Inspection·October 31, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy titled Resident with Weight Loss, dated 05/03, revealed the purpose is to monitor and assure that residents maintain acceptable nutritional parameters unless conditions exist that predetermine that a nutritional problem is unavoidable and to provide nutritional interventions to residents when indicated. If weight loss is identified the physician will be notified. Review of facility policy title Change of Condition: Observing, Recording, and Reporting, dated 04/02, revealed the purpose is the observe, record, and report any condition change to the nurse in charge and the attending physician so proper treatment will be implemented. Immediate notification of the resident, if known the resident ' s legal representative or interested family member, and the resident ' s physician will be completed for the following: significant change in the residents physical, mental, or psychosocial statue and the need to alter treatments significantly. This deficiency represents non-compliance investigated under Complaint Number OH00146963. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365996 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 365996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Swan Creek 1650 Swan Creek Lane Toledo, OH 43614 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 - Actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure physician orders for a nutritional supplement were followed and the physician and dietician were notified regarding a significant weight loss. This resulted in actual harm when Resident #3's ordered nutritional supplement was not available from the supplier for the facility to administer, the facility did not reach out to the physician or the dietician for an alternate supplement or different interventions, and the resident had a significant weight loss of 15.2 pounds/ 8.5 percent weight loss. Additionally, when the significant weight loss occurred the facility failed to notify the physician and dietician of the occurrence. This affected one (#3) of three residents reviewed for weight loss. The facility census was 28. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed an admission date of 06/10/23. Diagnoses included Parkinson, cognitive communication deficit, dysphagia, and Lewy body dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/18/23, revealed Resident #3 had severe cognitive impairment and required extensive assistance with activities of daily living, including eating. Review of a plan of care for Resident #3 initiated on 09/25/23, and revised on 10/26/23, revealed the resident was care planned for malnutrition related to decreased appetite and significant weight loss in 09/23. Review of physician orders for 09/23 revealed Resident #3 was on a regular, mechanical soft diet with thin liquids and Muscle Milk supplement twice daily. Review of the Medication Administration Record (MAR) from 09/05/23 through 09/19/23 revealed Resident #3's Muscle Milk was not available for administration per physician orders. Documentation on the MAR revealed that despite the Muscle Milk not being available, an alternate was offered and accepted by Resident #3 on one occasion on 09/05/23. Review of weights for Resident #3 revealed on 09/11/23 a weight of 176 pounds (#), 09/12/23 of 171.2#, 09/13/23 of 170#, 09/14/23 of 176.3#, 09/15/23 of 178#; and 09/16/23 of 162.8#, which was a 15.2# or an 8.5 percent (%) weight loss. Resident #3's weight continued to decline on 09/17/23 to 160.8#, and 09/19/23 of 158#. On 09/19/23 Resident #3 was sent to the hospital for change of condition and a readmission weight on 09/26/23 was 169#. Review of State Tested Nurse Aide (STNA) documentation for meal intake revealed on 09/12/23 the only documented meal was dinner at 51-75% consumed. On 09/13/23 Resident #3 consumed 51-75% for breakfast and 0% for lunch and dinner was not documented. There was no documentation of oral intake for Resident #3 on 09/14/23 for any meals. On 09/15/23 Resident #3 consumed 1-25% of both breakfast and lunch and there was no documentation for dinner. On 09/16/23 Resident #3 consumed 51-75% of breakfast and only 1-25% for lunch and dinner. Review of the intake documentation for Resident #3 revealed a nutritional supplement was offered and accepted on 09/12/23 with 100% consumed, 09/13/23 with 25% consumed, none on 09/14/23, 09/15/23 with 50% consumed, and 09/16/23 with 100% consumed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365996 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 365996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Swan Creek 1650 Swan Creek Lane Toledo, OH 43614 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 - Actual harm Residents Affected - Few Review of a readmission nutritional assessment, dated 09/28/23, for Resident #3 revealed a recent hospitalization for urinary tract infection (UTI), dehydration and acute kidney failure. Resident #3 had a readmission weight of 169.5 #, indicating a significant weight loss of 5.1% for 30 days. Resident #3's oral intakes are improving and are comparable to his previous nutritional assessment. He continues a pureed diet with thin liquids for dysphagia. He continues to receive Muscle Milk nutritional supplement twice daily. Interview on 10/26/23 at 9:15 A.M. with Licensed Practical Nurse (LPN) #103 stated Resident #3 gets Muscle Milk supplement that the family supplies and when they are waiting for more she will give the resident an Ensure supplement so he gets something. Interview on 10/26/23 at 10:10 A.M. with Registered Dietician (RD) #108 stated Resident #3 was not on her radar for significant weight loss. He had fluctuations since admission but nothing significant for her until his recent hospitalization. RD #108 stated upon admission she trialed Ensure nutritional supplement and he had a few refusals and the family suggested Muscle Milk as he was drinking this at home. RD #108 stated the family provided the supplement in the beginning and then the facility assumed responsibility for ordering the supplement of choice. RD #108 was aware the resident was being weighed daily but was not sure why he was a daily weight since he didn't trigger for monitoring daily for her. Interview on 10/31/23 at 11:19 A.M. with Central Supply Clerk (CSC) #107 stated the facility became responsible for ordering the Muscle Milk nutritional supplement for Resident #3 on 06/29/23. CSC #107 stated she began having a supplier issue with getting the supplement in the middle of the summer and she stated she alerted her supervisor of this problem. CSC #107 stated she began trying to find the supplement anywhere she could and was sometimes able to get it from Amazon. CSC #107 did not attempt to order anything different she is not able to make those decisions without direction from her supervisor. Interview on 10/31/23 at 11:08 A.M. with RD #108 stated she was not notified of a 15.2 # weight loss for Resident #3. RD #108 stated she would have identified the weight loss on her next monthly weight review. RD #108 also stated she was not notified of supplier issues with getting the Muscle Milk. Interview on 10/31/23 at 2:33 P.M. with Physician #120 she was not notified of a the significant weight loss for Resident #3 and was not notified that the supplement of choice, Muscle Milk, was not available from the supplier. Review of facility policy titled Resident with Weight Loss, dated 05/03, revealed the purpose is to monitor and assure that residents maintain acceptable nutritional parameters unless conditions exist that predetermine that a nutritional problem is unavoidable and to provide nutritional interventions to residents when indicated. If weight loss is identified the physician will be notified. This deficiency represents non-compliance investigated under Complaint Number OH00146963. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365996 If continuation sheet Page 4 of 4