sacrum in addition to standard care protocols for pressure ulcer prevention). Review of the admission Screen and Baseline Care Plan dated 05/02/23 documented Resident #159 had an unstageable pressure area to her coccyx. The area measured two centimeters (cm) long by two cm wide. There was no additional description of the area or wound bed included in the assessment completed on this date. Review of the physician's orders, dated 05/02/23 revealed Resident #159 had orders for peri guard barrier cream (may be kept in resident's room), applied by State Tested Nursing Assistants (STNA) every shift for prevention and as needed for prevention, turn and reposition supporting hip/leg to prevent adduction (movement toward the midline of the body) every shift and an order to float heels when in bed every shift. On 05/03/23 at 5:27 A.M., Rehabilitation Physician (RP) #402 noted Resident #159 initially complained of having buttock area pain. RP #402 indicated it was likely due to the way she was lying in her recliner and the resident was adjusted. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #159 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed Resident #159 required extensive assistance from two staff to complete bed mobility, dressing, toileting, and personal hygiene and required limited assistance from two staff to complete transfers. The MDS noted Resident #159 had one unstageable deep tissue injury (DTI) present upon admission. A pressure reducing device for the bed and application of ointments/medications were noted. A turning program, nutrition or hydration intervention, and pressure ulcer care were not indicated as being at place for the resident at the time of the assessment. Review of the medication administration record (MAR) and treatment administration record (TAR) dated May 2023 reflected orders to float heels when in bed every shift, turn and reposition, and Peri (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 24 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Guard Barrier Cream every shift for prevention. However, there was no evidence these interventions were provided as ordered on 05/03/23, 05/06/23, 05/09/23, or 05/12/23. Review of Nurse Practitioner (NP) #400's note dated 05/09/23 at 8:00 A.M. revealed Resident #159 had an open area to the coccyx. NP #400 discussed starting a foam dressing to coccyx until she was seen by the in-house wound physician in another week. The area was noted as an unstageable pressure injury with the treatment plan to start foam dressing, changes every three days and as needed and to follow up with the wound physician. There were not any measurements included in the note. On 05/09/23 at 10:41 A.M., Wound Physician (WP) #401 and staff nurse attempted to assess patient's sacral wound but were unable to due to Resident #159 being out for an appointment. The note indicated WP #401 would assess on the next visit. On 05/09/23 at 12:48 P.M. a progress note indicated a possible DTI to sacrum was noted. Peri area of wound reddened with areas of non-intact skin. Nurse Practitioner (NP) #400 was notified. A new order for Optifoam foam heart-shaped dressing to sacrum change every three days and as needed if soiled. Resident #159 was made aware of the new orders. WP #401 was notified, awaiting new orders. Resident #159 was to be turned every two hours and as needed using the pressure reduction cushion. Foam dressing in place. Staff in house were educated on turn schedule and to utilize the cushion. There were not any measurements included in the note. Review of Weekly Skin Observation Tool dated 05/09/23 at 12:58 P.M. revealed Resident #159 had a suspected deep tissue injury pressure wound to her sacrum. The area was blackened/reddened and notes as a possible DTI to the sacrum. There were not any measurements included in the assessment. There was no indication the wound was open on the assessment. Review of the physician orders, dated 05/09/23 (eight days following admission) revealed the following orders were given: Cleanse sacrum with normal saline, pat dry, apply silver alginate then an island dressing daily until healed every day shift for DTI with a start date on 05/10/23 and turn and reposition every two hours and as needed using the pressure reducing cushion every shift. On 05/09/23 at 1:22 P.M., per WP #401 an order was noted to cleanse sacrum with normal saline, pat dry, apply silver alginate then an island dressing daily until healed. Resident #159 was aware of the new order. On 05/11/23 at 11:09 A.M., a late entry progress note was entered for 05/09/23, son was notified of new skin area and new orders. Review of the physician's orders dated 05/12/23 (11 days following admission and three days after Resident #159's wound opened) revealed an air mattress was ordered due to compromised skin. Review of WP #401's note dated 05/16/23 revealed Resident #159 had a pressure wound on the sacrum. The wound was described as unstageable due to necrosis. The wound measured 3.1 cm long by 4.3 cm wide by 0.1 cm deep. There was moderate serous drainage. The wound had 70% thick adherent devitalized necrotic tissue. The wound was debrided to remove the necrotic tissue and establish the margins of viable tissue. The treatment plan included Mesalt (helps manage heavily discharging and discharging wounds in the inflammatory phase) then cover with an island bordered dressing daily until healed everyday shift for unstageable necrosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 25 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Level of Harm - Minimal harm or potential for actual harm Review of the Weekly Skin Observation Tool assessment dated [DATE] at 5:44 A.M. revealed Resident #159 had a Stage III pressure wound to her sacrum. The area measured 3.5 cm long by 3.0 cm wide. Adipose (body fat) tissue was visible surrounded by non-blanchable (discoloration of skin that does not turn white when pressed) redness. Resident #159 was observed to experience pain when the area was touched. Residents Affected - Few Review of the plan of care for Resident #159 revealed Resident #159 had actual or potential for skin breakdown. Interventions included administer treatment as ordered, apply moisture barrier to perineal area and buttocks after incontinence episodes, float heels while in bed or recliner, low air mattress for my bed (initiated 05/02/23), monitor effectiveness of treatment, notify the physician as needed if area worsens or does not respond, weekly skin screening, and turn and reposition frequently and as needed (initiated 05/02/23). On 05/16/23 at 2:32 P.M. Resident #159 was observed in her room with her son at the bedside. Interview with the resident at the time of the observation revealed she denied pain. The resident's son confirmed Resident #159's sacral wound was assessed by a wound specialist and treatment was changed. Resident #159's son stated the wound was present during her hospitalization but it was not an open area. Interview on 05/23/23 at 12:33 P.M. with Assistant [NAME] President Clinical (AVPC) #273 revealed the nurse who completed the initial admission Screen assessment on 05/02/23 did not stage the area correctly. AVPC #273 stated the area should have been noted as a DTI, not an unstageable pressure area because it was not an open area at that time. Interview on 05/23/23 at 12:41 P.M. with AVPC #273 confirmed there was not a comprehensive assessment including measurements and a full description of the wound completed from 05/02/23 until 05/16/23 (14 days). AVCP #273 confirmed there was no documentation WP #401 had been notified of the sacral wound area until 05/09/23 (eight days following admission), even though an area was noted on the admission Screen assessment. AVPC #273 confirmed Resident #159's sacral wound was not assessed by a wound specialist until 05/16/23 (15 days following admission). AVPC #273 stated Resident #159 was discharged from the hospital without an ordered treatment for the sacral wound area so the nurse ordered a zinc barrier cream and that was the treatment until 05/09/23 when the treatment was changed. AVPC #273 confirmed the low air mattress was not ordered or delivered until 05/12/23. AVPC #273 confirmed an order to turn and reposition Resident #159 every two hours and as needed was not written until 05/09/23 (eight days following admission). Interview on 05/25/23 at 12:56 P.M. with WP #401 revealed for most wounds that were not displaying signs of infection, standard wound prevention interventions would be acceptable to include a dry dressing, skin prep, and frequent turning and repositioning, until the resident was able to be assessed by a wound specialist. WP #401 confirmed he was first contacted via text message from the Director of Nursing (DON) regarding Resident #159 on 05/09/23. WP #401 stated the picture of Resident #159's sacral wound area on 05/09/23 showed a large DTI area and a little open area. WP #401 stated it was standard for a resident who required extensive assistance from two staff, was incontinent, and had an impaired skin area to be turned and repositioned every two hours and placed on an air mattress as prevention interventions and would have recommended those be put into place upon admission had he been notified of Resident #159's skin area. WP #401 confirmed it was standard to measure wounds weekly. 2. Review of the medical record for Resident #52 revealed an initial admission date of 12/09/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 26 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the latest readmission of 01/02/23 with diagnoses including quadriplegia, neuromuscular dysfunction of bladder, orthostatic hypotension, attention deficit hyperactivity disorder, insomnia, vitamin D deficiency, stage IV pressure ulcer of sacral region, traumatic brain injury and paraplegia. Review of the acute care hospital Discharge summary dated [DATE] revealed the resident had a Stage IV pressure ulcer to the sacrum measuring 5.5 centimeters (cm) by 4.0 cm by 3.9 cm with 75 to 100% granulation tissue. The assessment noted the ulcer had undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface) of 1.6 cm at 5 o'clock to 6 o'clock. Hospital discharge information noted a treatment to cleanse the wound with normal saline (NS), apply Clorpaotin moistened gauze, apply skin prep around wound and cover with abdominal (ABD) pad daily and as needed. Further review of the hospital record revealed the resident had an unstageable pressure ulcer to the left heel measuring 2.5 cm by 2.5 cm with 100% eschar covered. The hospital treatment indicated to cleanse with NS, pat dry, apply Cavilon advanced skin protectant then boot daily. Review of the admission screen and baseline care plan dated 12/09/22 revealed the resident was admitted to the facility with a pressure ulcer to the sacrum that measured 7.0 cm. The assessment had no staging, additional/accurate measurements, or description of the wound. Review of the medical record revealed no documented evidence that the resident's wounds were comprehensively assessed on admission to the facility by facility staff. Review of the plan of care dated 12/12/22 revealed the resident had actual skin breakdown related to Stage IV pressure ulcer to coccyx with osteomyelitis to coccyx with osteomyelitis and left heel, refuses treatments and wound doctor visits, putting resident at risk for a decline in wound. Interventions included administer treatment as ordered, enhanced barrier precautions, monitor effectiveness of treatment and notify physician as needed if area worsens or does not respond, monitor for pain, pressure reduction cushion to chair, pressure reduction mattress to bed, turn and reposition frequently and as needed, weekly skin screening. Review of the plan of care dated 12/12/22 revealed the resident had a Stage IV pressure ulcer to coccyx and left heel. Interventions included avoid scrubbing and pat dry sensitive skin, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify potential causative factors and eliminate/resolve when possible, keep skin clean and dry, use lotion on dry skin, monitor for side effects of medications, monitor location, size and treatment of skin injury, report abnormalities, failure to heel, signs/symptoms of infection, obtain blood work as ordered, pressure reducing devices as ordered, staff to encourage/assist with frequent turning and repositioning for pressure relief, treatment documentation to include measurement of each area of skin, breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations and use caution during transfers and bed mobility. Review of the resident's physician's orders revealed the first treatment order for the resident's Stage IV pressure ulcer to the left heel was initiated on 12/13/22 cleanse with NS, pat dry, apply Mesalt and cover with gauze island bordered dressing daily on evening shift. Further review revealed the first physician's ordered treatment to the Stage IV pressure ulcer to the resident's sacrum was dated 12/11/22 to cleanse wound to coccyx with NA, apply Clorpactin moistened gauze to wound bed apply skin prep to peri wound, cover with ABD twice daily for pressure ulcer. Review of the resident's December 2022 Medication Administration Record (MAR) revealed the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 27 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented treatment to the resident's coccyx was on 12/11/22 and the first documented treatment to the resident's left heel was on 12/14/23. Review of the wound physician progress note dated 12/13/22 revealed Stage IV pressure ulcer to the sacrum measured 6.3 cm by 2.8 cm by 1.5 cm with moderate exudate. The wound was described as 20% devitalized necrotic tissue, 10% slough, 30% granulation and 40% other tissue. The physician ordered to cleanse the wound, apply collagen powder, calcium alginate with silver and cover with gauze island dressing daily. The assessment of the Stage IV pressure wound to the left heel revealed the wound measured 4.2 cm by 2.0 cm by 0.3 cm with moderate serous exudate. The wound was described as 4.2 cm by 2.0 cm by 0.3 cm with moderate serous exudate. The wound was described as 20% devitalized necrotic tissue, 60% other tissue and 20% skin. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. The resident requires extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene. The assessment indicated the resident had function limitation in range of motion to both lower extremities. The assessment indicated the resident had an indwelling urinary tract infection and was frequently incontinent of bowel. The assessment indicated the was at risk for skin breakdown and had two stage IV pressure ulcer present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems and pressure ulcer/injury care. Review of the wound physician progress note dated 05/19/23 revealed the Stage IV pressure ulcer to the sacrum measured 0.3 cm by 0.2 cm by 0.2 cm with the wound bed being pink. The wound was determined to be non-healing. The Stage IV pressure ulcer to the left heel measured 3.0 cm by 1.0 cm by 0.2 cm with dark edges, maceration and red tissue. The wound was determined to be non-healing. Surgical debridement was completed. Review of the physician orders for May 2023 identified orders dated 01/24/23 cleanse left heel with NS, pat dry, apply calcium alginate with silver and cover with gauze island border dressing every two days and as needed, 03/29/23 weekly skin assessment to be completed by a licensed nurse, 05/11/23 low air mattress, offloading boots to both heel when in bed every shift for prevention, sit on roho cushion at all times when out of bed and cleanse sacral wound with NS, gently pack the wound with PRISMA then apply Calcium Alginate with silver, make sure to pack all undermined areas, cover with gauze island border dressing daily. On 05/23/23 at 1:54 P.M., an interview with [NAME] President of Clinical Services (VPCS) #278 verified the resident's sacral wound had no treatment until 12/11/22 (two days after admission) and the left foot wound had no treatment until 12/13/22 (four days after admission) after the wound physician assessed the wound. She also verified the sacral wound, and the left foot wound were not comprehensively assessed until 12/13/22 when the wound physician assessed the wound. 3. Review of the medical record for Resident #13 revealed an initial admission date of 12/21/15 with the latest readmission of 12/27/18 with the diagnoses including multiple sclerosis (MS), major depressive disorder, thiamine deficiency, hyperlipidemia, hypertension, nonpsychotic mental disorder, irritable bowel syndrome, dysphagia, contracture to left hand, contracture to right hand, constipation, dry eye syndrome and pressure ulcer to sacral region. Review of the plan of care dated 03/29/20 (last revised on 02/20/23) revealed the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 28 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few potential for pressure ulcer development related to decreased mobility related to MS, incontinence related to irritable bowel syndrome and a pressure ulcer to sacrum. Interventions included administer medications as ordered, administer treatments as ordered, enhanced barrier precautions, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status, monitor/report as needed any changes in skin, turn and reposition with max assist of one to two staff at least every two hours, more often as needed or requested, treat pain per orders prior to treatment/turning, treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and weekly skin assessment. Review of the Braden scale dated 09/09/22 revealed the resident was a moderate risk for skin breakdown. Review of the progress note dated 10/29/22 revealed the resident refused to be straight cathed and wanted to urinate on her own. The resident was placed on a bedpan, fluids encouraged, and the oncoming shift was made aware. Review of the progress note dated 10/30/22 revealed the resident had redness around her buttocks that was found during wound treatment. Barrier cream was applied. The family and Nurse Practitioner (NP) was notified and a request to put on the wound physician list was made. An order was entered for the resident to be turned every two hours. Review of the resident's discontinued physician orders identified an order dated 10/31/22 to reposition every two hours due to skin breakdown. The order was discontinued on 11/01/22. Review of the wound physician progress note dated 11/01/22 revealed the resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer to the left buttocks measuring 23 centimeters (cm) by 22 cm. The assessment had no description of the wound. Review of the wound physician progress note dated 11/08/22 revealed the resident had a Stage II pressure ulcer to the left buttocks measuring 17.5 centimeters (cm) by 22 cm and described as 80% skin. The facility implemented the treatment zinc ointment daily, off-load wound and reposition per facility protocol. Review of the wound physician progress note dated 11/15/22 revealed the wound was resolved. Review of the resident's physician orders identified an order dated 11/16/22 apply protective ointment to buttocks/perineal area every shift and as needed. On 05/22/23 at 3:20 P.M., interview with the Director of Nursing (DON) #259 revealed she was not employed with the facility at the time of the resident's skin breakdown but her understanding of the cause was the resident was left on the bedpan to long. The DON revealed the staff are no longer permitted to place the resident on the bedpan. On 05/22/23 at 3:41 P.M., interview with the VPCS #273 revealed the resident had two wounds. She revealed the first wound was noted on 10/31/22 and was seen by the wound doctor on 11/01/22. She revealed the wound was a superficial Stage II that was healed in two weeks. She revealed the Stage II pressure ulcer was the only wound attributed to the bedpan. She revealed an interview with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 29 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0686 #13, the resident felt the bedpan caused the wound. Level of Harm - Minimal harm or potential for actual harm On 5/25/23 at 12:56 P.M., interview with Wound Physician (WP) #401 revealed the Stage II pressure ulcer was in the shape of the bed pan and that was his understanding was that it was from a bedpan. Residents Affected - Few Review of the facility policy, Skin Care Management Procedure, revised 12/09/22, revealed the policy stated, at least weekly at a minimum, documentation should include the date observed, location and staging, size (length, width, and depth), exudates, pain, wound bed color and type of tissue/character including evidence of healing or necrosis and % of tissue, and description of wound edges and surrounding tissue as appropriate. Furthermore, the physician will be notified of all skin areas of concern and consulted for treatment orders. Review of the facility policy titled, Skin Care Management, last revised on 11/17/22 revealed it was the policy of the facility to identify individuals at risk for development of pressure ulcers and initiate management programs which stabilize or minimize underlying risk factors or changes in condition. 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 care management, promote healing of pressure ulcers that are present, evaluate and manage potential risks for development of additional pressure ulcers including changes in condition, identify and manage potential for infection and promote comfort by managing pain associated with pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 30 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to obtain a physician's order for the use of an orthopedic back brace for one resident (Resident #3). This affected one resident (Resident #3) out of five residents reviewed for positioning and range of motion. The facility census was 56. Findings Include: Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating. The resident required limited assistance from one staff for eating. Review of the physician orders dated May 2023 revealed there was not an order for Resident #3 to wear a back brace. Observation on 05/15/23 at 3:31 P.M. of Resident #3 in her room revealed the resident was wearing a back brace while sitting in her recliner. Observation on 05/16/23 at 2:54 P.M. of Resident #3 in her room revealed the resident was sitting her recliner without the back brace on. The brace was observed laying on the end of the resident's hospital bed. Interview on 05/16/23 at 3:06 P.M. with Nurse Trainer (NT) #277 confirmed Resident #3 wore a back brace. NT #277 stated she thought Resident #3 was admitted to the facility with the brace. NT #277 confirmed there was not an order in place related to the back brace and when Resident #3 should have the brace on and off. NT #277 confirmed there should be an order in place. NT #277 stated she believed the brace should be put on the resident when she was up out of bed. Observation on 05/16/23 at 3:26 P.M. of Resident #3 in her room revealed the resident was out of bed and sitting in her recliner without the back brace on. The back brace was observed sitting on the end of the hospital bed. Interview on 05/17/23 at 9:59 A.M. with the Director of Nursing (DON) confirmed there was not a physician order in place for Resident #3's back brace to verify when the resident should have the brace on and when Resident #3 should have the brace taken off. The DON stated she thought Resident #3 went to an outside orthopedic appointment and returned with the back brace but there were not any orders provided. The DON stated the facility attempted to obtain an order but did not have an order in place until this morning, 05/17/23. A facility policy related to physician orders was requested during the survey period but the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 31 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0688 facility did not provide a policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 32 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one resident (#24) received appropriate and timely treatment for a urinary tract infection (UTI). This affected one of four residents reviewed for catheter/UTI. Also, the facility failed to ensure indwelling urinary catheter collection bag was covered with a privacy bag for four residents (#1, #24,#52, #53) reviewed for indwelling urinary catheter and one resident (#210) reviewed for bowel and bladder. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admission date of 07/05/22 with the diagnoses including senile degeneration of brain, dementia, severe protein calorie malnutrition, dysphagia, hyperlipidemia, osteoarthritis, hypertension, bipolar disorder, diverticulosis of intestine, retention of urine and disorders of bladder. Review of the admission screen and baseline care plan dated 07/05/22 revealed the resident was admitted was admitted to the facility with an indwelling urinary catheter. Review of the plan of care dated 07/18/22 revealed the resident was at risk for urinary tract infection (UTI) due to history of frequent UTI, bladder disorders, urinary retention, catheter use and history of malignant neoplasm of bladder. Interventions included educate on proper peri-care, encourage fluid intake, monitor urine for signs/symptoms of UTI, lab work as ordered, medications as ordered, notify physician of any concerns and UTI stat as ordered. Review of the plan of care dated 10/28/22 revealed the resident had an indwelling urinary catheter related to urinary retention and bladder disorders. Interventions included maintain 20 FR/30 milliliter (ml) Foley catheter, position catheter bag and tubing below the level of the bladder and away from entrance room door, change Foley catheter monthly, check tubing for kinks frequently each shift, encourage the resident to allow the Foley catheter to be changed as ordered, monitor and document intake and output as per facility policy, monitor for pain/discomfort due to catheter and monitor for signs/symptoms on urination and frequency. Review of the progress note dated 05/01/23 at 3:08 P.M. revealed new orders were obtained for a complete blood count (CBC), basic metabolic panel (BMP) urinalysis/culture & sensitivity (UA/C&S) and vitamin D level. Review of the progress note dated 05/02/23 at 6:13 A.M. revealed the lab had not arrived at the facility to draw labs. The nurse was asked to follow up and the urine was collected and in the refrigerator. Review of the UA/C&S results dated 05/05/23 revealed the resident had greater that 100,000 proteus mirabilis and was sensitive to the antibiotic Augmentin. Review of the progress note dated 05/08/23 at 12:42 P.M. revealed a new order for Augmentin 500 milligrams (mg) by mouth twice a day for five days for urinary tract infection (UTI). Review of the monthly physician orders for May 2023 identified orders dated 07/07/22 provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 33 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some urinary catheter care every shift, 07/21/22 urinary catheter size 20 FR with 30 milliliter (ml) balloon continuously, 09/07/22 changed catheter collection bag weekly and as needed, change indwelling urinary catheter monthly and as needed for diagnoses of urinary retention, 10/07/22 check patency of catheter every shift, may irrigate catheter as needed and urinary catheter output every shift. On 05/15/23 at 11:54 A.M., observation of the resident revealed the indwelling urinary catheter collection bag was not covered for privacy. On 05/15/23 at 12:00 P.M., interview with State Tested Nursing Assistant (STNA) #244 verified the catheter collection bag was not covered with a privacy cover. On 05/22/23 at 11:01 A.M., interview with Director of Nursing (DON) #259 verified the physician was not notified of the culture results delaying the resident's treatment for UTI. 2. Review of the medical record for Resident #1 revealed an initial admission date of 03/19/21 with the latest readmission of 11/11/22 with the diagnoses including cerebrovascular infarct with left sided hemiplegia, diabetes mellitus, dysphagia, major depressive disorder, neuromuscular dysfunction, hyperlipidemia, right above the knee amputation, hypertension, gastro-esophageal reflux disease, constipation and retention of urine. Review of the plan of care dated 03/19/21 revealed the resident had a Foley catheter related to a neurogenic bladder. Interventions included the resident had a 16 FR Foley catheter with 30 ml balloon, position catheter bag and tubing below the level of the bladder and away from entrance of room door, change catheter as ordered and/or as needed, change collection bag weekly, catheter care every shift, irrigate catheter as ordered, check tubing for kinks frequently each shift, enhanced barrier precautions, monitor for pain/discomfort due to catheter, monitor for signs/symptoms of discomfort on urination and frequency and monitor for signs/symptoms of UTI. Review of the resident's quarterly MDS assessment dated [DATE] revealed had no cognitive deficit. The resident required extensive assistance of two for bed mobility, transfers and was dependent on two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and frequently incontinent of bowel. The assessment indicated the resident had a significant weight loss, not on a prescribed weight loss regimen and receives a therapeutic diet. Review of the monthly physician's orders for May 2023 identified orders dated 03/27/21 Foley catheter care every shift and as needed with soap and water, secure straps if applicable, document output every shift, 04/08/21 change urinary catheter as needed for patency, 07/27/21 Foley catheter 16 FR with 30 ml balloon to continuous drain every shift for neurogenic bladder, 03/09/22 change urinary catheter bag weekly, 03/30/22 irrigate Foley catheter with 60 ml normal saline as needed for prophylaxes related to retention of urine, 10/07/22 urine output every shift, 11/18/22 check urinary catheter patency each shift and 02/09/23 change urinary catheter each month. On 05/15/23 at 10:56 A.M., observation of Resident #1 revealed the resident's indwelling urinary catheter had no privacy cover. On 05/16/23 at 8:35 A.M., observation of Resident #1 revealed the resident's indwelling urinary catheter had no privacy cover. On 05/16/23 at 8:37 A.M., interview with Licensed Practical Nurse (LPN) #216 verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 34 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 indwelling catheter collection bag was not covered with privacy cover. Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #52 revealed an initial admission date of 12/09/22 with the latest readmission of 01/02/23 with diagnoses including quadriplegia, neuromuscular dysfunction of bladder, orthostatic hypotension, attention deficit hyperactivity disorder, insomnia, vitamin D deficiency, stage IV pressure ulcer of sacral region, traumatic brain injury and paraplegia. Residents Affected - Some Review of the admission screen and baseline care plan dated 12/09/22 revealed the resident had an indwelling urinary catheter upon admission. Review of the plan of care dated 12/12/22 revealed the resident had an indwelling urinary catheter related to neurogenic bladder. Interventions included change catheter monthly, check tubing for kinks frequently each shift, monitor and document intake and output as per facility policy, monitor for pain/discomfort due to catheter, monitor/report to physician for signs/symptoms of UTI, position catheter bag and tubing below the level of the bladder and away from entrance room door and apply a dignity bag to catheter bag. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. The resident requires extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene. The assessment indicated the resident had function limitation in range of motion to both lower extremities. The assessment indicated the resident had an indwelling urinary tract infection and was frequently incontinent of bowel. On 05/15/23 at 11:14 A.M., observation of the the resident revealed the resident's urinary catheter collection bag was not cover with a dignity bag. On 05/15/23 at 11:30 A.M., interview with STNA #300 verified the urinary collection bag was not covered with a dignity bag. 4. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following stroke, Type II Diabetes Mellitus, diabetic chronic kidney disease Stage III, and major depressive disorder-recurrent. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #53 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of the physician orders dated May 2023 revealed Resident #53 had the following orders in place: check urinary catheter patency each shift and document negative findings, may irrigate catheter as needed, change urinary catheter bag, tubing, and graduate weekly on Sundays, and catheter care every shift. All orders were dated 04/26/23. There was not an order for the catheter bag to be covered for privacy. Observation on 05/15/23 at 3:48 P.M. revealed Resident #53 was laying in bed with the catheter bag handing from the side rail of the hospital bed uncovered. The catheter bag was full of urine at the time of the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 35 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/15/23 at 5:31 P.M. revealed Resident #53 was sitting in his wheelchair. The catheter bag was hanging from the right side of the wheelchair uncovered. The catheter bag had amber colored urine in it and it was approximately a quarter of the way full at the time of the observation. Observation on 05/18/23 at 1:57 P.M. revealed Resident #53 was laying in bed. The resident's wife was visiting the resident at the time of the observation. Resident #53's catheter bag was laying on the floor underneath the resident's hospital uncovered. Resident #53 and the resident's wife both indicated they would prefer the resident's catheter bag to be covered. Interview and observation on 05/18/23 at 1:59 P.M. with State Tested Nurse Aide (STNA) #287 confirmed Resident #53's catheter bag was uncovered. 5. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. He had an indwelling catheter. Review of the plan of care dated 05/16/23 revealed Resident #210 had an indwelling catheter. Interventions included positioning catheter bag and tubing below the level of the bladder, changing catheter, catheter bag, and tubing as ordered, monitoring for pain and discomfort, and monitoring for signs of urinary tract infection. Observation on 05/15/23 at 9:40 A.M. revealed Resident #210's catheter bag was uncovered and visible from the doorway, the catheter bag was observed to be almost full. Further observation at 10:40 A.M. and 11:40 A.M. revealed Resident #210's catheter bag remained uncovered and visible from the doorway and was entirely full at both observations. Interview on 05/15/23 at 11:40 A.M. with Agency Aide #294 verified the observation, she reported she had emptied the bag at the beginning of her shift. Review of the staffing schedule revealed nurse aide shifts went from 7:00 A.M. to 3:00 P.M. A policy was requested regarding covering catheter bags for privacy during the survey period. The facility did not have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 36 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #1 revealed an initial admission date of 03/19/21 with the latest readmission of 11/11/22 with the diagnoses including cerebrovascular infarct with left sided hemiplegia, diabetes mellitus, dysphagia, major depressive disorder, neuromuscular dysfunction, hyperlipidemia, right above the knee amputation, hypertension, gastro-esophageal reflux disease, constipation and retention of urine. Residents Affected - Some Review of the plan of care dated 03/19/21 revealed the resident was at possible nutrition risk due to diabetes mellitus. Interventions included diet as ordered, medications as ordered and monthly weight. Review of the plan of care dated 07/02/21 revealed the resident was at nutritional risk due to health status, history of significant weight change, dysphagia, diabetes mellitus, hyperlipidemia, chronic obstruction pulmonary disease, hypertension, constipation, use of therapeutic diet and hemiplegia. Interventions included educate the resident on importance of adequate calorie and protein intake as appropriate, offer substitutes if resident does not like what is being served, monitor skin and wound reports, address any negative findings, offer the supplement the physician ordered and review weights, skin , labs and intakes routinely and as available and report changes as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed had no cognitive deficit. The resident required extensive assistance of two for bed mobility, transfers and was dependent on two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and frequently incontinent of bowel. The assessment indicated the resident had a significant weight loss, not on a prescribed weight loss regimen and receives a therapeutic diet. Review of the monthly physician's orders for May 2023 identified orders dated 03/19/21 weights monthly, 04/30/21 regular one-half portion dessert diet, regular texture, thin liquids and 05/15/23 Glucerna Thera Shake three times a day. Review of the resident's weights revealed on 02/01/23 the resident weighted 160.4 pounds, on 03/04/23 the resident weighed 149.5 pounds, on 04/05/23 the resident weighed 159.5 pounds and on 05/05/23 the resident weighed 142.5 pounds indicating the resident had an 11.16% weight loss in 90 days and a 10.66% weight loss in 30 days. Further review of the resident's weights revealed all weights documented for 12/22 were stuck out with no reason. Review of the medical record revealed no evidence the resident's significant weight loss was addressed or the resident's family and physician were notified of the weight loss. Review of the resident's meal percentage intakes for the past 30 days revealed the resident's nutritional intake was not monitored on 04/18/23 all three meals, 04/19/23 for two meals, 04/21/23 for two meals, 04/22/23 all three meals, 04/24/23 one meal, 04/26/23 for one meal, 04/28/23 for all three meals, 04/29/23 for one meal, 04/30/23 for one meal, 05/01/23 for one meal, 05/03/23 and 05/04/23 all three meals, 05/05/23 for two meals, 05/06/23 through 05/11/23 for all three meals, 05/12/23 for two meals, 05/13/23 for two meals, 05/15/23 and 05/16/23 for all three meals. On 05/16/23 at 3:45 P.M., interview with Resident #1 revealed she does not receive a supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 37 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some On 05/16/23 at 3:50 P.M., interview with Coach #265 verified House 402 had no Glucerna in stock to provide the physician ordered supplement to Resident #1. On 05/17/23 09:06 AM with the DON revealed the STNA's are responsible for ensuring the residents receive the supplements. She said it does flow over on the Medication Administration Record (MAR) for the nurses to initial the supplement was provided to the resident. The DON revealed the facility ordered a bulk amount in the March and currently using Glucerna tube feeding formula stored in house 400. The DON verified the resident was not receiving the supplement Glucerna. The DON revealed meals are free style and if the resident doesn't want what is on the menu, the resident is provided the food requested. The DON revealed meals were offered as an ala cart and they pick and choose what they want. The DON verified the Register Dietician (RD) had no way of tracking how many calories the residents were taking in. The DON verified the the resident's physician and family were never notified of the significant weight loss. On 05/17/23 at 10:50 A.M., interview with RD #269 verified he had not addressed the weight loss prior to the note on 05/15/23. The RD revealed the STNA should offer what is on the menu and if the resident refuses the food from the always available menu should be offered. He revealed if the resident continues to refuse the STNA should provide the requested items. He revealed in the event the supplement was not available the physician should be contacted for a substitute until the ordered supplement was restocked. He revealed verified the resident was never reweighed following the weight loss. On 05/17/23 at 11:25 A.M., interview with Resident #1 revealed the resident had never received a supplement. She stated, I told you once I never got them. On 05/17/23 at 11:38 A.M., interview with STNA #267 revealed she is the lead STNA for house 402 on first shift. She revealed rooms 203, 204, 207 and 209 receive a supplement daily at lunch and 206 receives a supplement at 1:00 P.M. She revealed Resident #1 receives the supplement Ensure. She said they offer each resident what is on the menu and if they don't want that the always available menu is offered. She said if the resident doesn't want those food items then they will fix what the resident wants to eat. She said they chart the percentage of what is served to the resident, not what is scheduled on the menu. On 05/17/23 at 11:27 A.M., observation of the pantry in house 400 revealed four unopened boxes of Glucerna 1.2 in the pantry. Further observation revealed the sticker documented four of four boxes. Review of the facility menu for 05/17/23 revealed the scheduled lunch meal consisted of four ounces of hot turkey sandwich, one half cup of coleslaw, one banana, eight ounces of milk and one desert of choice. On 05/17/23 at 1:05 P.M., the resident was served her lunch meal consisting of breaded chicken patty sandwich on a bun with a slice of cheese, an unmeasured amount of fries, banana and lemonade. The resident had no supplement delivered with her lunch meal. 05/17/23 at 1:45 P.M., observation and interview with Resident #1 revealed she consumed 100% of her meal. Resident #1 revealed she did not receive the physician ordered Glucerna supplement with her lunch meal as ordered. On 05/17/23 at 2:39 P.M., interview with Licensed Practical Nurse (LPN) #216 revealed she initialed the Glucerna supplement as being given but had no visualized the resident receiving the supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 38 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 LPN #216 verified the resident had not received the physician ordered 12:00 P.M. supplement Glucerna. Level of Harm - Minimal harm or potential for actual harm Review of the policy dated 12/02/21 revealed if a significant weight change was noted the dietitian or diet tech would proceed as appropriate including reviewing diet order, requesting weekly weights, observing the resident, speaking with the resident at mealtime, evaluating data, making recommendations, documenting in the medical record and updating the plan of care. Residents Affected - Some Review of the policy dated 03/10/23 revealed the resident was at risk for dehydration due to low fluid balance. Interventions included encouraging fluids. Based on observations, record review, resident and staff interviews, the facility failed to ensure nutritional supplements were administered as ordered to three residents (Residents #1, #45, and #210), failed to timely address significant weight changes for two residents (Residents #1 and #12), and failed to ensure fluids were kept within reach of two residents (Residents #12 and #53). This deficient practice affected five residents (Residents #1, #12, #45, #53, and #210) out of 12 residents reviewed for nutrition and hydration. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following stroke, Type II Diabetes Mellitus, diabetic chronic kidney disease Stage III, and major depressive disorder-recurrent. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including bed mobility. Observations on 05/15/23 at 3:42 P.M., 05/16/23 at 2:46 P.M., and 05/18/23 at 1:57 P.M. of Resident #53 in his room revealed there were not any fluids within reach of the resident. Interview on 05/18/23 at 1:57 P.M. with Resident #53 and the resident's wife, who was visiting at the time of the observation, revealed fluids were not kept within reach for the resident, especially when the resident was in bed because a fall mat was placed next to the bed and the bed side table was pulled out away from the bed. Resident #53 was not able to reach the small bedside table that was next to the bed but was placed slightly behind the head of the bed. There was a bottle of 7 UP sitting on the small table. Resident #53 attempted to reach the bottle but was unsuccessful. Interview on 05/18/23 at 1:59 P.M. with State Tested Nurse Aide (STNA) #287 confirmed there were not any fluids within Resident #53's reach. 2. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 39 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some Review of the plan of care dated 04/30/23 revealed Resident #210 was at possible nutrition risk due to current health status. Interventions included diet as ordered, medications as ordered, monitoring oral intake, and monitoring weight. Review of the physician order dated 05/07/23 revealed an order for Nepro after meals at 12:00 P.M. and 5:00 P.M. Review of the task supplement documentation for the 30 days leading up to 05/17/23 revealed Nepro was not documented as having been given to Resident #210. Additionally, the task documentation did not indicate whether one supplement or two should be given and when it should be given. Observation on 05/17/23 of the lunch meal revealed Resident #210 was not provided with a Nepro Supplement. Interview on 05/17/23 at 9:06 A.M. with the Director of Nursing (DON) and on 05/17/23 at 10:50 A.M. with Dietitian #269 revealed the nurse aides were responsible for giving residents their supplements and documenting it in the 'task' area of the electronic medical record. Interview on 05/17/23 at 12:50 P.M. with STNA #250 revealed in Resident #210's building there were no residents on supplements other than Ensure. Interview on 05/17/23 at 2:25 P.M. with STNA #251 revealed Resident #210 did not get a supplement on that day. STNA #251 reported they only gave supplements to residents when they eat poorly. Interview on 05/17/23 at 3:52 P.M. and 05/18/23 at 11:17 A.M. with Dietitian #269 verified Resident #210 should have been given supplement Nepro and the documentation did not indicate that he had received it or that the aides knew how much to give and when to give it. He reported the aides administered the oral supplements and used the task documentation to inform them of the amount and time to give them. 3. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the plan of care dated 01/18/23 revealed Resident #45 was at nutritional risk related to her health status. Interventions included encouraging to eat calorically dense foods and encouraging to participate in menu planning. Review of the physician order dated 03/01/23 to 05/17/23 revealed an order for health shake three times a day. Interview on 05/17/23 at 9:06 A.M. with the DON and on 05/17/23 at 10:50 A.M. with Dietitian #269 revealed the nurse aides were responsible for giving residents their supplements and documenting it in the 'task' area of the electronic medical record. Interview on 05/17/23 at 10:51 A.M. and 5:26 P.M. with Dietitian #269 revealed the health shake was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 40 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 - Some being fazed out, in the meantime staff were supposed to replace it with ensure. Supplements were to be given as ordered regardless of intake. Observation of the lunch meal on 05/17/23 revealed Resident #45 was not given an Ensure. Interview on 05/17/23 at 2:25 P.M. and 2:34 P.M. with STNA #251 revealed Resident #45 did not receive a supplement at breakfast or lunch because she ate well. 4. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 04/07/23 revealed Resident #12 was at possible nutrition risk due to health status, use of therapeutic diet, and diagnoses. Interventions included providing diet as ordered, medications as ordered, monitoring oral intake, and monitoring skin and wound reports. Review of Resident #12's weights revealed on 09/06/22 she weighed 233.5 pounds, on 10/12/22 she weighed 221.0 pounds (a 5.4% weight loss over 36 days), on 10/22/22 pounds she weighed 190.5 pounds (18.4 % over 46 days and 13.8% over 10 days), on 11/01/22 she was 190.5 pounds, on 12/01/22 she was 190.5 pounds, on 01/09/23 she weighed 184.2 pounds, on 02/09/23 she weighed 175 pounds, on 03/03/23 she weighed 175.4 pounds, on 04/05/23 she weighed 173.6, and on 05/01/23 she weighed 152 pounds (12.4% over 30 days and 20.2% over 180 days). Review of the physician order dated 11/24/22 to 03/03/23 revealed an order for Ensure two times a day. Review of the physician order dated 03/03/23 to 04/29/23 revealed an order for a health shake two times a day. Review of the physician order dated 04/30/23 to 05/15/23 revealed an order for health shake three times a day. Review of the progress note dated 10/25/22 revealed Diet Technician #440 acknowledge that Resident #12 weighed 221 pounds, which was a significant weight loss. He reported he suspected the elder was following food recommendations. Review of the progress note dated 10/26/22 revealed Diet Technician #440 acknowledged that Resident #12 weighed 190.5 pounds which was a significant weight change. He reported mild to moderate weigh changes related to constipation and fluid balance. Review of the progress notes for October 2022 revealed nothing to indicate Resident #12 had fluid changes or constipation. Review of the progress note dated 12/09/22 revealed a nutrition assessment was completed, Diet Technician #440 noted no weight changes, reported supplements in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 41 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 Review of the progress note dated 01/18/23 revealed Resident #12 weighed 184.2 pounds which was a significant weight loss suspected to be related to varied intake, altered mental status, and decreased fluid imbalance. Review of the progress note dated 02/01/23 revealed Resident #12 received ensure twice a day. Residents Affected - Some Review of the progress note dated 03/03/23 revealed Diet Technician #440 noted Resident #12 had a significant weight loss of 8.1% over three months. He updated the supplement regimen to health shakes three times a day. Review of the progress note dated 03/10/23 revealed Diet Technician #440 completed a nutrition assessment. The resident had a significant weight change over three months related to sedentary lifestyle and increase caloric of high fat foods. Supplements twice a day and fluids were to be encouraged. Review of the progress note dated 04/29/23 indicated Resident #12 had a significant weight loss suspected to be related to altered mental status and limited food acceptance. Health shake regimen was increased to three times a day. Observation on 05/15/23 at 9:52 A.M. and 11:04 A.M. revealed Resident #12 had a glass of water, on a bedside tablet. The bedside table out of reach it was on the other side of a fall mat. Further observation at 2:30 P.M., 3:52 P.M., and 4:12 P.M. revealed Resident #12 had a glass of water that was on a bedside table at the foot of her bed. Interview on 05/15/23 at 1:22 P.M. with Resident #12's family revealed she had ongoing discussions with the facility about keeping water in reach for Resident #12. Interview on 05/15/23 at 4:12 P.M. with STNA #241 verified Resident #12's water was out of reach. She reported Resident #12 had poor vision; her bedside table was kept out of reach because she would knock her water off. Interview on 05/18/23 at 10:59 A.M. with Dietitian #269 verified there was no evidence that Resident #12 had constipation or significant fluid changes as referenced in Diet Technician #440's 10/26/23 note. He verified the supplement was not in place until 11/24/22 to address the weight loss. Dietitian #269 verified that Diet Technician #440's 03/03/23 progress note indicates he wanted to increase the supplements however, they were not increased until 04/30/23. Dietitian #269 indicated he was unsure why in his 04/29/23 note Diet Technician #440 indicated Resident #12 was losing weight due to sedentary lifestyle and increased calorie intake as that would indicate a weight gain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 42 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure oxygen nasal cannula tubing was changed weekly as physician ordered for two residents (#3, #40). Also, the facility failed to ensure respiratory equipment was stored properly to prevent infection for Resident #40. This affected two of two residents reviewed for oxygen therapy. The facility identified seven residents receiving respiratory treatments. The facility census was 56. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 08/12/20 with the latest readmission of 05/02/23 with the diagnoses including cerebrovascular accident with right sided hemiplegia, diabetes mellitus, atrial fibrillation, hypertension, gastro-esophageal reflux disease, hyperlipidemia, cardiomyopathy, anemia, chronic kidney disease and dysphagia. Review of the plan of care dated 03/28/23 revealed the resident had an altered respiratory status/difficult breathing related to cardiac difficulties. Interventions included oxygen as needed per physician orders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident received oxygen. Review of the monthly physician orders for May 2023 identified orders dated 05/15/23 may titrate oxygen one to two liters to keep oxygen saturation above 92%, change aerosol tubing/mask weekly and change oxygen tubing weekly. On 05/15/23 at 11:06 A.M., observation of the resident's oxygen tubing revealed a date of 11/28. Further observation revealed the nebulizer machine sitting on the floor and nebulizer delivery system was tucked under the handle of the concentrator without a plastic bag. The resident also had a mask nebulizer delivery system laying on the floor unbagged. On 05/15/23 at 11:10 A.M., interview with Registered Nurse (RN) #284 verified the oxygen nasal cannula was not changed weekly as physician ordered and verified the nebulizer and the disposable nebulizer kit were not stored properly to prevent infection. 2. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating. The resident required limited assistance from one staff for eating. Resident #3 used oxygen. Review of the physician orders dated May 2023 revealed Resident #3 had the following order: change oxygen tubing weekly. The order was dated 04/06/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 43 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Observations on 05/15/23 at 2:31 P.M. and 05/18/23 at 5:44 P.M. revealed Resident #3's oxygen tubing was dated 04/29. The date did not have a year. Interview and observation on 05/18/23 at 5:47 P.M. with Interim Coach (IC) #271 confirmed Resident #3's oxygen tubing was dated 04/29 and did not have a year. IC #271 confirmed Resident #3 had an order to have the tubing changed weekly. Event ID: Facility ID: 366430 If continuation sheet Page 44 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 interview and record review the physician failed to date when he addressed pharmacy recommendations and failed to provide reasoning for declining a gradual dose reduction (GDR) recommendation from the pharmacist for Resident #29. This affected one resident (#29) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record revealed an admission date of 12/22/21 with diagnoses including Parkinson's disease, paranoid personality disorder, essential tremor, anxiety disorder, unspecified hearing loss, dementia, depression, dysphagia, and delusional disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had impaired cognition. During the lookback period she received antipsychotic's, antianxiety medications, and antidepressants. Review of the medication regimen review (MRR) summary dated 06/03/22 revealed the pharmacist made a recommendation related to Resident #29 to add a stop date for Enoxaparin. The physician indicated he agreed with the recommendation but did not date the day they addressed the recommendation. Review of the MRR summary dated 07/04/22 revealed the pharmacist made a recommendation to consider a GDR. Resident #29 had been using Lexapro for six months without an attempted GDR or contraindication. The physician indicated he disagreed but did not provide a reason or date when they addressed the concern. Interview on 05/18/23 at 4:31 P.M. with the Director of Nursing (DON) verified the physician had not dated the recommendations or addressed the reasons for declining the GDR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 45 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medication parameters were monitored as ordered for Resident #12. This affected one resident (#12) of five reviewed for unnecessary medications. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the physician order dated 04/17/23 revealed Resident #12 was to receive Metoprolol Succinate extended release 100 milligrams (mg) one and a half tablets at bedtime. The medication had parameters to hold for systolic blood pressure less than 100 mm/hg and for heart rate less than 55 beats per minute (bpm). Review of the physician order dated 04/17/23 revealed Resident #12 was to receive Digoxin Tablet 125 microgram (mcg) by mouth one time a day. The medication had parameters to hold for systolic blood pressure less than 100 mm/hg and for heart rate less than 55 beats per minute (bpm). Review of Resident #12's Medication Administration Record (MAR) for May 2023 revealed the residents blood pressure and heart rate were not assessed daily. Review of Resident #12's vitals from 05/01/23 to 05/16/23 revealed their heart rate and blood pressure were only assessed on 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/09/23, 05/13/23, 05/14/23, and 05/16/23. Interview on 05/18/23 at 3:12 P.M. with the Director of Nursing (DON) verified Resident #12's blood pressure and heart rate were not being monitored as ordered prior to medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 46 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 record review and staff interview, the facility failed to ensure antipsychotics were used with a proper diagnosis for two resident (Residents #3 and #46). The deficient practice affected two (Residents #3 and #46) of five residents reviewed for unnecessary medications. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating, limited assistance from one staff was required. Resident #3 was administered antipsychotic medication on a routine basis. Review of the physician orders dated May 2023 revealed Resident #3 had the following order: Risperdal (an antipsychotic medication) two milligrams (mg) twice daily for antipsychotic. Review of the care plan dated 04/03/23 revealed Resident #3 had potential for drug related complications related to antipsychotic medication. Interventions included administer antipsychotic medications as ordered by physician, monitor for side effects and effectiveness, consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician and family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, monitor/document/report as needed any adverse reactions of antipsychotic medications, offer music and memory, refer to social services/psychological counseling/psychiatric counseling as appropriate, and while resident is receiving psychotropic medication therapy: provide one on one, reassurance, allow to verbalize feeling and concerns and validate, redirect as appropriate, teach and encourage relaxation techniques, etc. Interview on 05/23/23 at 12:14 P.M. with Assistant [NAME] President Clinical (AVPC) #273 confirmed there was not a valid diagnosis listed for the use of an antipsychotic medication for Resident #3. 2. Review of the closed medical record for former Resident #46 revealed an admission date on 11/01/22 and a discharge date on 05/22/23. Medical diagnoses included vascular dementia with other behavioral disturbance, anxiety disorder, and major depressive disorder-recurrent. There were not any other mental health diagnoses listed. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 had impaired cognition and scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Behaviors displayed included hallucinations, delusions, other behavioral symptoms not directed towards others (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 47 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 one to three days out of the review period, and wandering one to three days out of the review period. Resident #46 required limited to extensive assistance form one staff to complete Activities of Daily Living (ADLs). Resident #46 was administered antipsychotic medication daily. No gradual dose reductions had been attempted or contraindicated. Review of the physician orders dated May 2023 revealed Resident #46 had the following order: Quetiapine Fumarate (Seroquel) (an antipsychotic medication) 25 milligrams (mg) with instructions to give 12.5 mg daily at bedtime for insomnia and give 25 mg in the morning for agitation. The order was dated 05/08/23. Review of the progress noted dated from 11/01/22 through 05/22/23 revealed Resident #46 was noted to have dementia with Sundowner's Syndrome (occurs when a resident has increased confusion during the evening and night time). Resident #46 displayed some confusion and exit-seeking behaviors that were noted. Review of the care plan dated 11/01/22 revealed Resident #46 had potential to be physically aggressive (pinching/scratching/spitting) related to dementia. Interventions included to administer medications as ordered and monitor/document for side effects and effectiveness of medications. Resident #46 had potential for drug related complications related to antipsychotic medication for diagnosis of behavior management. Interventions included administer antipsychotic medications as ordered by physician, monitor for side effects and effectiveness, consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician and family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, monitor/document/report as needed any adverse reactions of antipsychotic medications, offer music and memory, refer to social services/psychological counseling/psychiatric counseling as appropriate, and while resident is receiving psychotropic medication therapy: provide one on one, reassurance, allow to verbalize feeling and concerns and validate, redirect as appropriate, teach and encourage relaxation techniques, etc. Interview on 05/23/23 at 12:14 P.M. with AVPC #273 confirmed there was not a valid diagnosis listed for the use of an antipsychotic medication for Resident #46. A facility policy was requested during the survey period however, per the Administrator, the facility did not have a policy related to unnecessary medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 48 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and medical record review, the facility failed to ensure Resident #19's prescribed medications were stored securely. This affected two residents (#10 and #19) of two residents reviewed for medication storage. The facility census was 56. Findings include: 1. Observation on 05/15/23 at 2:40 P.M. of Resident #19's room revealed she had seven unknown pills in a medicine cup in her room. Resident #19 reported she was unsure when it was from and did not know if she should take it. Interview on 05/15/23 at 2:45 P.M. with Agency Registered Nurse #304 verified the observation. She reported she had just done change over with the previous nurse. She did not know what the pills were or when they were supposed to be administered. Review of the medical record for Resident #19 revealed an admission date of 11/07/22 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, depression, hypertension, fibromyalgia, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed cognition was not assessed but staff interview revealed no memory concerns and no delirium. She was independent for cognitive skills for daily decision making. Review of the physician order dated 03/01/23 revealed an order for niacinamide oral tablet 500 mg one tablet my mouth three times a day. Review of the physician order dated 04/18/23 revealed an order for Cholecalciferol Tablet 1000 units, two tablets by mouth one time a day for supplement. Review of the physician order dated 04/18/23 revealed an order for Cranberry Tablet 450 mg one tablet by mouth at bedtime. Review of the physician order dated 04/18/23 revealed an order for Cyanocobalamin Tablet 500 micrograms(mcg) one time a day. Review of the physician order dated 04/18/23 revealed an order for Ducosate Sodium Capsule by mouth two times a day for constipation. Review of the physician order dated 04/18/23 revealed an order for Donepezil Hcl Tablet 10 mg one tablet by mouth at bedtime. Review of the physician order dated 04/18/23 revealed an order for Fluoxetine Hcl Capsule 20 mg one capsule by mouth one time a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 49 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 04/18/23 revealed an order for Furosemide tablet 40 mg one tablet by mouth onetime a day. Review of the physician order dated 04/18/23 revealed Gabapentin Capsule 300 mg one capsule by mouth two times a day for diabetic. Residents Affected - Few Review of the physician order dated 04/18/23 revealed an order for for Potassium Chloride extended release one capsule by mouth one time a day for diuretic use. Review of the physician order dated 04/18/23 revealed an order for Trazdone Hcl Tablet 50 mg one tablet by mouth in the evening related to insomnia. Review of the physician order dated 04/18/23 revealed an order for Melatonin Tablet 5 mg one tablet by mouth at bedtime. 2. Interview on 05/16/23 at 10:00 A.M. with Resident #10's daughter revealed she had found eye drops in her mother's room and did not understand why as her mother could not administer them herself. She reported she then realized they were not even her mother's eye drops. Observation on 05/16/23 at 10:00 A.M. revealed a bottle of eye drops for Resident #19 was on Resident #10's bedside table. Interview on 05/26/23 at 10:15 A.M. with the Director of Nursing (DON) verified the observation and confirmed the eye drops should not be in Resident #10's room. Review of the medical record for Resident #10 revealed an admission date of 06/11/16 with diagnoses including cerebral infarction, multiple sclerosis, paraplegia, hyperlipidemia, anxiety disorder, contractures of left and right hand, unspecified dementia, peripheral vascular disease, and as of 03/24/23 fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate. Review of Resident #10's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. Review of Resident #10's physician order dated 04/18/23 revealed an order for PredForte Suspension one drop in left eye one time a day for post op inflammation. The order did not allow for self-Administration. Review of Resident #10's physician order dated 04/18/23 revealed an order for Ketotifen Fumarate 0.025% one drop in both eyes every morning and at bedtime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 50 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure staff were competent to serve meals according to the menu and diet order, to obtain temperatures prior to serving food, and use appropriate serving sizes. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56. Findings include: 1. Review of the menu for the lunch meal on 05/17/23 revealed residents were to receive four ounces of a hot turkey sandwich, 0.5 cups of coleslaw, one banana, eight ounces of milk, and dessert of choice. Observation of the lunch meal in the 400 building on 05/17/23 from 11:49 A.M. to 1:41 P.M. revealed the following concerns: a. State Tested Nursing Aide (STNA) #250 prepared lunch which included hot turkey sandwiches she put turkey, cheese, tomato, spinach, and ranch dressing on bread and put it in the oven. She reported they did not have to follow a recipe for all meals, including this one. She reported there was a recipe book, however, it took her and STNA #251 several minutes to find it. The recipe book contained around 10 recipes printed from the internet, which did not include hot turkey sandwiches, this was verified by STNA #250. b. All but two residents (#31 and #210) were served hot turkey sandwiches, coleslaw, mandarin oranges, bananas, and milk. STNA #250 reported the menu called for 'dessert of choice', however, they had mandarin oranges so that was the dessert residents were going to get. c. Observation of meal service revealed STNA #250 used a regular spoon to serve an unmeasured amount coleslaw to residents and a varying amount of meat for the turkey sandwiches. d. Observation of the meal service revealed STNA #250 did obtain the temperature of any food prior to serving it. e. Observation of the lunch meal revealed Resident #25, who had an order for a puree diet, received a regular diet. Interview with STNA #250 verified she did not measure the amount coleslaw and used two to three slices of turkey for the sandwiches. STNA #250 verified they had serving spoons available, but revealed she only used them when serving soup. STNA #250 verified she did not obtain the temperature of the foods. She reported she only did temperatures for puree foods and soups to ensure they were not too hot. STNA #250 additionally verified Resident #25's order called for a puree diet, however, she had been told she could do a regular diet with supervision. Review of the medical record revealed Resident #25 admitted on [DATE] with diagnoses including dementia, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit, bell's palsy, and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 51 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0801 Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was rarely or never understood. She was on a mechanically altered diet. Level of Harm - Minimal harm or potential for actual harm Review of the diet order dated 04/08/23 revealed she was to be getting a regular diet with pureed texture. Residents Affected - Some 2. Observation of meals in house 402 revealed the following concerns: a. Review of the facility menu for 05/15/23 revealed the breakfast meal consisted of two waffles, one cup of cold cereal or hot cereal, one egg of choice, two slices of toast, half a cup of fruit and eight ounces of milk. Observation of the breakfast meal on 05/15/23 in house 402 revealed the following: On 05/15/23 at 10:15 A.M., observation of Resident #41 revealed he was served a small bowl of oatmeal (one package of instant oatmeal), and an eight ounce of orange juice. On 05/15/23 at 11:23 A.M., observation of the resident revealed the resident consumed the oatmeal and the orange juice. STNA #301 picked up the empty bowl and the resident stated, don't take that. The STNA asked the resident if he wanted more food, the resident stated, yes. STNA #301 stated, I will get you an ensure. The resident was provided a container of Ensure (a nutritional supplement) instead of more food as requested. b. Review of the menu for the lunch meal on 05/17/23 revealed residents were to receive four ounces of a hot turkey sandwich, 0.5 cups of coleslaw, one banana, eight ounces of milk, and dessert of choice. On 05/17/23 at 12:52 P.M., observation of the lunch meal for house 402 revealed STNA #285 prepared breaded chicken patties, French fries and a fruit cup consisting of strawberries and grapes for the lunch meal. She revealed she gives the resident three choices of meals and the one that received the most votes she fixes. Further observations revealed the residents were served a chicken patty on a bun, an unmeasured amount of French fries. Five residents received the fruit cup and the other seven residents received a banana. The residents were served eight ounces of lemonade. On 05/17/23 at 1:42 P.M., interview with STNA #285 verified the planned meal was not served and the residents were not offered milk. 3. Observation of the lunch meal on 05/17/23 in building 403 revealed the following: a. Coleslaw was not measured or portioned and was put on a plate using a large spoon. b. The meat for the sandwiches was not measured to ensure it matched the menu. c. The temperature of foods was not obtained prior to serving. Interview on 05/17/23 at 1:04 P.M. with STNA #215 verified they did not have any measuring utensils to ensure the proper portions. Interview on 05/17/23 at 1:05 P.M. with Agency STNA #293 revealed she had prepared the lunch. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 52 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verified she had not obtained the temperature of foods prior to serving. Agency STNA #293 reported this had been her first day in the facility and the first time being expected to cook for residents. 4. Review of the menu for the lunch meal on 05/22/23 revealed residents were to receive a deli sandwich with three ounces of meat, 10 curly fries, four ounces of yogurt, and four ounces of milk. On 05/22/23 at 11:53 A.M. the menu was verified by Household Aide #240 who was preparing the meal. Observation of the lunch meal in the 401 building on 05/22/23 from revealed the following concerns: a. Residents were offered lemonade, apple juice, pop, other juices, and water. At no point during the meal was milk offered. This was verified by Household Aide #248. b. Observation of the lunch meal revealed each deli sandwich was made with two to three slices of meat, mayonnaise, tomato, and lettuce. Eleven sandwiches were made using a nine-ounce container of meat. Interview with Household Aide #240 verified the observation, she reported she thought three slices of meat was three ounces. c. Observation revealed residents received waffle fries instead of curly fries, each resident received four to five waffle fries. Interview with Household Aide #248 verified this she reported they portioned the waffle fries based on how much they know each resident will eat. Review of the policy Neighborhood Diets Policy dated 01/01/09, revealed puree diet was a regular diet with texture altered to accommodate those with difficulty swallowing or chewing. Texture varied from thin like applesauce to thick like mashed potatoes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 53 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and review of the menu, the facility failed to ensure the menu, recipes, and portion sizes were followed in all buildings. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56. Findings include: 1. Review of the facility menu for 05/15/23 revealed the breakfast meal consisted of two waffles, one cup of cold cereal or hot cereal, one egg of choice, two slices of toast, half a cup of fruit and eight ounces of milk. Observation of the breakfast meal on 05/15/23 in house 402 revealed the following: On 05/15/23 at 10:15 A.M., observation of Resident #41 revealed he was served a small bowl of oatmeal (one package of instant oatmeal), and an eight ounce of orange juice. On 05/15/23 at 11:23 A.M., observation of the resident revealed the resident consumed the oatmeal and the orange juice. State Tested Nursing Assistant (STNA) #301 picked up the empty bowl and the resident stated, don't take that. The STNA asked the resident if he wanted more food, the resident stated, yes. STNA #301 stated, I will get you an Ensure. The resident was provided a container of Ensure (a nutritional supplement) instead of more food as requested. 2. Review of the menu for the lunch meal on 05/17/23 revealed residents were to receive four ounces of a hot turkey sandwich, 0.5 cups of coleslaw, one banana, eight ounces of milk, and dessert of choice. Observation of the lunch meal in the 400 building on 05/17/23 from 11:49 A.M. to 1:41 P.M. revealed the following concerns: a. STNA #250 prepared lunch which included hot turkey sandwiches. She put turkey, cheese, tomato, spinach, and ranch dressing on bread and put it in the oven. She reported they did not have to follow a recipe for all meals, including this one. She reported there was a recipe book, however, it took her and STNA #251 several minutes to find it. The recipe book contained around 10 recipes printed from the internet, which did not include hot turkey sandwiches, this was verified by STNA #250. b. All but two residents (#31 and #210) were served hot turkey sandwiches, coleslaw, mandarin oranges, bananas, and milk. STNA #250 reported the menu called for 'dessert of choice', however, they had mandarin oranges so that was the dessert residents were going to get. c. Observation of meal service revealed STNA #250 used a regular spoon to serve an unmeasured amount coleslaw to residents and a varying amount of meat for the turkey sandwiches. Interview with STNA #240 verified she did not measure the amount coleslaw and used two to three slices of turkey for the sandwiches. STNA #240 verified they had serving spoons available, but revealed she only used them when serving soup. 3. On 05/17/23 at 12:52 P.M., observation of the lunch meal for house 402 revealed STNA #285 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 54 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm prepared breaded chicken patties, French fries and a fruit cup consisting of strawberries and grapes for the lunch meal. She revealed she gives the resident three choices of meals and the one that received the most votes she fixes. Further observations revealed the residents were served a chicken patty on a bun, an unmeasured amount of French fries. Five residents received the fruit cup and the other seven residents received a banana. The residents were served eight ounces of lemonade. Residents Affected - Some On 05/17/23 at 1:42 P.M., interview with STNA #285 verified the planned meal was not served and the residents were not offered milk. 4. Observation of the lunch meal on 05/17/23 in building 403 revealed the following: a. The coleslaw was not measured or portioned and was put on a plate using a large spoon. b. The meat for the sandwiches was not measured to ensure it matched the menu. Interview on 05/17/23 at 1:04 P.M. with STNA #215 verified they did not have any measuring utensils to ensure the proper portions. 5. Review of the menu for the lunch meal on 05/22/23 revealed residents were to receive a deli sandwich with three ounces of meat, 10 curly fries, four ounces of yogurt, and four ounces of milk. On 05/22/23 at 11:53 A.M. the menu was verified by Household Aide #240 who was preparing the meal. Observation of the lunch meal in the 401 building on 05/22/23 from revealed the following concerns: a. Residents were offered lemonade, apple juice, pop, other juices, and water. At no point during the meal was milk offered. This was verified by Household Aide #248. b. Observation of the lunch meal revealed each deli sandwich was made with two to three slices of meat, mayonnaise, tomato, and lettuce. Eleven sandwiches were made using a nine-ounce container of meat. Interview with Household Aide #240 verified the observation, she reported she thought three slices of meat was three ounces. c. Observation revealed residents received waffle fries instead of curly fries, each resident received four to five waffle fries. Interview with Household Aide #248 verified this she reported they portioned the waffle fries based on how much they know each resident will eat. Interview on 05/16/23 at 10:00 A.M. with Resident #10 revealed the facility did not provide the residents with the drinks on the menu. 6. Review of the menu for the week of 05/12/23 revealed it lacked variety. The residents were served sandwiches five times throughout the week. They were served green beans three times on 05/12/23, 05/17/23, and 05/18/23. On 05/15/23 for dinner they received meatloaf and for dinner on 05/16/23 they received swiss steak Interview on 05/17/23 at 12:58 P.M. with Resident #21 revealed the resident was served an alternative option including a bowl of chicken noodle soup, a piece of chocolate cake, and a cup of coffee. Resident #21 confirmed she received the foods she had requested. Resident #21 stated, I've had enough ham and cheese here. Resident #21 also stated she did not really like chicken noodle soup and preferred vegetable soup but the kitchen never had vegetable soup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 55 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 05/17/23 at 12:38 P.M. with Resident #15 revealed she had not been served lunch yet. Resident #15 asked what was being served. This surveyor reviewed the menu and Resident #15 stated, oh, the same as yesterday. Interview with two residents (#9 and #37) during resident council 05/22/23 at 11:37 A.M. revealed food was one of the problems in the facility. They reported they offered the same things too often and they did not provide the menu as it was posted. Event ID: Facility ID: 366430 If continuation sheet Page 56 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to serve pureed foods in an appropriate and palatable manner. This affected one resident (#25) of two receiving a pureed diet. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record revealed Resident #25 admitted on [DATE] with diagnoses including dementia, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit, bell's palsy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was rarely or never understood. She was on a mechanically altered diet. Review of the diet order dated 04/08/23 revealed she was to be getting a regular diet with pureed texture. Observation on 05/22/23 at 8:52 A.M. revealed State Tested Nursing Aide (STNA) #225 feeding Resident #25 unidentifiable food out of one bowl. Interview with STNA #225 at that time revealed she was unsure what Resident #225 was eating, and thought it was eggs. Interview on 05/22/23 at 8:55 A.M. with STNA #264 revealed they had prepared the pureed food that was served to Resident #31 and Resident #25. She reported she had blended all the breakfast foods together, STNA #264 reported she knew it was supposed to be prepared separately. STNA #264 stated she prepared it that way because it was what Resident #31 preferred, however, she verified it was what Resident #25 received as well. Review of the breakfast menu on 05/22/23 revealed residents should have received French toast sticks, eggs of choice, bacon strips, cantaloupe, orange juice, and milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 57 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 05/17/23 at 12:52 P.M., observation of the lunch meal for house 402 revealed STNA #305 prepared chicken patty and French fries for the lunch meal. The STNA prepared a fruit cup consisting of strawberries and grapes. Observation of the STNA prepare the lunch meal revealed the resident's were served a chicken patty on bun, an unmeasured amount of fries with ketchup, an unmeasured bowl of fruit and offered lettuce and tomatoes for the sandwich. On 05/17/23 at 1:20 P.M., observation of STNA #305 serve Resident #44 the lunch meal revealed the STNA cut up a chicken patty and placed on the plate. The STNA placed an unmeasured amount of french fries on the plate and an unmeasured amount of fruit in a bowl. The STNA then served Resident #41 a cut up chicken patty and an unmeasured amount of french fries and fruit. Resident #41 and #44 were given an eight ounce glass of lemonade. The residents were not offered utensils to eat with. Resident #41 and #44 began eating their food with their fingers. Interview with STNA #305 at the time of the observation revealed Resident #41 and #44 were on regular textured diets and was able to eat a sandwich. Review of the facility policy, Neighborhood Diets Policy, revised 05/2013, revealed the policy stated, a pureed diet was a regular diet with texture altered to accommodate those with difficulty swallowing and/or chewing. Texture varies from thin (applesauce) to thick (mashed potatoes). Bread or bread substitutes is incorporated into recipes to meet nutritional guidelines. The policy did not address providing the appropriate textured diet as ordered by a physician. Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure four residents (Residents #3, #25, #41, and #44) were served the appropriate textured diet as ordered. The deficient practice affected four residents (Residents #3, #25, #41, and #44) of 12 residents reviewed for food and nutrition. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating, limited assistance from one staff was required. Review of the physician orders dated May 2023 revealed Resident #3 had the following order in place: No Added Salt diet, pureed texture, thin consistency; supervised with each meal, patient is not to eat alone in room dated 04/08/23. Observation and interview on 05/16/23 at 2:54 P.M. with Resident #3 in her room during lunch meal. Resident #3 was eating a regular sandwich with turkey on it. The resident stated, It has a lot of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 58 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lunchmeat on it. Surveyor intervened to notify staff of Resident #3's order for a pureed diet due to safety concerns as the resident was not being supervised during the meal either. Observation on 05/17/23 at 12:21 P.M. of the lunch meal revealed Resident #3 was in her room eating. Resident #3 had been served a regular diet and not a pureed diet as ordered. Resident #3 took a couple of bites of a regular lunchmeat sandwich. No staff were present to supervise the resident while eating. Surveyor intervened to notify staff due to safety concerns. Interview and observation on 05/17/23 at 12:24 P.M. with Registered Dietitian (RD) #269 confirmed Resident #3 was served a regular diet and had an order for a pureed diet. RD #269 removed the plate of food from Resident #3 and agreed to provide a pureed diet to the resident instead as ordered. Observation on 05/22/23 at 12:34 P.M. of the lunch meal revealed Resident #3 was served a regular diet again. Resident #3 was observed eating curly fries. There was not any staff supervising the resident while eating either. Again, this surveyor intervened to notify the staff due to safety concerns. Interview on 05/22/23 at 12:34 P.M. with Household Aide (HA) #248 confirmed Resident #3 was served a regular diet and was unsupervised while eating in her room. HA #248 stated Resident #3 was not served a pureed diet last Friday either. HA #248 confirmed Resident #3 had an order for a pureed diet when this surveyor showed the aide the resident's physician orders. Interview on 05/22/23 at 12:40 P.M. with HA #248 revealed she was not aware of any residents who needed a pureed diet. HA #248 stated Resident #3 was on a pureed diet but had been told by the speech therapist that the resident no longer required a pureed diet anymore approximately one month ago. Interview on 05/23/23 at 9:18 A.M. with Speech Language Pathologist (SLP) #425 confirmed Resident #3 should be supervised for all meals by staff due to the resident's history of choking on food, impaired cognition at times, and history of pocketing foods. SLP #425 stated Resident #3 had difficulty with putting too much food in her mouth at one time and adequately chewing it up before swallowing. SLP #425 stated she had upgraded Resident #3's diet from pureed in April 2023 but Diet Technician #440 downgraded Resident #3's diet back to pureed for unknown reasons. Resident #3 had received new dentures which affected her ability to chew safely until she adjusted to the new dentures so that may have been the reason for the downgrade. SLP #425 stated she would agree to upgrade Resident #3's diet to a minced, moist diet at this time but confirmed according to the orders, Resident #3 should have been receiving a pureed diet and should continue to be supervised by staff for all meals for safety. 2. Review of the medical record revealed Resident #25 admitted on [DATE] with diagnoses including dementia, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit, bell's palsy, and anxiety disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #25 was rarely or never understood. She was on a mechanically altered diet. Review of the diet order dated 04/08/23 revealed she was to be getting a regular diet with pureed texture. Observation on 05/17/23 of the lunch meal revealed Resident #25 was given a regular diet. She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 59 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 given a turkey sandwich cut into pieces, coleslaw, banana, and mandarin oranges. Level of Harm - Minimal harm or potential for actual harm Interview on 05/17/23 at 1:41 P.M. with STNA #250 verified Resident #25 received a regular diet. She reported she was aware the physician order called for a puree diet, however, she had been told Resident #25 could do a regular diet when she got assistance at meals. Residents Affected - Some Interview on 05/17/23 at 3:52 P.M. with Dietitian #269 verified Resident #25 should have received a puree diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 60 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, review of the facility menu and facility policy review, the facility failed to ensure one resident (#41) received the requested food as scheduled on the facility menu. This affected one of 12 residents residing in house 402. The facility census was 56. Findings included: Review of the facility menu for 05/15/23 revealed the breakfast meal consisted of two waffles, one cup of cold cereal or hot cereal, one egg of choice, two slices of toast, half a cup of fruit and eight ounces of milk. On 05/15/23 at 10:15 A.M., observation of Resident #41 revealed he was served a small bowl of oatmeal (one package of instant oatmeal), and an eight ounce of orange juice. On 05/15/23 at 11:23 A.M., observation of the resident revealed the resident consumed the oatmeal and the orange juice. State Tested Nursing Assistant (STNA) #301 picked up the empty bowl and the resident stated, don't take that. The STNA asked the resident if he wanted more food, the resident stated, yes. STNA #301 stated, I will get you an ensure. The resident was provided a container of Ensure (a nutritional supplement) instead of more food as requested. On 05/15/23 at 11:25 A.M., interview with STNA #301 revealed the only breakfast item saved for the resident was the oatmeal. STNA #301 verified the resident had not received the breakfast as scheduled or given more oatmeal as requested. Review of the facility policy titled, Meal Times, last revised 04/26/21 revealed breakfast was available whenever the resident requests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 61 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Interview on 05/17/23 at 11:26 A.M. with State Tested Nurse Aide (STNA) #293 in House 403 revealed she was starting to prepare lunch meal. Stated she would be serving a hot turkey sandwich, coleslaw, banana, milk, and an unspecified dessert for lunch. Observation on 05/17/23 from 11:30 A.M. to 12:30 P.M. revealed the staff had completed serving residents lunch meal as STNA #293 was observed putting food items away again. This surveyor did not observe Resident #15 get served a lunch meal. Interview on 05/17/23 at 12:38 P.M. with Resident #15 confirmed she had not been served lunch yet. Resident #15 asked what was being served and this surveyor reviewed the menu. Resident #15 confirmed she did want the lunch that was served. Continued observation on 05/17/23 from 12:38 P.M. to 12:50 P.M. revealed a lunch meal was not served to Resident #15. Interview on 05/17/23 at 12:51 P.M. with STNA #293 confirmed Resident #15 had not been served a lunch meal. STNA #293 stated when she completed incontinence care with the resident prior to starting meal preparation, Resident #15 stated she did not want lunch. STNA #293 confirmed she had not checked with Resident #15 again to see if the resident wanted lunch. STNA #293 confirmed she had not planned to serve lunch to Resident #15. Interview and observation on 05/17/23 at 12:52 P.M. with Resident #15 and STNA #293. STNA #293 asked Resident #15 if she wanted lunch and Resident #15 stated, sure. Interview on 05/17/23 at 1:19 P.M. with Registered Dietitian (RD) #269 confirmed the appropriate procedure if a resident initially refuses a meal would be to offer the meal again at a later time as well as offer alternative options to the resident. Review of the facility policy, Meal Times, revised 04/26/21, revealed the policy stated, the purpose of the policy was to ensure that meals were served at scheduled times. The policy did not address the proper procedure for when a resident refuses a meal. Based on observation, interview, and policy review, the facility failed to ensure Resident #31 and #210 received timely meal assistance and that Resident #15 was served lunch without intervention. This affected three out of three people observed for timely meals. The facility census was 56. Findings include: 1. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. He required the extensive assistance of one person for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 62 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #31 revealed an admission date of 06/27/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage three, type two diabetes mellitus, epilepsy, adjustment disorder with depressed mood, left and right knee contractures, cognitive communication deficit, dysphagia, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. He required the extensive assistance of one person for eating. Observation on 05/15/23 at 9:52 A.M. revealed Agency Aide #294 finishing feeding breakfast to Resident #25 and leaving her room. She reported she was the only staff member in the building at the time. Agency Aide #294 reported there was a lot for her to do in the mornings and she was behind. Agency Aide #294 reported she had not assisted Resident #31 and Resident #210 with breakfast yet as she had not had time. Observation on 05/15/23 at 10:04 A.M. revealed Agency Aide #294 entering Resident #210's room with food. Observation on 05/15/23 at 10:18 A.M. revealed Agency Aide #294 entering Resident #31's room with food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 63 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 5. Observations on 05/15/23 at 11:18 A.M. of the kitchen in House 403 revealed the following items stored in the refrigerator: Residents Affected - Many A package of uncooked bacon, opened and wrapped in saran wrap, was dated 05/10/23. A bag of shredded mild cheddar cheese was opened and dated 05/04/23. A bag of shredded mozzarella cheese was opened and dated 05/04/23. Interview with STNA #209 confirmed the above findings. STNA #209 stated the food was dated to indicate when the food should be used or thrown out. Review of the policy titled Food Storage Policy and Procedure dated 10/01/09, revealed prepared food should be covered, dated, and labeled with the month and day on which it was prepared. Food should also have a use by date which is four to seven days after the food was prepared. Prepackaged foods or baking goods are marked with month and day and placed in a covered and sealed container. The policy stated, the purpose of the policy was to assure that all food is stored, labeled and dated properly to assure stock rotation and prevent food illnesses. Furthermore, Shelf stable items may need to be refrigerated once they are open. Do not store in their original containers once opened. Based on observation, interview, and review of facility policy, the facility failed to ensure food was dated, not kept past its use by date, thermometers were in place to monitor refrigerator and freezer temperatures, eggs were pasteurized, and that food temperatures were obtained prior to serving meals to residents. This was observed in all five kitchens. This had the potential to affect 56 of 56 residents who consumed food from the kitchen. Findings include: 1. Observation of the kitchen in building 401 on 05/15/23 at 9:30 A.M. revealed an undated and unlabeled container of an unidentified food, that Household Aide #240 reported was soup, an opened container of coleslaw dated 05/04/23, a whole rotisserie chicken dated 04/27/23, a container of vanilla yogurt dated February 2023, and two containers of Kentucky Fried Chicken's (KFC) coleslaw. Interview on 05/15/23 at 9:30 A.M. with Household Aide #240 verified the observations. She reported the dietary manager was supposed to go through the refrigerators. She reported leftovers should be kept for seven days. Observation of the kitchen in building 400 on 05/15/23 at 9:55 A.M. revealed three individual containers of chicken salad dated March 2023, a container of cottage cheese dated 03/06/23, and a large container of yogurt dated 03/16/23. This observation was verified by Agency Aide #294, she was unsure who was responsible for clearing out the refrigerator. 2. On 05/15/23 at 9:20 A.M., initial observation of home 402's kitchen revealed the reach in refrigerator in the kitchen revealed a bottle of barbecue sauce with no lid and not dated, a plate of hard boiled eggs covered with clear plastic wrap with no date, the refrigerator had a partial case of 60 eggs that were not pasteurized, an opened bottle of red power aide not dated. Observation of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 64 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many household refrigerator in the pantry revealed a container of fresh strawberries not dated, a brown paper bag of Chinese food not dated. Neither of the two side by side household refrigerators had a thermometer inside to monitor the internal temperature. The wall behind the stove had dried grease. The wall beside the stove had a dried splattered red substance. A bowl of oatmeal was noted sitting in the microwave which was observed being given to Resident #41 at 10:15 A.M. for his breakfast meal. Observation were verified by State Tested Nursing Assistant (STNA) #310 at the time of the observations. 3. On 05/15/23 at 10:35 A.M., observation of home 404's kitchen revealed the reach in refrigerator had an opened undated bottle of barbecue sauce, a container of chicken and macaroni salad not dated, a can of opened evaporated milk and non-pasteurized eggs. The two household side by side refrigerators had no thermometer in side the refrigerator or the freezer to monitor the internal temperature. Observations were verified by STNA #244 at the time of the observations. 4. Observation of the lunch meal in building 400 on 05/17/23 revealed residents on a regular diet were served a hot turkey sandwich, coleslaw, mandarin oranges, and bananas. STNA #250 prepared the meal and served the meal without obtaining the temperature of any of the foods. Interview on 05/17/23 at 1:41 P.M. with STNA #250 verified she did not obtain the temperature of the foods for the regular diet. She reported she only got the temperature of puree foods and soups because she did not want them too hot. She verified the only foods that temperatures were obtained for were Resident #31 and #210. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 65 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #1 revealed an initial admission date of 03/19/21 with the latest readmission of 11/11/22 with the diagnoses including cerebrovascular infarct with left sided hemiplegia, diabetes mellitus, dysphagia, major depressive disorder, neuromuscular dysfunction, hyperlipidemia, right above the knee amputation, hypertension, gastro-esophageal reflux disease, constipation and retention of urine. Review of the plan of care dated 07/02/21 revealed the resident was at nutritional risk due to health status, history of significant weight change, dysphagia, diabetes mellitus, hyperlipidemia, chronic obstruction pulmonary disease, hypertension, constipation, use of therapeutic diet and hemiplegia. Interventions included educate the resident on importance of adequate calorie and protein intake as appropriate, offer substitutes if resident does not like what is being served, monitor skin and wound reports, address any negative findings, offer the supplement the physician ordered and review weights, skin , labs and intakes routinely and as available and report changes as needed. Review of the resident's quarterly MDS assessment dated [DATE] revealed had no cognitive deficit. Review of the monthly physician's orders for May 2023 identified an order dated 05/15/23 Glucerna Thera Shake three times a day. Review of the resident's May 2023 Medication Administration Record (MAR), revealed Licensed Practical Nurse (LPN) #216 initialed the 12:00 P.M. Glucerna supplement was provided. On 05/16/23 at 3:45 P.M., interview with Resident #1 revealed she does not receive a supplement. On 05/16/23 at 3:50 P.M., interview with Coach #265 verified House 402 had no Glucerna in stock to provide the physician ordered supplement to Resident #1. On 05/17/23 09:06 AM with the Director of Nursing (DON) revealed the facility ordered a bulk amount in the March and currently using Glucerna tube feeding formula stored in house 400. On 05/17/23 at 11:27 A.M., observation of the pantry in house 400 revealed four unopened boxes of Glucerna 1.2 tube feeding in the pantry. Further observation revealed the sticker documented four of four boxes. On 05/17/23 at 1:45 P.M., observation and interview with Resident #1 revealed she had not received the physician ordered Glucerna supplement with her lunch meal as ordered. On 05/17/23 at 2:39 P.M., interview with Licensed Practical Nurse (LPN) #216 revealed she initialed the Glucerna supplement as being given but had no visualized the resident receiving the supplement. LPN #216 verified the resident had not received the physician ordered 12:00 P.M. supplement Glucerna. Based on observations, record review, and resident and staff interviews, the facility failed to accurately document the administration of nutritional supplements for two residents (Resident #1 and #45). The deficient practice affected two residents (Resident #1 and #45) of 12 residents reviewed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 66 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0842 food and nutrition. The facility census was 56. Level of Harm - Minimal harm or potential for actual harm Findings Include: Residents Affected - Few 1. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the physician order dated 03/01/23 to 05/17/23 revealed an order for health shake three times a day. Review of the supplement documentation revealed State Tested Nursing Aide (STNA) #251 indicated Resident #45 consumed 100% of a supplement twice on 05/17/23. Observation of the lunch meal on 05/17/23 revealed Resident #45 was not given an Ensure. Interview on 05/17/23 at 2:25 P.M. with STNA #251 indicated Resident #45 had not received any supplements on that day due to eating her meals well. Further interview at 2:34 P.M. verified she had documented Resident #45 consumed 100% but she had not received any supplements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 67 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection in the area of wound care, incontinence care, glucometer (machine used to check blood sugar), and proper storage of catheter bags. The deficient practices had the potential to affect one (Resident #53) of four residents reviewed for catheters, one (Resident #13) of four residents reviewed for pressure ulcers, one (Resident #13) of one residents reviewed for incontinence care, and one (Resident #17) of one residents reviewed for glucometer testing. The facility census was 56. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #13 revealed an initial admission date of 12/21/15 with the latest readmission of 12/27/18 with the diagnoses including multiple sclerosis (MS), major depressive disorder, thiamine deficiency, hyperlipidemia, hypertension, nonpsychotic mental disorder, irritable bowel syndrome, dysphagia, contracture to left hand, contracture to right hand, constipation, dry eye syndrome and stage IV pressure ulcer to sacral region. Review of the plan of care dated 03/29/20 and last revised on 02/20/23 revealed the resident had potential for pressure ulcer development related to decreased mobility related to MS, incontinence related to irritable bowel syndrome and stage IV pressure ulcer to sacrum. Interventions included administer medications as ordered, administer treatments as ordered, enhanced barrier precautions, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status, monitor/report as needed any changes in skin, turn and reposition with max assist of one to two staff at least every two hours, more often as needed or requested, treat pain per orders prior to treatment/turning, treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and weekly skin assessment. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the mood and behavior revealed the resident displayed no behaviors, including rejection of care. The resident required extensive assistance of two staff for bed mobility, transfers and dependent on two staff for toilet use. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one Stage IV pressure ulcer not present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care and application of ointments/medications other than to feet. Review of the monthly physician orders for May 2023 identified orders dated 11/16/20 skin prep topically to bilateral heels every shift, low air loss mattress to bed, pressure reducing cushion to custom wheelchair, apply protective ointment to buttocks/perineal area every shift and as needed, 03/14/23 reposition every shift, 03/29/23 weekly skin assessment to be completed by licensed nurse, 05/04/23 cleanse wound to sacrum with normal saline (NS), pat dry, apply collagen, then alginate and cover with bordered island gauze daily. On 05/16/23 at 2:50 P.M., observation of Licensed Practical Nurse (LPN) #216, Registered Nurse (RN) #203 and State Tested Nursing Assistant (STNA) #238 provide incontinence care and the physician ordered treatment to the stage IV pressure ulcer to the sacral region revealed the staff washed their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 68 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hands and donned gloves. LPN #216 positioned the bed, pulled the resident's incontinence brief down and instructed STNA #238 to provide incontinence care. STNA #238 obtained a disposable wipe and wiped from front to back using the same section of the disposable wipe multiple times and disposed of the cloth. LPN #216 and STNA #238 positioned the resident's on left side. The LPN sanitized her hands and donned gloves. The LPN then cleansed the wound with wound cleanser and 4 X 4. RN #203 then cut a piece of calcium alginate and handed an opened package of collagen powder and calcium alginate to the LPN. The LPN then placed the cut piece of calcium alginate, with the same gloves used to cleanse the wound with, into the package of powder and pressed the calcium alginate into the collagen powder. The LPN then turned the calcium alginate over and pressed into the collagen powder. The LPN then placed the calcium alginate into the wound and covered with a bordered gauze dressing. The LPN and the STNA positioned the resident on her back. On 05/16/21 at 3:05 P.M., interview with LPN #216 and RN #203 verified the breaks in infection control for the potential spread of infection. 2. On 05/22/23 at 11:55 A.M., observation of RN #229 obtain the physician ordered blood glucose for Resident #17 revealed the RN entered the room and set a plastic orange caddy on the resident's bedside table without a barrier. She sanitized her hands and donned a pair of gloves. She placed the reading strip into the glucometer machine and sat on the resident's bedside table without a barrier. She cleansed the resident's left middle finger with a single use alcohol swab and obtained a drop of blood with a single use lancet. The resident's blood sugar was 111, requiring no coverage. The RN cleansed the glucometer machine with a disposable alcohol swab. The RN revealed the glucometer machine was used for house 400, 402 and 404 due to one being lost and one being broken. She revealed if she had more than one resident she cleans the machine with bleach wipes, but because Resident #17 was the only resident in house 400 requiring blood glucose monitoring she uses an alcohol swab. 3. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following stroke, Type II Diabetes Mellitus, diabetic chronic kidney disease Stage III, and major depressive disorder-recurrent. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #53 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of the physician orders dated May 2023 revealed Resident #53 had the following orders in place: check urinary catheter patency each shift and document negative findings, may irrigate catheter as needed, change urinary catheter bag, tubing, and graduate weekly on Sundays, and catheter care every shift. All orders were dated 04/26/23. Review of the care plan dated 03/30/23 revealed Resident #53 had an indwelling catheter related to urine retention. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door. The care plan did not address storage of the catheter bag off the floor. Observations on 05/16/23 at 2:46 P.M. and 05/18/23 at 1:57 P.M. of Resident #53 in his room, laying in his hospital bed, revealed the resident's catheter bag was laying on floor underneath the bed. Interview and observation on 05/18/23 at 1:59 P.M. with STNA #287 confirmed Resident #53's catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 69 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 bag was laying on the floor underneath the bed. STNA #287 stated, oh, it shouldn't be like that. Level of Harm - Minimal harm or potential for actual harm A facility policy was requested related to the proper storage of a catheter bag however, per the Administrator, the facility did not have a policy that addressed this. Residents Affected - Few Review of the facility policy titled, Hand Hygiene Procedure, revised on 11/05/21 revealed hand hygiene means cleansing hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub sanitizer including foam or gel or surgical hand antisepsis. Hand hygiene should occur at the beginning of the shift, returning from break, after using the restroom and during routine patient care as indicated, if hands will be moving from a contaminated body site to a clean-body site during patient care. Review of the facility policy titled, Glucometer Cleaning, revealed each medication cart would have two glucometer machines available for use. Upon completion of the glucometer blood sugar check the glucometer machine will be cleansed with either dispatch hospital cleaner disinfectant towels with bleach, medline micro-kill disinfecting cleaning with alcohol or clorox healthcare bleach germicidal and disinfectant wipes or medline micro-kill bleach germicidal bleach wipes and set it aside to dry. The second glucometer will then be used for the next elder's blood sugar test. The nurse will continue to alternate the use of the glucometer's when testing. Both glucometer machines are to be cleaned prior to storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 70 of 71 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure the environment was maintained in a clean, odor free, and homelike manner for Resident #1, #2, #10, #17, #12, and #39. This affected six residents (#1, #2, #10, #12, #17, and #39) of nine residents reviewed for environment. The facility census was 56. Findings include: Observation on 05/15/23 and 05/16/23 revealed the following environmental concerns: a. Observation on 05/15/23 at 9:42 A.M. revealed Resident #12 had a variety of unidentifiable stains on her carpet. b. Observation on 05/15/23 at 10:30 A.M. revealed Resident #2's carpet had multiple black stains throughout the room. His bathroom floor was observed to have multiple black marks. Interview on 05/15/23 at 10:30 A.M. with Resident #2's wife revealed she cleaned every time she visited because the staff did not clean. c. Observation on 05/15/23 at 10:56 A.M. revealed Resident #1's room had a strong odor of urine. d. Observation on 05/16/23 at 8:23 A.M. revealed Resident #39's carpet had black stains in multiple locations. e. Observation on 05/16/23 at 8:24 A.M. revealed Resident #17 had a personal refrigerator in her room. The freezer was covered in unidentifiable black and brown substances. f. Observation on 05/16/23 at 10:00 A.M. revealed Resident #10's carpet had black stains on her carpet throughout her room. Interview on 05/16/23 at 10:00 A.M. with Resident #10 revealed she was unhappy with the look of the carpet. During a tour on 05/23/23 from 9:54 A.M. to 10:15 A.M. with Interim Coach #271 Resident #1, #2, #10, #17, and #39's rooms were visited and remained in the same conditions. Interim Coach #271 verified the above observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366430 If continuation sheet Page 71 of 71

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Citations

26 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Epotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0580GeneralS&S Epotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0801GeneralS&S Epotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0809GeneralS&S Dpotential for harm
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Epotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the May 26, 2023 survey of OTTERBEIN GAHANNA?

This was a inspection survey of OTTERBEIN GAHANNA on May 26, 2023. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OTTERBEIN GAHANNA on May 26, 2023?

Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 26, 2023