Inspection·May 1, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Further record review for Resident #23 revealed the last PASARR assessment had been completed on 01/05/22, with a new PASARR not being completed after the resident received a new diagnosis of unspecified psychosis on 09/22/22. Interview with Regional [NAME] Office Manager #999 on 04/25/23 at 2:34 P.M. verified there had not been a new PASARR completed for Resident #23 after the resident had a new diagnoses of unspecified psychosis on 09/22/22. Event ID: Facility ID: 366445 If continuation sheet Page 2 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete an initial baseline plan of care to include fluid restrictions and daily weights monitoring for three Residents ( #216, #214 and #212 ) of three residents reviewed for baseline care plans. The facility census was 57. Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. Review of the initial base line plan of care dated 04/20/23 revealed no initial risk assessment, goals, and interventions to address the physician ordered fluid restriction of 1000 milliliters per day. Record review of Resident #216 weight log from 04/19/23 to 04/24/23 revealed a weight increase of 4.4 pounds. Review of Medication Administration Record, (MAR) dated April 2023) on 04/24/23 revealed no fluid restriction of 1000 milliliters listed and no documentation of the fluid restriction. 2. Record review of Resident #214 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #214 included acute respiratory failure, heart failure, mitral valve insufficiency and hypokalemia. Review of the initial admission assessment dated assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on 04/14/23, revealed orders for clear liquid diet and enteral feeding of Two Cal HN at 119 cc bolus every four hours with 30 milliliter of water flush every six hours. On 04/17/23, physician orders included 2000 milliliters of fluid restrictions. Review of the initial base line plan of care dated 04/14/23 revealed no initial risk assessment, goals, and interventions to address the physician ordered fluid restriction of 2000 milliliters per day. 3. Record review of Resident #212 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #212 includes dysphagia, myocardial infarction, heart disease, atrial fibrillation and hypertension. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders dated 04/13/23 daily weights and notify physician if weight changes five pounds per day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 3 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 0655 Level of Harm - Minimal harm or potential for actual harm Review of the initial base line plan of care dated 04/12/23 revealed no initial risk assessment, goals, and interventions to address the physician ordered daily weights. Record review of weights log and April MAR, revealed no weights were obtained and recorded on 04/15/23, 04/16/23 ,04/22/23 and 04/24/23. Residents Affected - Few Interview on 04/27/23 at 10:30 A.M. the Director of Nursing, (DON) verified there should have been a baseline plans of care identifying fluid restrictions, including no goal and interventions, for Residents #216 and for Resident #214. Resident #212 should have had a baseline care plan for daily weight monitoring. No policy was provided regarding baseline care plans for fluid restrictions and daily weight monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 4 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 record reviews, interviews, and review of online guidance, the facility failed to ensure hospital discharge instructions were ordered and implemented, failed to ensure surgical follow-up appointments were made, failed to ensure surgical wounds received adequate monitoring and treatment, and failed to ensure adequate care of a Portacath (an implanted venous access device). This affected one resident (#21) identified as having an implanted Portacath device and one resident (#24) who returned from the hospital after surgical intervention of a hip fracture. The facility census was 57. Residents Affected - Few Findings include: 1. Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, adjustment disorder, and presence of other specified devices. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/23/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require supervision for bed mobility and transfers and limited assistance from one staff member for toileting. Review of the active care plans for Resident #21 revealed no plan of care in place for the monitoring or care of the residents Portacath device. Review of the active physicians orders for Resident #21 revealed no orders for flushing the residents Portacath device to maintain patency and no orders for monitoring the Portacath for complications or infection. Interview with Resident #21 on 04/25/23 at 12:28 P.M. revealed facility staff did not flush or monitor the residents Portacath. Interview with Registered Nurse (RN) #901 on 04/27/23 at 9:00 A.M. verified there were no orders maintenance or flushing of Resident #21's Portacath device. Review of the online guidance from the Cleveland Clinic titled Implanted Port (https://my.clevelandclinic.org/health/treatments/21701-implanted-port), last reviewed on 08/25/21, revealed implanted ports were to be flushed out once a month when not used regularly to reduce the risk of clots and blockages. 2. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnosis including displaced intertrochanteric fracture of the right femur. Review of the annual MDS assessment, dated 01/25/23, revealed this resident was assessed to have moderately impaired cognition evidenced by a BIMS assessment score of 05 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the care plan, dated 03/30/23, revealed this resident required orthopedic after-care related to right hip fracture. Interventions included orthopedic consults as needed and monitor right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 5 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 hip surgical wound for signs and symptoms of infection. Level of Harm - Minimal harm or potential for actual harm Review of the hospital discharge instructions, dated [DATE], revealed orders for mobile compression devices to be applied for 20 hours per day for three weeks, leave mepilex silver dressing on hip unless it becomes saturated then change, and follow up with orthopedic surgeon in two weeks. Residents Affected - Few Review of the physicians order, dated 03/29/23, revealed an order to follow up with orthopedic surgeon in two weeks. Review of additional physicians orders for Resident #24 revealed no orders for mobile compression devices to be applied. Review of additional physicians orders for Resident #24 revealed no wound care orders for the residents surgical incision to the right hip. Further record review for Resident #24 revealed no evidence of monitoring or care of the residents right hip surgical incision, implementation of mobile compression devices, or follow up appointment with orthopedics. Interview with Licensed Practical Nurse (LPN) #510 on 04/25/23 at 11:40 A.M. revealed Resident #24 had a bandage in place to the surgical incision located on the right hip when he returned from the hospital which had fallen off. Interview with RN #901 on 04/26/23 at 12:30 P.M. verified hospital discharge orders for a follow up appointment in two weeks had not been scheduled for Resident #24. RN #901 also verified orders for mobile compression devices for Resident #24 had not been ordered or implemented upon the residents discharge from the hospital. RN #901 further verified Resident #24 did not have evidence of wound care being provided to the residents right hip surgical incision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 6 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of facility incident log, the facility failed to ensure residents received adequate supervision to prevent a fall with injury. Actual harm occurred when Resident #24 who was assessed and care planned for two staff assistance for toileting fell and sustained a fracture which required hospitalization and surgical intervention after being left unattended while toileting. This affected one resident (#24) out of the three residents reviewed for falls during the annual survey. The facility census was 57. Findings include: 1. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including difficulty walking, muscle weakness, shortness of breath, and restlessness and agitation. Review of the annual Minimum Data Set (MDS) assessment, dated 01/25/23, revealed this resident was assessed to have moderately impaired cognition. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the care plan, initiated 02/01/22, revealed this resident had an Activities of Daily Living (ADL) self-care and/or physical mobility deficit related to weakness. Interventions included extensive assistance from two staff members for toileting and moving between surfaces. Review of the care plan, revised 02/12/23, revealed this resident was at risk for falls. Interventions included Dycem to wheelchair to prevent sliding, anticipate and meet needs, and keep needed items in reach. Review of the facility incident log, dated 04/01/22 through 04/25/23, revealed Resident #24 was documented to have fallen in the facility on 05/19/22, 06/11/22, and 03/24/23. Review of the nurse progress note, dated 03/24/23, revealed Resident #24 had an unwitnessed fall in the bathroom around 10:40 A.M. and was found lying on his right side with his head towards the shower. The resident stated he was trying to ambulate to the shower and lost his balance. The resident was complaining of pain to the right hip. The Nurse Practitioner was notified and provided new orders for an X-ray of the right hip to be performed. Review of the nurse's progress note, dated 03/25/23, revealed X-ray results for Resident #24 came back positive for a closed fracture of the femoral neck of the right hip. The Nurse Practitioner was notified and provided orders for the resident to be sent out to the hospital. Review of the nurse's progress note, dated 03/29/23, revealed Resident #24 returned to the facility after being hospitalized with an admitting diagnosis of closed displaced fracture of right femoral neck. There were orders to leave the Mepilex silver dressing in place to the right hip unless it became saturated. Interview with State Tested Nursing Assistant (STNA) #800 on 04/26/23 at 1:40 P.M. revealed she was working on 03/24/23 and had assisted Resident #24 to the restroom prior to giving the resident a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 7 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 shower. STNA #800 stated she realized she had forgotten to get towels and had asked Resident #24 if he could stay put while she went to get towels and Resident #24 stated he would. STNA #800 stated when she returned to the room, Resident #24 was lying on the floor. Interview with STNA #540 and STNA #840 on 04/26/23 at 3:30 P.M. revealed both STNA's worked evening shift at the facility and frequently provided care to Resident #24. They stated prior to Resident #24's fall on 03/24/23, the resident required assistance from two staff members for transfers and toileting due to being weak and unsteady and was not to be left on the toilet unsupervised due to the risk of falling. Event ID: Facility ID: 366445 If continuation sheet Page 8 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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** Based on record review, staff interview, and policy review, the facility failed to monitor fluid restrictions and daily weights as ordered by the physician for three residents (#216, #214 and #212) of four residents reviewed for fluid restrictions and daily weights. The facility census was 57. Residents Affected - Few Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. Record review of Resident #216 weight log from 04/19/23 to 04/24/23 revealed a weight increase of 4.4 pounds. Review of Medication Administration Record, (MAR) dated April 2023 on 04/24/23 revealed no fluid restriction of 1000 milliliters listed and no documentation of the fluid restriction. Interview on 04/26/23 at 4:35 P.M. with Licensed Practical Nurse, (LPN) # 590 verified there had been no fluid restriction listed in the April MAR for monitoring the 1000 milliliters of fluid restriction for Resident #216 from 04/19/23 through 04/25/23. LPN #590 verified Resident #216 weight had increased and stated there were no parameters for physician notification of weight changes related to fluid restriction monitoring. 2. Record review of Resident #214 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #214 included acute respiratory failure, heart failure, mitral valve insufficiency and hypokalemia. Review of the initial admission assessment dated assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on 04/14/23, revealed orders for clear liquid diet and enteral feeding of Two Cal HN at 119 cc bolus every four hours with 30 milliliter of water flush every six hours. On 04/17/23, physician orders included 2000 milliliters of fluid restrictions. Review of Medication Administration Record, (MAR) dated 04/17/23 through 04/24/23 revealed no documentation of the amount of fluids consumed from tube feeding, flushes and oral intake. There were no parameters for physician notification regarding weight change. Interview on 04/26/23 at 4:35 P.M. with LPN # 590 verified there had been no fluid restriction listed in the April MAR for monitoring the 2000 milliliters of fluid restriction for Resident #214 from 04/17/23 through 04/24/23. LPN #590 stated there were parameters in the orders for physician notification of weight changes, or delineation of fluid amounts divided between nursing and the meal service. She verified as there was no documentation from nursing as to the fluid amounts consumed by tube feedings, flushes, and oral intake, monitoring of the 2000 milliliters fluid restriction was not accurate. Interview on 04/27/23 at 10:37 A.M. with the Director of Nursing verified the fluid restriction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 9 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders of Residents #214 and #216 should have been listed, and documented in the MAR when the order was obtained. The orders should have had delineation of fluid amounts between meal service and nursing. There should have been parameters for weight monitoring to notify the physician of fluid intake and weight changes. There was no facility policy provided regarding fluid restriction weight change parameters and monitoring management. 3. Record review of Resident #212 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #212 includes dysphagia, myocardial infarction, heart disease, atrial fibrillation and hypertension. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders dated 04/13/23 daily weights and notify physician if weight changes five pounds per day. Record review of weights log and April Medication and Administration Record, (MAR), revealed no weights were obtained and recorded on 04/15/23, 04/16/23 ,04/22/23 and 04/24/23. Interview on 04/25/23 at 12:15 P.M. with Diet Technician, (DTR) # 720 verified Resident #212 had a daily weight ordered on 04/13/23 and did not have weights documented on 04/15/23, 04/16/23, 04/22/23 and 04/24/23. DTR #720 stated she no knowledge Resident #212 had missing daily weights. Review of facility policy, Weight Policy, dated 12/02/21, revealed a copy of weight reports are shared with the diet technician and or Registered Dietitian to review, assess and make recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 10 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 - Some 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** 4. Record Review of Resident #11 on 04/26/23 at 08:27 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: unspecified dementia, osteoarthritis, stress incontinence, Vitamin D deficiency, tremors, anxiety, depression, difficult ambulation, akathisia, and muscle weakness. Review of the MDS assessment completed on 02/28/23 revealed this resident is rarely/never understood. Review of Physician Orders revealed this resident is receiving the following medications: Depakote 250 milligrams (mg) 1 tablet by mouth twice daily for agitation and Risperidone oral solution 1mg/ml give 0.5 ml by mouth three times a day for agitation. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with Registered Nurse #901 on 04/26/23 at 11:37 A.M. verified Risperidone and Depakote are to have an actual diagnosis and not just treating a symptom such as agitation. 5. Record Review of Resident #39 on 04/25/23 at 03:24 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: chronic kidney disease, atherosclerosis, vascular dementia, congestive heart failure, atrial fibrillation, hypercholesterolemia, hypertension, orthopnea, anxiety, depression, and edema. Review of the MDS assessment completed on 02/21/23 revealed this resident had severe cognitive impairments. Review of Physician Orders revealed this resident is receiving the following medications: Lexapro 10 mg 2 tablet by mouth daily for vascular dementia without behavioral disturbance, mood disorder, anxiety, and psychotic disturbance. Interview with the Registered Nurse #901 on 04/26/23 at 11:41 A.M. verified this resident is receiving an antidepressant for a diagnosis of vascular dementia without behavioral disturbance, mood disorder, anxiety, and psychotic disturbance as written on Physician Orders. She stated this is not an acceptable diagnosis for the use of Lexapro. Based on record reviews, staff interviews, and review of on line medication guidance, the facility failed to ensure as needed (prn) psychotropic medications were not prescribed for longer than 14 days and failed to ensure psychotropic medications were only used for appropriate indications. This affected five residents (#5, #11, #21, #34, and #39) out of the six residents reviewed for unnecessary medications and hospice services. The facility census was 57. Findings include: 1. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] and had diagnoses including depression and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 11 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 - Some Review of the significant change Minimum Data Set (MDS) assessment, dated 04/01/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. This resident was assessed to require extensive assistance from two staff members for transfers, bed mobility, and toileting. This resident was assessed to receive hospice services. Review of the active physicians order, dated 03/22/22, revealed this resident had an order for Lorazepam (an anti-anxiety medication) to be administered every four hours prn for anxiety. This order did not contain a stop date. Interview with Registered Nurse (RN) #901 on 04/27/23 at 9:00 A.M. verified Resident #5 had an active order for the prn administration of Lorazepam which did not contain a stop date. 2. Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and adjustment disorder. Review of the quarterly MDS assessment, dated 03/23/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require supervision for bed mobility and transfers and limited assistance from one staff member for toileting. Review of the active physicians order, dated 04/15/23, revealed this resident had an order for Vistaril (an anti-anxiety medication) to be administered every six hours prn for itching. This order did not contain a stop date. Interview with RN #901 on 04/27/23 at 9:00 A.M. verified Resident #21 had an active order for the prn administration of Vistaril which did not contain a stop date. 3. Record review for Resident #34 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, down syndrome, and anxiety. Review of the quarterly MDS assessment, dated 04/14/23, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 02. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 11/10/22, revealed this resident had an order for Risperidone (an anti-psychotic medication) to be administered every afternoon for agitation related to anxiety. Interview with RN #901 on 04/27/23 at 9:00 A.M. verified Resident #34 had an active order for the administration of Risperidone to treat agitation related to anxiety. Review of the online medication guidance from Drugs.Com titled Risperidone (https://www.drugs.com/risperidone.html), last updated on 02/20/23, revealed the medication Risperidone was used to treat Schizophrenia and symptoms of Bipolar Disorder (manic depression). The guidance contained a warning that Risperidone was not approved for use in older adults with dementia-related psychosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 12 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record Review of Resident #40 on 04/25/23 at 01:36 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: cerebral infarction, hypertension, asthma, hypothyroidism, hyperlipidemia, depression, morbid obesity, anxiety, arthropathy, osteoarthritis, cataracts, and hypertensive heart disease. Review of the MDS assessment completed on 02/07/23 revealed this resident had minimal cognitive impairments. Interview with Resident #40 on 04/24/23 at 12:10 P.M. revealed she is unaware of any meal substitutes being provided with the exception of a peanut butter and jelly sandwich or a grilled cheese sandwich. She stated she has never been provided with a substitution menu if she does not like what is being served. This resident stated this bothers her that those are the only items that she knows of that are available. Interview with Dietary Technician #720 on 04/26/23 at 08:37 A.M. stated that always available foods are not displayed due to the owner not wanting it posted to maintain a homelike environment. She verified there is no posting for residents or staff to know of alternate foods or what else is available. This deficiency represents non compliance investigated under Complaint Number OH00136551. Based on record review, observation, resident and staff interviews, and review of the menu, the facility failed to provide food portions as approved by a Registered Dietitian and offer food choices. This affected thirteen residents, (#11,#10,#09,#16,#19,#02,#36,#15,#48,#33,#40,#47, and #216) of 55 residents who received food from the kitchen. The total facility census was 57. Findings Include: 1. Review of the Resident #33 chart revealed Resident #33 admitted to the facility on [DATE] with diagnoses including hemiplegia, anorexia nervosa, gastro- esophageal reflux disease, vitamin D deficiency and iron deficiency anemia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and the physician ordered a regular pureed texture with nectar thick liquid diet. Review of the breakfast meal menu on 04/26/23 for House #9 revealed the 04/26/23 breakfast menu posted on the kitchen refrigerator consisting of one doughnut, two eggs, one cup of cereal, four ounces of fruit and six ounces of yogurt. Observation on 04/26/23 at 8:26 A.M. State Tested Nurse Aide (STNA) #120 in House #9 kitchen prepared one doughnut and one package of oatmeal for Resident #33. STNA # 120 measured the prepared one package of oatmeal at four ounces. No other items were prepared until the surveyor brought the posted menu to STNA #120's attention. Interview on 04/26/23 at 8:37 A.M. with Diet Technician, (DTR) # 720 verified STNA #120 only prepared the doughnut and cereal until the surveyor brought it to STNA #120 attention. DTR #720 verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 13 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 the prepared cereal portion measured four ounces instead of the posted menu amount of eight ounces, DTR #720 verified the STNA #120 should have prepared the posted menu for food items and portions , unless the resident preferred an alternate food. Interview on 04/026/23 at 8:48 A.M. STNA #120 verified she did know the menu and food portions was posted on the refrigerator, and did not know eggs, fruit and yogurt were listed in addition to the doughnut and cereal. STNA #120 stated she should have prepared two packages of cereal to reach measurement of eight ounces as listed on the menu. Interview on 04/26/23 at 9:14 A.M. Resident #33 stated she does not like yogurt but likes eggs and fruit in additional to cereal and doughnuts. She denied she had been asked her food preferences for the breakfast meal on 04/026/23. 2. Record review for Residents #10, #16, #36,#15,#48, and #47 revealed physician orders for regular diet. Residents #11 and #02 had physician orders for regular with soft bite sized foods diet. Residents #09 and #19 had physician orders for no added salt diets. Review of lunch menu of House #9, dated 04/26/23, revealed diets of regular, regular with bite sized foods and no added salt diets were to receive six ounces of bean and [NAME] casserole, four ounces of tater tots, four ounces of corn, four ounces of fruit and four ounces of ice cream. Observation on 04/26/23 at 11:57 A.M. revealed STNA #780 served Residents #10, #16, #36, #15, #48, #47, #11, #02, #09 and #19 four ounces of beans and [NAME] casserole, four ounces of tater tots and four ounces of corn. Four ounces of fruit and four ounces of ice cream were not served or offered to the residents. Observation on 04/26/23 at 12:48 P.M. DM #720 measured the beans and [NAME] serving spoon portion and the portion was four ounces. Interview on 04/26/23 at 12:35 P.M. STNA #780 verified she had not followed the portions of beans and [NAME] and food items posted on the menu for resident served regular, soft and bite sized and no added salt diets. She stated she did not see the fruit and ice cream on the menu and had not asked the residents their preferences for fruit and ice cream. No resident had denied fruit or ice cream. Interview on 04/26/23 at 12:48 P.M. DTR #720 verified the bean and [NAME] portion was posted on the refrigerator with portion size of six ounces and fruit and ice cream were listed on the menu. DTR #720 verified STNA #780 served the residents in House #9 a four-ounce portion of beans and [NAME] instead of six ounces. The fruit and ice cream were not served as posted on the menu. 3. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized nectar thick liquid texture diet, ice chips, and fluid restriction 1000 milliliters a day. Review of diet listing provided on 04/24/24 at 8:30 A.M., Resident #216 was listed on diet of regular soft and bite sized nectar thick liquid texture diet. There was no listing of 1000 milliliters fluid restriction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 14 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 Observation on 04/24/23 at 9:15 A.M., the kitchen diet posting dated 04/24/23 revealed Resident #216 had regular soft and bite sized nectar thick liquid texture diet. There was no listing of 1000 milliliters fluid restriction. Interview on 04/26/23 at 9:42 A.M. State Tested Nurse Aide (STNA) # 940 revealed she relied on the kitchen diet postings for resident therapeutic diets. She verified on 04/26/23 Resident #216 diet had been changed and posted to include fluid restriction of 1000 milliliter and the amount to be provided by meal service on 04/26/23. Prior to 04/26/23, the therapeutic diet posting did not include a fluid restriction. Interview on 04/26/23 at 2:57 P.M. Registered Dietitian, (RD) # 950 verified Resident #216 was not listed on the kitchen diet therapeutic diet list for 1000 milliliters fluid restriction dated 04/24/23 , but had been updated on 04/26/23 and now included fluid amount divided by meal service and nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 15 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to obtain and document dishwasher and food temperatures, failed to label and date foods, and discard expired foods. This had the potential to affect 55 residents who receive food from the kitchen. The facility census was 57. Findings include: Review of April 2023 dishwasher logs of House #9 and House #10 revealed multiple days of no documentation of dishwasher temperatures. For April 2023 log of House # 9, only temperatures on 04/02/23 and 04/03/23 were completed. For April 2023 log of House #10, only 04/15/23 temperature was documented. Review of food temperatures logs for House #9 revealed 49 meal temperatures from 04/01/23 through 04/25/23 were not documented. Observation on 04/24/23 at 8:20 A.M. revealed following kitchen sanitation violations in House 15: 1. Package of open meat dated 04/06/23. 2. Reach in refrigerator with no internal thermometer. 3. Torn uncovered package raw meat exposing raw meat and blood in the refrigerator compartment. 4. Refrigerator temperature log not completed for month of April 2023 Observation on 04/24/23 at 8:44 A.M. revealed following kitchen sanitation violations in House 9: 1. Container of fruit with no label or date 2. Bag of fresh asparagus undated and very wet and gel like decayed substance 3. Two packages of open sliced meat dated 04/14/23 and 03/14/23. 4. Open page of tubular meat, undated and unlabeled. 5. Refrigerator temperature log not completed for month of April 2023 Observation on 04/24/23 at 9:10 A.M. revealed following kitchen sanitation violations in House 5: 1. Pan of apparent egg-based quiche no label and no date 2. Pitcher of yellow liquid no label and no date 3. Two packages of open sliced meat dated 04/05/23 and 03/15/23. 4. Reach in refrigerator with no thermometer inside the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 16 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 5. Bulk storage container labeled flour with the scoop stored inside the container. Level of Harm - Minimal harm or potential for actual harm Observation on 04/24/23 at 9:15 A.M. revealed following kitchen sanitation violations in House 10: 1. Container of pineapple dated 04/18/23. Residents Affected - Some 2. Container of opened applesauce with no open date 3. Package of open sliced meat undated. 4. Internal Thermometer in reach in refrigerator registered at 48-degree Fahrenheit, and external thermometer registered 37 degrees Fahrenheit 5. Package of unopened pork chops with store label use by 04/22/23. Observation 04/24/23 at 9:23 A.M. revealed following kitchen sanitation violations in House 19: 1. Container of unidentifiable food unlabeled and undated 2. Pitcher of yellow liquid no label and no date 3. Bowl of unknown food unlabeled and undated 4. Package of open sliced meat dated 04/19/23 5. Open page of tubular meat, undated and unlabeled 6. Opened container coleslaw dated 04/12/23 7. Reach in refrigerator with no internal thermometer Interview on 04/24/23 at 8:20 A.M., with State Tested Nurse Aide, (STNA) #470, in House 15, verified the refrigerator temperature log was not completed, opened containers of foods were labeled with delivery dates, and the raw meat was uncovered. STNA #470 verified foods required an open date label to ensure opened leftover food was monitored and discarded according to the facility policy. Interview on 04/24/23 at 8:44 A.M., STNA #940, in House 9, verified opened foods need an open date to ensure leftover foods were monitored and discarded according to the facility policy. The fresh asparagus was no longer edible, and the refrigerator log lacked multiple entries of refrigerator temperatures. Interview on 04/24/23 at 9:10 A.M., STNA #180, in House 5, verified foods were dated with delivery date and not open date and not able to state what would be a discard date. STNA #180 verified scoops should not be stored in bulk food containers and refrigerators did not have internal thermometers to monitor accurate temperatures. Interview on 04/24/23 at 9:15 A.M., STNA #650, in House 10, verified foods should be labeled, and dated after opening. STNA #650 verified the internal refrigerator thermometer was registering higher than the external and was not sure which was accurate. She verified the pork chops should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 17 of 18 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 366445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Loveland 6405 Small House Circle Loveland, OH 45140 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 discarded on 04/22/23. Level of Harm - Minimal harm or potential for actual harm Interview on 04/24/23 at 9:23 A.M., STNA #975, in House 19, verified multiple foods were unlabeled and needed a date when opened to monitor discard date. STNA #19 verified there were no internal thermometers to monitor refrigerator temperatures were accurate. Residents Affected - Some Interview of 04/26/23 at 9:00 A.M., STNA # 120, who worked in House #9, verified the April 2023 dishwasher temperatures had two days of temperatures documented. STNA #120 verified meal temperatures were missing for multiple meals and should have been obtained and recorded at each meal. Interview on 04/26/23 at 9:40 A.M., STNA # 940, who worked in House #10, verified the April 2023 dishwasher temperature log was only documented on 04/15/23 and should have been completed every day at each meal. Interview on 04/26/23 at 04/01/22 at 2:57 P.M. Registered Dietitian, (RD)# 450 verified foods should be marked with an open date to ensure foods are discarded timely after opened. RD #450 verified temperature logs are to be maintained to monitor food and equipment temperatures. Review of facility policy Food Storage Policy and Procedure dated May 2013, revealed food is covered, dated and labeled with the month and day which it was opened and used by four to 7 days after the food was opened/prepared. Policy titled, Dishwashing Policy and Procedure, dated 06/01/17, when dishwasher is complete and reached a temperature of at least 165 degrees, record the result s o the Dishwashing Monitoring Log. Policy titled, Refrigerator and Freezer Temperature Policy and Procedure, dated 06/01/08 , revealed refrigerator temperatures are checked twice daily and recorded on the refrigerator temperature log. Thermometers are to be placed in the warmest part of the refrigerator to monitor the temperature between 36 to 40 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366445 If continuation sheet Page 18 of 18