Inspection·May 1, 2025

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on staff interview and review of facility staffing documentation, the facility failed to ensure the facility was staffed with sufficient Registered Nursing staff each day. This affected all residents residing in the facility. Facility census was 14. Findings include: Review of facility nursing schedules between 04/21/25 and 04/27/25 revealed the schedule lacked documentation indicating a Registered Nurse (RN) was scheduled to work in the facility on 04/26/25 and 04/27/25. On 04/30/25 at 1:37 P.M. interview with the Administrator and Director of Nursing (DON) during a review of the nurse staffing scheduled between 04/21/25 and 04/27/25 verified the facility was not staffed with a Registered Nurse on 04/26/25 or 04/27/25. The Administrator stated the DON was on call on 04/26/25 and 04/27/25. However, the DON did not report to the facility on either date. On 05/01/25 at 7:50 A.M. review of facility weekly staffing sheet between 04/21/25 and 04/27/25 during interview with the DON confirmed no Registered Nurse was working in the facility on 04/26/25 and 04/27/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 2 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 medical record review and staff interview, the facility failed to ensure resident pharmacy medication regimen reviews were conducted monthly. This affected two of five sampled residents (#4, #1) reviewed for unnecessary medications and related pharmacy services in a facility census of 14. Findings include: 1. Resident #4 admitted to the facility on [DATE] with the diagnosis including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received scheduled pain medications. Review of Resident #4's medical record noted current physician orders for 17 medications including oral, topical, eye, and inhalation. According to progress notes on 04/05/25 at 6:39 P.M. a pharmacy review was completed including the resident's medication regimen and have noted any irregularities and/or observations on a separate report to the Director of Nursing (DON) and prescriber. No documentation contained in the medical record indicated information related to the result of the medication regimen review. On 04/30/25 at 7:35 A.M. interview with the DON verified no documentation contained in the medical record was available indicating the results of the pharmacist monthly medication review or specific medication adjustments. 2. Review of Resident #1's record revealed an admission date of 01/17/19. Diagnoses include severe dementia with behavioral and mood disturbance, anxiety disorder, heart failure, morbid obesity, hyperlipidemia, osteoarthritis, hypothyroidism, insomnia, edema, major depressive disorder, type 2 diabetes mellitus with neuropathy, and hypertension. Resident #1 was admitted to hospice 08/15/24 based on the dementia diagnosis. Review of Resident #1's quarterly MDS assessment, dated 04/03/25, indicated the resident had severe cognitive impairment and received multiple medications including antianxiety medication, antidepressant medication, antibiotic medication, opioid medication, hypoglycemic medication, and anticonvulsant medication. Review of Resident #1's physician orders revealed they included orders for 20 medications, including oral, topical, eye, sublingual (under the tongue), and subcutaneous (under the skin). Review of Resident #1's progress notes revealed they included a monthly progress notes by the consulting pharmacist. Each progress note stated the resident's medication regimen was reviewed and any irregularities and/or observations were provided on a separate report provided to the Director of Nursing (DON) and prescriber. Review of the remaining record revealed no such reports were included. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 3 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 04/30/25 at 12:55 P.M. with the DON confirmed the pharmacist's monthly medication regimen review reports, were not part of Resident #1's medical record or otherwise available. Review of a policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, last revised December 2019, confirmed a record of the consultant pharmacist's observations and recommendations must be made available in an easily retrievable form to nurses, prescribers, medical directors, and the care planning team. The policy further stated the findings of the monthly medication regimen review should be included in the medical record. Additionally, the policy stated recommendations shall be acted upon and documented by the staff and/or prescriber within 30 days or the DON and/or consulting pharmacist will take appropriate action, including with the medical director. Event ID: Facility ID: 366148 If continuation sheet Page 4 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 medical record review, and staff interview, the facility failed to ensure psychoactive medication recommendations were implemented as directed by the physician. This affected one of five sampled residents (#4) reviewed for the provision of unnecessary medication administration in a facility census of 14. Residents Affected - Few Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received pain medications. On 12/13/16 a nursing plan of care was initiated to address Resident #4 risk for side effects from psychotropic medication use for diagnosis of depression. Interventions included the following; Administer Effexor medication as ordered by doctor. Discuss with resident and family potential side effects of the drug Venlafaxine. Monitor and record resident behaviors. Observe resident for adverse side effects, document if noted, notify resident physician. The pharmacy consultant will review medication every month, and make recommendations as needed. On 05/07/24 a physician order was initiated for the administration of Venlafaxine HCl ER 37.5 milligrams (mg) to be administered related to major depressive disorder. According to pharmacy recommendation note to attending physician/prescriber dated 01/10/25 Consultant Pharmacist listed current psychiatric medication to include the administration of Effexor ER 37.5 mg QD since at least 05/07/24. The Consultant Pharmacist requested the physician consider a possible gradual dose reduction (GDR). Please complete the form indicating any change in medication (med) orders or documentation as to why you (physician) consider a GDR is not indicated at this time. Physician response dated 01/31/25 documented to involve psych (psychiatry/psychology). No documentation contained in the medical record indicated the physician response was implemented. On 04/30/25 at 7:35 A.M. interview with the Director of Nursing (DON) during a review of pharmacy the recommendation 01/31/25 confirmed the physicians response had note been implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 5 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were provided as ordered by the physician and without error. This resulted in three errors of 37 medications being administered with a 8.11% error rate. This affected one of three residents (#20) observed for medication administration in a facility census of 14. Residents Affected - Few Findings include: Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral Tablet 100 milligrams (mg) (Cilostazol) Give 1 tablet by mouth every morning and at bedtime for claudication. On 03/18/25 Dorzolamide HCl Ophthalmic Solution 2 % (Dorzolamide HCl) Instill 1 drop in both eyes every morning and at bedtime for glaucoma. On 03/20/25 Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in left eye every 12 hours for glaucoma. Observation on 04/29/25 at 9:22 A.M. noted Registered Nurse (RN) #207 gathering medications for Resident #20. Medications included brimonidine 0.2% eye drops and dorzolamide 2% eye drops. At the time of observation RN #207 stated the medication cilostzol 100 milligrams (mg) was not available and would not be administered. RN #207 then proceeded to Resident #20's room and administered several medications mouth. At 9:31 A.M. RN #207 placed one drop of brimonidine 0.2% into Resident #30 left eye. After 30 seconds RN #207 placed one drop of dorzolamide 2% into each eye. No pause between eye drop medications was attempted. On 04/29/25 at 9:40 A.M. interview with RN #207 verified eye drops were given one after another with no pause between. In addition the medication cilostazol 100 mg was to be administered twice daily and the morning dose would be omitted due to not being available at the facility. According to medication administration procedure revised November 9, 2021. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time. According to facility medication administration procedure for eye drop administration dated May 2022. The time for optimal eye drop absorption is approximately 3 to 5 minutes. If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes. In the case of administering levobunolol, timolol, brinzolamide, or dorzolamide, wait 10 minutes before administering additional drops. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 6 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered to prevent the occurrences of significant medication errors. This affected two of four sampled residents (#20, #125) reviewed for the administration of medications in a facility census of 14. Residents Affected - Few Findings include: 1. Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral Tablet 100 milligrams (mg) (Cilostazol) Give 1 tablet by mouth every morning and at bedtime for claudication. On 03/18/25 Dorzolamide HCl Ophthalmic Solution 2 % (Dorzolamide HCl) Instill 1 drop in both eyes every morning and at bedtime for glaucoma. On 03/20/25 Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in left eye every 12 hours for glaucoma. Observation on 04/29/25 at 9:22 A.M. noted Registered Nurse (RN) #207 gathering medications for Resident #20. Medications included brimonidine 0.2% eye drops and dorzolamide 2% eye drops. At there time of observation RN #207 stated the medication cilostzol 100 milligrams (mg) was not available and would not be administered. RN #207 then proceeded to Resident #20 room and administered several medications mouth. At 9:31 A.M. RN #207 placed one drop of brimonidine 0.2% into Resident #30 left eye. After 30 seconds RN #207 placed one drop of dorzolamide 2% into each eye. No pause between eye drop medications was attempted. On 04/29/25 at 9:40 A.M. interview with RN #207 verified eye drops were given one after another with no pause between. In addition the medication cilostazol 100 mg was to be administered twice daily and the morning dose would be omitted due to not being available at the facility. According to facility medication administration procedure for eye drop administration dated May 2022. The time for optimal eye drop absorption is approximately 3 to 5 minutes. If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes. In the case of administering levobunolol, timolol, brinzolamide, or dorzolamide, wait 10 minutes before administering additional drops. 2. Resident #125 admitted to the facility on [DATE] with diagnoses including, nondisplaced right femur fracture, paranoid schizophrenia, type 2 diabetes mellitus, urinary tract infection, anemia, chronic kidney disease, hypertension, alzheimer's disease, dementia, depression, coronary artery disease and heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 7 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the functional abilities assessment dated [DATE] assessed Resident #125 to require substantial to maximal assistance with activities of daily living. On 04/26/25 skilled nursing charting assessed Resident #125 as alert and oriented to person and place, received oxygen via nasal cannula, continent of bowel and bladder, unable to bear weight with unsteady gait, and intact skin. Review of physician orders dated 04/26/25 noted Vilazodone 20 milligrams (mg) to be administered in the morning related to depression. Review of Medication Administration Records (MAR) between 04/26/25 and 04/28/25 noted the medication documented as not administered. No further documentation contained evidence indicating the medication was administered or the physician being notified of the omission. On 05/01/25 at 9:34 A.M. interview with Director of Nursing following medical record review verified Resident #125 did not receive Vilazodone 20 mg on 04/26/25, 04/27/25, 04/28/25 due to medication not available in facility. According to medication administration procedure revised November 9, 2021, medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 8 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 Based on interview, facility documentation, and a policy for water management, the facility failed to ensure a sufficient water management program based on an accurate risk assessment. This had the potential to affect all residents. The census was 14. Residents Affected - Many Findings include: Review of a document titled Legionnaire's Risk Assessment revealed the document was undated, unsigned, and did not include the name of the facility. Interview on 05/01/25 at 9:15 A.M. with Administrator and Environmental Services Director #233 confirmed the risk assessment did not include the date of the assessment, a signature, or the name of the facility. Both denied knowledge of when the risk assessment was completed and by whom. Review of policy titled, Water Management Program for Legionella Risk Reduction, dated 2017, revealed the facility shall conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 9 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and review of fire drill reports, corrective action plans, and a state fire marshal report, the facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. This had the potential to affect all residents. The census was 14. Findings include: Interview on 05/01/25 at 9:15 A.M. with the Administrator and Environmental Services Director (ESD) #233 revealed fire drills were not conducted on first or third shift in the first quarter of 2024, and no fire drill was conducted on third shift in the third quarter of 2024. Follow-up interview on 05/01/25 at 1:15 P.M. with the Administrator revealed the state fire marshal issued a violation on 07/25/24 for failure to conduct fire drills across all shifts during each quarter. Review of the Emergency and Disaster Plan, last reviewed 11/26/24, confirmed fire drills are to be conducted monthly and rotated so drills are conducted on each shift at least once per quarter. The deficient practice was corrected on 12/24/24 when the facility implemented the following corrective actions: • On 08/22/24 and 08/23/24, the facility educated all staff, including maintenance staff, on fire safety. • On 10/01/24, the (former) Environmental Services Director was educated by the Administrator on conducting fire drills. This employee was later terminated for continued failure to perform job duties, including those pertaining to fire drills. • The facility conducted fire drills on 10/12/24 on third shift, on 11/12/24 on first and second shifts, on 12/12/24 on third shift, on 12/16/24 on first shift, and on 12/19/24 on second shift. These drills met the state fire marshal's required corrective actions. • The Administrator conducted audits of fire drill documentation on 10/12/24, 11/12/24, 12/16/24, and 12/19/24 and found no further deficiencies. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 10 of 11 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 366148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset House 4020 Indian Rd Toledo, OH 43606 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 - Many On 11/26/24, a representative from the [NAME] Fire Prevention Bureau and the Administrator reviewed the facility's Emergency and Disaster Plan and deemed it satisfactory. • On 12/24/24, the Division of State Fire Marshal Code Enforcement Bureau conducted an onsite inspection and determined the facility had corrected the drill violation, effective 12/24/24. Since the date of correction on 12/24/24, the facility conducted fire drills on 01/17/25, 02/27/25, 03/20/25, and 04/18/25. Review of the fire drill reports for drills conducted since the 12/24/24 correction, confirmed the facility has had no further deficiencies with fire drills. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366148 If continuation sheet Page 11 of 11