Health inspection·August 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few The resident complained of generalized right arm pain but unable to be specific about the pain or a pain level. The resident was contracted at baseline and the resident's range of motion (ROM) in the right arm was not within normal limits. The provider was notified of incident and provided new orders for a stat (immediate) X-ray of the right shoulder and right elbow. The X-ray results were received on 06/23/24 at 12:05 A.M. and Resident #32 had an acute right mildly displaced humeral head fracture. The resident was assessed by the Nurse Practitioner (NP) on 06/23/25 and spoke with family regarding treatment options. A sling was ordered for the resident and no further orthopedic follow up was needed. The resident's pain was managed with Tylenol and ibuprofen, and the family was in in agreement with the treatment plan. CNA #168 indicated she was aware Resident #32 required a two-person transfer via mechanical Hoyer lift and transferred the resident by herself. The facility's investigation was unsubstantiated for abuse/neglect related to the incident not meeting definitions of neglect in the regulations. CNA #168 was terminated on 06/27/25 for violations of company policy regarding delivery of patient care. The SRI was completed on 06/27/25 at 12:34 A.M. and unsubstantiated due to evidence indicating abuse, neglect or misappropriation did not occur.Review of the X-ray report dated 06/22/25 at 11:02 P.M. for Resident #32, revealed an acute fracture involving the neck of the right humerus with mild displacement. Review of a witness statement dated 06/22/25 and authored by Registered Nurse (RN) #170, revealed CNA #112 and #168 stated Resident #32 had a fall. CNA #168 reported she attempted to transfer Resident #32 to a wheelchair but tripped and fell with Resident #32. RN #170 reported she observed Resident #32 on the floor on her back in front of the dresser. RN #170 reported she assessed Resident #32 and identified an abrasion on her right arm approximately three centimeters (cm) by two (cm). RN #170 reported Resident #32 complained of right arm pain. RN #170 report she obtained an order for a stat (immediate) X-ray of the right arm and shoulder. Review of a NP #500 progress note dated 06/23/25 at 1:00 A.M. for Resident #32, revealed the resident was seen for an acute /follow-up visit. The chief complaint was a right arm injury related to a fall and right arm fracture. On 06/22/25 at 4:00 P.M., the resident had a fall related to an improper transfer and the imaging showed an acute mildly displaced humeral head fracture, The resident was placed in a shoulder sling and recommended for a follow-up X-ray in six weeks. The resident's family requested no opioids be ordered due to the resident's tolerance level. Review of an Interdisciplinary Team (IDT) note dated 06/23/25 at 3:32 P.M., revealed RN #170 was alerted by CNA #168 on 06/22/25 at 4:00 P.M. that she tripped as she attempted to transfer Resident #32 to her wheelchair when the resident fell. Resident #32 was lying flat on her back in front of her dresser with her legs outstretched. Resident #32 was assisted off the ground using a Hoyer lift with three staff members. An abrasion was noted to Resident #32's right elbow that measured approximately three cm by two cm. Resident #32 complained of right arm pain, guarded her right arm and cried when the nurse attempted to move and assess the right arm. An X-ray was completed which revealed Resident #32 had an acute right humeral neck fracture. Review of a witness statement dated 06/23/25 and authored by CNA #168, revealed on 06/22/25 around 3:45 P.M., she began her rounds and Resident #32 was in her bed. CNA #168 stated she checked and changed the resident's incontinent brief. CNA #168 indicated that since it was close to dinner time, she attempted to transfer Resident #32 then tripped and fell. CNA #168 sated she fell on her left side and Resident #32 fell on her right side. CNA #168 stated she went to the kitchen and called the nurse to tell her about the fall. Review of a witness statement dated 06/23/25 and authored by CNA #112, revealed on 06/22/25 around 4:00 P.M., she observed CNA #168 go into Resident #32's room then came out and stated Resident #32 was on the floor. CNA #112 called RN #170 to report the resident was on the floor. During an interview on 08/07/25 at 11:07 A.M., the Administrator stated on 06/22/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 2 of 4 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 366439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few CNA #168 completed an improper transfer on Resident #32 by transferring the resident without a Hoyer and without additional staff. Administrator reported CNA #168 tripped and fell with the resident during the transfer and Resident #32 sustained a fractured right arm. The Administrator verified Resident #32 was ordered to be transferred via mechanical Hoyer lift with two staff members for all transfers. The Administrator stated CNA #168 picked up Resident #32 with one arm under her shoulders and one arm under her knees and they both fell. The Administrator stated CNA #168 was terminated for an improper transfer of a Resident #32.Review of the personnel file for CNA #168 revealed a hire date of 05/21/25. CNA #168 had an active and unrestricted license. CNA #168 was terminated on 06/27/25 for an incident that occurred on 06/22/25 when CNA #168 failed to ensure the safety of self and others when she provided care inconsistent with Resident #32's care plan. Resident #32 required a Hoyer mechanical lift with two staff, and CNA #168 transferred Resident #32 without the assistance of another and without a mechanical Hoyer lift. CNA #168 was signed off on competency skills for Hoyer transfers during orientation. Subsequent interview with the Administrator on 08/07/25 at 4:19 P.M., revealed he did not report CNA #168 to the abuse registry because he reported her on the SRI. The Administrator stated he unsubstantiated the allegation of neglect because he felt the facility provided CNA #168 with the appropriate tools to provide the care for Resident #32 and CNA #168 chose not to utilize the tools. The Administrator stated he did not feel this met the definition of neglect, so the SRI investigation was unsubstantiated. During an interview on 08/11/25 at 9:36 A.M., RN #170 stated she was the charge nurse on 06/22/25 when she got the call from CNA #112 who stated Resident #32 had a fall. RN #170 stated there were small houses on the campus where the residents reside. RN #170 stated when she arrived in Resident's #32 house, she learned CNA #168 was the only CNA in the house. RN #170 stated CNA #168 picked up Resident #32 with her arms around her and attempted to pivot her to a wheelchair when both fell to the ground. CNA #168 stated CNA #112 was not in the house at the time of the fall. RN #170 stated Resident #32 had an abrasion on her right elbow and complained of pain in her right arm. RN #170 stated she obtained an order for a stat X-ray and provided pain medication to Resident #32.Review of the undated Kardex form (a quick reference guide for caregivers, providing a snapshot of a resident's status and care plan) for Resident #32, revealed the resident required a mechanical lift with two staff members using a red sling for transfers.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property-Ohio only dated 10/25/22, revealed the definition of neglect is the failure of the facility or its staff to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy titled Falls Management dated 12/03/19, revealed the facility would have procedures in place to prevent and/or reduce falls. The definition of a fall is an unintentional coming to rest on the ground, floor, or other lower level. When a Resident is observed on the floor, a fall is considered to have occurred.The deficient practice was corrected on 07/03/25 when the facility implemented the following corrective actions: On 06/22/25 at 5:23 P.M., immediate education was sent out to all employees via a facility application installed on all the employees' phones. The education consisted of ensuring staff followed the residents' care plans, Kardex, physician orders, ensuring all staff utilized a mechanical lift if required and transferring resident with two staff members if required. The Administration was able to verify all employees received the education via a read message returned to the facility. Starting on 06/23/25 and completed on 07/03/25, the DON initiated education for all nursing staff which included nurses and CNA on providing care as documented in the residents' care plan, the importance of utilizing two staff members with resident care when required, safe transfers, utilizing mechanical lifts if required and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 3 of 4 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 366439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete providing care per physician orders. A return demonstration on resident transfers via Hoyer lift was completed with all nursing staff. A post-education quiz was utilized with all staff to verify the staff's knowledge related to proper transfers, abuse, neglect, and how to access the Kardex or Care Plan. On 06/23/25 and 06/24/25, the DON completed an audit for all current residents who used a Hoyer lift for transfers. The facility identified 11 (#01, #02, #13, #20, #28, #37, #38, #40, #45, #53 and #60) additional residents required the use of a Hoyer lift for transfers and/or to obtain ordered weights. There were no adverse findings.Beginning on 06/23/25, the DON/designee conducted randomized observational audits of mechanical Hoyer lift transfers on at least five residents weekly for four weeks. The results were reported to the Administrator and Quality Assurance and Performance Improvement (QAPI) committee for any modification of intervention or adjustments as needed. On 06/23/25, The DON completed an audit on all current residents to ensure physician orders, Care Plans, and Kardexs were current and up to date and current per physician orders. No additional concerns were identified.On 6/23/25, an ad hoc QAPI meeting was held by the IDT with the medical director in attendance to discuss the incident and review the audits completed of all elder records to ensure physician orders, care plans, and Kardexs were accurate. Additional QAPI meetings were held weekly for four weeks to ensure audits were completed and to review them to determine if any modification of intervention or adjustments were needed.On 06/23/25, the previous physician order dated 09/03/22 related to Resident #32 being transferred via Hoyer, was discontinued and a new order was placed so the physician order would transfer over to the treatment administration record (TAR) which required the nurses to sign off when the transfer was completed via Hoyer. This same order was also completed for the 11 additional residents identified as utilizing a Hoyer for transfers. On 06/25/25, skin assessments were completed for all residents who could not be interviewed. No issues were identified. On 06/27/25, CNA #168 was terminated for an improper transfer related to the transfer with Resident #32.This deficiency represents non-compliance investigated under Complaint Number OH00167463. Event ID: Facility ID: 366439 If continuation sheet Page 4 of 4