Health inspection·March 28, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and policy review, the facility failed to perform appropriate hand hygiene while preparing food for residents. This affected four (#13, #20, #21, and #22) of six residents sampled for food preparation. The facility census was 58. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and had diagnoses including unspecified epilepsy and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and had diagnoses including type II diabetes and vascular dementia. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact, had no behaviors, did not wander, and did not reject care. 3. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, and coronary artery disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact, had no behaviors, did not wander, and did not reject care. 4. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and alcoholic polyneuropathy. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #22 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Observations made on 03/28/2024 from 12:24 P.M. to 12:34 P.M. revealed Stated Tested Nurse Aide (STNA) #119 prepared lunch for Residents #21 and #22. STNA #119 used gloved hands to place slices of pizza onto serving platter after using salad tongs to transfer salad from carryout carton to a porcelain serving dish. STNA #119 handed serving tray and porcelain bowl to STNA #115. STNA #119 did not change gloves or sanitized hands before preparing lunch plate for Resident #13. STNA #119 sliced pizza in the box with a wheeled pizza slicer then used her gloved hands to transfer pizza from the pizza (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 2 Event ID: 366445 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 03/28/2024 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)