Inspection·October 18, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #36 revealed an admission date of 05/22/20 and readmission date of 08/16/20. Diagnoses included chronic kidney disease, anxiety disorder, chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis following cerebral infarction. Residents Affected - Few Review of the Medicare five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired and was dependent on staff for personal hygiene. Review of the plan of care focus area last revised on 06/16/22 revealed Resident #36 had an activities of daily living (ADLs) self-care and/or physical mobility performance deficit related to activity intolerance, dementia, hemiplegia, range of motion impairments, contractures and stroke. Interventions included up to total assistance of one staff for personal hygiene and oral care. Observation and interview on 10/11/22 at 9:16 A.M. of Resident #36 revealed his fingernails were long, jagged and dirty. Resident #36 stated he preferred his fingernails to be shorter and his nails needed cut. Resident #36 was unable to recall when his fingernails were last trimmed. Observation on 10/12/22 at 11:56 A.M. revealed Resident #36 was sitting in the dining room eating lunch. Resident #36's fingernails were long, jagged and dirty. Interview on 10/12/22 at 1:35 P.M. with Resident #36's family member revealed Resident #36's son used to trim his nails when he visited, but the family member stated the son no longer did that because he wanted to spend time with Resident #36 while he was there and not provide care for him. The family member stated Resident #36's fingernails really needed trimmed and cleaned. Interview on 10/12/22 at 1:53 P.M. with State Tested Nurse Aide (STNA) #293 revealed Resident #36 sometimes ate with his hands and food got under his fingernails. STNA #293 stated sometimes Resident #36's family trimmed his nails but he was unsure if family still did that or when they last did it. STNA #293 verified Resident #36's fingernails were long, jagged, and dirty. STNA #293 stated he believed it was food under the Resident #36's fingernails. Based on medical record review, observations, family and resident interview, and staff interview, the facility failed to ensure residents who required assistance from staff with activities of daily living received adequate and timely personal hygiene to promote promote proper hygiene and cleanliness. This affected two (Residents #3 and #36) of three residents reviewed for activities of daily living. The facility identified all 45 residents required assistance from staff with bathing and 44 residents required assistance from staff with dressing. The facility census was 45. Findings include: 1. Record review for Resident #3 revealed an original admission date of 09/03/21 and a readmission on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarct, severe protein-calorie malnutrition, gastrostomy tube, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. Resident #3 required limited assistance from staff with personal hygiene and was totally dependent on staff for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 2 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #3's care plan dated 09/21/21 revealed staff were to provide oral care and to monitor for dental problems needing attention. Observations of Resident #3 on 10/11/22 at 10:36 A.M. revealed a gray film noted on Resident #3's front of teeth. Observation on 10/12/22 at 9:22 A.M. revealed a white flaky film on the front of Resident #3's teeth and on his lips. Interview with Licensed Practical Nurse (LPN) #395 on 10/12/22 at 9:25 A.M. verified Resident #3 had dry, flaky lips and a dry mouth. Interview on 10/12/22 at 9:58 A.M. with State Tested Nursing Assistant (STNA) #256 stated she started her shift at 6:00 A.M. and was unaware of the last time oral care had been completed for Resident #3, and further added she had not provided oral care during her shift. Additional observation on 10/12/22 at 1:33 P.M. revealed Resident #3's white and flaky parts on his lips, and the white film on teeth peeled off during oral care that was being provided by STNA #256. Observation and interview on 10/13/22 at 4:30 P.M. with Resident #3 and the family member at the bedside revealed a thick white film stuck between the upper and lower lips of Resident #3 when the resident opens his mouth to talk. At the time of the observation, Resident #3 verified he had a dry mouth. Interview with STNA #323 on 10/13/22 at 4:45 P.M. verified Resident #3 had consistent film on his lips and teeth. STNA #323 stated her shift had started at 2:00 P.M. and stated she had not provided oral care to Resident #3 and further stated she was unaware of the last time oral care had been provided to Resident #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 3 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview, review of the facility's policy, and review of Safety Data Sheets (SDS), the facility failed to ensure potentially hazardous chemicals were properly secured. This had the potential to affect nine residents (#2, #6, #8, #9, #14, #30, #33, #38, and #145) identified by the facility as being cognitively impaired and independently mobile and residing on the secured memory care unit. The facility census was 45. Findings include: Observation on 10/11/22 at 9:14 A.M. of the janitor closet on the secured memory care unit revealed the door was unlocked. Inside the closet was a 19-ounce can of furniture polish, approximately half full, with warnings indicating can be harmful and fatal; a full 42-ounce container of antibacterial hand wash; a 16-ounce half full container of laundry pre-spotter with warnings including caused severe skin burns and serious eye damage, may be corrosive to metal and keep out of reach; and lastly, a 32-ounce, one-third full, bottle of glass and plastic cleaner with warnings including caused eye irritation and keep out of reach. Additional observations on 10/11/22 at 9:41 A.M., 10:37 A.M., 11:41 A.M., 12:02 P.M., 12:22 P.M. and 12:32 P.M. revealed the janitor closet remained unlocked with the above noted chemicals in the closet. Observation and interview on 10/11/22 at 3:58 P.M. of the janitor closet revealed the closet remained unlocked. Interview with State Tested Nurse Aide (STNA) #355 verified the janitor closet should be kept locked and confirmed the furniture polish, hand wash, laundry pre-spotter and glass and plastic cleaner were unsecured in the closet. STNA #355 stated she observed this surveyor open the janitor closet door and had commented to another staff that the door should have been locked. Review of the facility's resident list of residents who resided on the memory care unit revealed Resident 2, #6, #8, #9, #14, #30, #33, #38, and #145 resided on the memory care unit and were independently mobile. Review of the Safety Data Sheet (SDS) for the Array Lemon Oil Furniture Polish, undated, revealed the product caused eye irritation and precautionary statements included avoid contact with eyes, skin and clothing. Additionally, if swallowed, contact a physician or poison control center. Review of the SDS for the Array Ready to Use Glass and Plastic Cleaner, undated, revealed the product caused eye irritation and precautionary statements included avoid contact with eyes, skin and clothing. Review of the SDS for the Array [NAME] Scent Antibacterial Foam Handwash, revised 01/08/19, revealed precautionary statements included caused severe eye irritation. Additionally, if swallowed, do not induce vomiting, rinse mouth with water and seek medical attention. Review of the SDS for the Array Ready to Use Laundry Pre-Spotter, undated, revealed precautionary statements included wear chemical-splash safety goggles, chemical-resistant protective gloves and protective footwear, avoid contact with eyes, skin and clothing, do not breath vapors or mist, do not eat or drink when using the product and absorb spillage to prevent material damage. If swallowed, rinse mouth, do not induce vomiting, dilute by drinking up to a cupful of milk or water if conscious (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 4 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 and immediately call a poison control center or physician. Lastly, store locked up. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy's titled Storage and Use of Poisonous Substances Policy and Procedure (Cleaning Supplies, Pesticides, Etc), revised May 2013, revealed the three categories of poisonous substances were pesticides, detergents, sanitizers, corrosives and other chemicals and flammables. Additionally, each of the above categories should be stored in locked cabinets. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 5 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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** 2. Review of Resident #7's medical record revealed an admission date of 03/02/16. Diagnoses included hemiplegia and hemiparesis, insomnia, type I diabetes, major depressive disorder, dementia, cerebral infarction, dysphagia, and chronic obstructive pulmonary disease. Residents Affected - Few Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. Resident #7 was totally dependent on staff for transfer. Resident #7 displayed no behaviors during the review period. Review of Resident #7's Nutrition/Dietary Note, dated 09/12/22, revealed Resident #7 had a non-significant weight loss of nine pounds (lbs) equal to a 4.9% weight loss. It was noted Resident #7's weight loss was very close to the significant weight loss threshold of 5.0%. The dietitian recommended to add weekly weights to monitor. Review of Resident #7's care plan, last revised on 09/28/22, revealed supports and interventions for risk for nutritional complications related to inconsistent intakes. Interventions included to monitor and record food intake with each meal and diet as ordered. On 09/28/22 the care plan was updated to weigh Resident #7 weekly for four weeks then return to monthly weights as appropriate. Review of Resident #7's weight monitoring revealed only two weights were taken between 09/02/22 (176 lbs) and 10/01/22 (178 lbs). After surveyor intervention, an additional weight was recorded on 10/13/22 and Resident #7 weighed 181 lbs. This weight was completed twelve days after the 10/01/22 weight. There was no evidence of weekly weights per the dietitian's recommendation and Resident #7's care plan. Interview on 10/12/22 at 7:58 A.M. with State Tested Nursing Assistant (STNA) #266 revealed Resident #7 was able to make his needs known, was cooperative with care and was independent with eating. STNA #266 reported Resident #7's meal intakes varied but he had been doing better recently. Interview on 10/12/22 at 9:30 A.M. with Register Nurse (RN) #394 revealed the dietitian made the recommendation to increase to weekly weights for Resident #7. Otherwise, the facility only completed monthly weights on residents. Interview on 10/13/22 at 2:03 P.M. with the Director of Nursing (DON) verified Resident #7's electronic medical record had one weight collected since the 09/12/22 dietitian recommendation for weekly weights for monitoring. The DON stated they had paper weight records for some of the residents' weights. The DON said she would look to see if there were any additional documentation with weights. Review of the facility's policy titled Weight Policy, revised 12/02/21, revealed if weekly weights were requested they would be done on a daily basis or weekly basis based on the day the initial weight was obtained. The weight would be recorded in the electronic medical record. A copy of the report would be shared with the dietician to review, assess, make recommendations where necessary, and document on a person needing follow up. Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure resident weights were monitored according to dietician recommendations. This affected two (Resident #6 and #7) of three residents reviewed for nutrition. The facility identified five (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 6 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 residents with a recent significant weight loss. The facility census was 45. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. Review of the medical record for Resident #6 revealed an admission date of 11/08/21. Diagnoses included Alzheimer's disease, major depressive disorder, and schizoaffective disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired for daily decision making, rejected care, and had a wandering behavior. Resident #6 required limited assistance from staff with eating and had no significant weight loss. Review of the plan of care focus area, last revised on 09/29/22, revealed Resident #6 was at risk for changes to nutrition and hydration status due to dementia and cognitive impairment, depression and difficulty communicating dietary needs. Interventions included to encourage to drink all fluid provided with medications, encourage to drink fluids and eat snacks between meals and during activities as appropriate, encourage to eat and drink by offering preferred foods and fluids, assist at meals and snacks by cueing or assisting as needed, offer ordered diet, offer ordered medications, review weights and intakes routinely and as available and report changes as needed, serve supplements ordered and record amount of consumption. Review of Resident #6's weight history revealed Resident #6 weighed the following: 154.2 pounds on 09/05/22, 143.9 pounds on 09/30/22 and 10/01/22. This indicated a significant weight loss of 6.7% in one month. No weights after 10/01/22 were available for review. Review of the quarterly nutrition progress note dated 09/29/22 revealed Resident #6 had some decline in oral intake, likely due to COVID-19 positive but intakes had returned to above 50% at meals. Resident #6's skin was intact and there were no signs or symptoms of chewing or swallowing difficulty. No significant weight change was noted at the time, however, Resident #6 had a gradual trend down in weight over the last year. The Registered Dietitian (RD) recommended to add Boost (a high calorie nutritional supplement) one time daily and would continue to monitor. Review of a physician order dated 09/29/22 revealed Resident #6 was ordered Boost one time daily for weight loss and was on a regular diet, regular texture and regular consistency. Review of a late entry nutrition progress note, effective 10/04/22, confirmed Resident #6 had a significant weight loss of 6.5% in one month, representing a significant weight loss. The dietitian noted a supplement had been added a few days prior and recommended Resident #6 be added to weekly weights. Review of a late entry nursing progress note, effective date of 10/06/22, revealed the physician was notified of Resident #6's significant weight loss, Boost was in place, and was awaiting dietitian recommendations. Interview on 10/12/22 at 9:16 A.M. with Registered Nurse (RN) #394 revealed weights were documented on a paper weight sheet and entered into the electronic medical record (EMR) by Wednesday each week in order for the weights to be available for dietitian review. If a resident had a significant weight loss, the dietitian would review and make recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 7 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 Interview on 10/12/22 at 12:09 P.M. with Registered Dietitian (RD) #400 revealed she typically ran weight reports weekly from the electronic medical record (EMR) system to review resident weights. If a significant weight loss was noted, RD #400 stated she would review and make recommendations. During Resident #6's quarterly review, completed 09/29/22, RD #400 stated she had noted a trend of weight loss and added a supplement one time daily, with the most recent weight available during that review obtained on 09/05/22. RD #400 confirmed Resident #6 had a significant weight loss of approximately 6.5% in one month when she reviewed the weight report on 10/04/22. Since a supplement had been added on 09/29/22, RD #400 recommended Resident #6 be added to weekly weights to closely monitor his weight to determine if the supplement one time daily was beneficial, but stated she discovered the recommendation sheet she created on 10/07/22 was not emailed to the facility as she thought. RD #400 confirmed her recommendations were not communicated to the facility until today, 10/12/22. Additionally, RD #400 did not have any updated weights available since 10/01/22 to assist with assessing Resident #6's weight loss. Interview on 10/12/22 at 1:31 P.M. with RN #394 confirmed dietitian recommendations for weekly weights to monitor Resident #6's significant weight loss were not received until today (10/12/22) and Resident #6 had not been weighed since 10/01/22. Observation on 10/12/22 at 2:18 P.M. of State Tested Nurse Aide (STNA) #264 obtain a current weight on Resident #6 revealed the Resident #6 weighed 142.6 pounds, indicating Resident #6 had lost 1.3 pounds since the previous weight was obtained on 10/01/22. Review of the facility's policy titled Weight Policy, dated 12/02/21, revealed the purpose was to identify person(s) who may be at risk nutritionally. If a significant weight change is noted, the dietitian and or diet technician would proceed with the following as appropriate: review current diet order, request weekly weights, observe person regarding weight change, evaluate above data, make recommendations for interventions, update the plan of care and document the above in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 8 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 - Few 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** Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure anti-anxiety medications that were ordered as needed did not exceed the fourteen day limitation without physician rationale to continue the medication. This affected one (Resident #19) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: Review of the medical record for Resident #19 revealed an admission date of 08/08/22 and a re-admission date of 09/08/22. Diagnoses included major depressive disorder and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was moderately cognitively impaired. Review of a physician order dated 08/18/22 revealed Resident #19 was ordered Ativan (medication used to treat anxiety) 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for agitation. The order did not have an end date and was subsequently discontinued on 09/08/22, upon Resident #19's return from the hospital. On 09/14/22, a current physician orders for Resident #19 to receive Ativan 0.5 mg one tablet by mouth every eight hours as needed for agitation. The order end date was listed as indefinite. Review of the Medication Administration Record (MAR) for September 2022 revealed Ativan was administered to Resident #19 on 09/04/22 and 09/05/22. The MAR for October 2022 revealed Ativan was administered to Resident #19 on 10/02/22, 10/09/22, and 10/10/22. Interview on 10/13/22 at 11:34 A.M. with Registered Nurse (RN) #394 revealed orders for as needed psychotropic medications, including Ativan, were to be limited to 14 days unless the physician reviewed and provided rationale to continue the medication. RN #394 verified Ativan was administered to Resident #19 on 09/04/22, 09/05/22, 10/02/22, 10/09/22, and 10/10/22 and each of those administrations were outside of the 14 day limitation for an as needed medication. RN #394 verified the Ativan order dated 09/14/22 listed the order end date as indefinite and stated it was appropriate for an as needed medication to be continued beyond 14 days if the physician provided rationale to continue the medication. RN #394 stated the physician completed paper notes that were then scanned into the electronic medical record (EMR). RN #394 confirmed Resident #19's EMR did not contain any physician notes providing rationale to continue Ativan past 14 days. Review of Resident #19's hard chart medical record, with RN #394, confirmed Resident #19 was last seen by the physician on 09/12/22 and the hard chart medical record contained no information the physician had provided rationale to continue the order for Ativan beyond 14 days. Review of the facility's policy titled Gradual Dose Reduction (GDR) Policy and Procedure, dated 11/29/17, revealed as needed orders for psychotropic medications was limited to 14 days. Order limitation could extend beyond 14 days if the attending physician or prescribing practitioner believed it was appropriate to extend the order. Required action of the attending physician to extend the order included documentation of the rationale for the extended time period included in the medical record and to indicate a specific duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 9 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 review of the facility's policy, the facility failed to ensure foods and beverages were properly stored, labeled and dated in the serving kitchen on the secured memory care unit. This had the potential to affect 19 of 19 residents residing on the secured memory care unit who received beverages from the kitchen. The facility census was 45. Findings include: Observation on 10/11/22 at 9:28 A.M. of the reach-in refrigerator in the serving kitchen on the secured memory care unit revealed an opened and undated half-full 46 ounce container of ready thickened cranberry juice cocktail; three squeeze bottles of various salad dressings, uncapped with dried salad dressing covering the openings, undated and unlabeled; one opened and undated 46 ounce container, approximately three - quarters full of apple juice; two opened and undated 46-ounce containers, each approximately one-third full, of apple juice; and a full half-gallon pitcher of an unknown liquid, unlabeled and undated. Additional observation of the reach in freezer revealed a slice of pie placed on a Styrofoam container, uncovered, undated and unlabeled. Interview on 10/11/22 at 9:33 A.M. with Dietary Aide (DA) #289 verified the above findings. DA #289 stated the unlabeled pitcher of liquid was likely a mixture of juices and carbonated lemon-lime drink made by staff for the residents. DA #289 confirmed all food and beverage items placed in the refrigerator and freezer were to be properly covered, dated with the discard by date and labeled with what the food or beverage was. DA #289 stated foods were to be used or disposed of within seven days of opening and she would have to dispose of the unlabeled and undated food and beverages because she was unsure of when they had been opened. Additionally, DA #289 state the pie should have been covered, dated, and labeled prior to being placed in the freezer. Review of the facility's policy titled Food Storage and Procurement, dated 05/11/22, revealed once a package was opened, any remaining food must be placed in sealed containers or bags and marked to identify what was in the container. Food in the freezer shall be placed in sealed containers or bags and marked to identify what is in the container and must be labeled with the date the food item was opened and the use by date. If the item was placed in a refrigerator, a production or opened date and a use by date must be placed on the item. The use by date was seven days from the date that the food item was prepared or opened. Condiments must be dated with the open or production date and the use by date of three months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 10 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure accurate medical records were kept for residents receiving dialysis. This affected one (Resident #15) of one resident reviewed for dialysis. The facility identified one resident who received dialysis. The facility census was 45. Findings include: Review of Resident #15's medical record revealed an admission date of 05/24/22. Diagnoses included kidney failure. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Resident #15 was receiving dialysis at the time of the review. Review of Resident #15's care plan revised 05/05/22 revealed supports and interventions for self-care deficit, risk for pain, and dialysis. Interventions for dialysis included to check/monitor for bruit and thrill each shift. Review of Resident #15's physician orders dated 08/20/22 revealed an order to complete pre-dialysis Communication Form in the electronic medical record one time a day on Tuesday, Thursday, and Saturday for dialysis. On 08/27/22, an order to complete post dialysis form every evening shift Tuesday, Thursday, and Saturday for dialysis. Review or Resident #15's assessments revealed Pre-Dialysis Communication Forms were completed on 09/10/22, 09/15/22, and 09/29/22 by Licensed Practical Nurse (LPN) #281 and indicated Resident #15's dialysis fistula was checked for thrill and bruit and both were present. Review of Resident #15's assessments revealed Post Dialysis Forms were completed on 09/01/22, 09/10/22, 09/13/22, 09/15/22, 09/27/22, 09/29/22, and 10/11/22 by Registered Nurse (RN) #345 and indicated Resident #15's dialysis fistula was checked for thrill and bruit and both were present. Interview on 10/12/22 at 11:59 A.M. with LPN #283 revealed Resident #15 had a port for dialysis and not a fistula. The nurses monitored the area for any redness or drainage and documented that in the electronic medical record. LPN #283 reported dialysis ports were not checked for thrill and bruit, only fistulas would be checked. Observation on 10/13/22 at 8:13 A.M. of Resident #15 and her dialysis site found Resident #15 had a port and not a fistula. Corresponding interview with State Tested Nursing Assistant (STNA) #288 verified Resident #15 had a port and not a fistula. Interview on 10/13/22 at 10:45 A.M. with LPN #281 verified she completed Resident #15's pre-dialysis assessments on 09/10/22, 09/15/22, and 09/29/22 and should not have documented a thrill and bruit as Resident #15 had a port and not a fistula. A port was checked for redness and infection and a fistula was checked for thrill and bruit. Interview on 10/13/22 at 2:45 P.M. with RN #345 verified she completed the post dialysis forms on 09/01/22, 09/10/22, 09/13/22, 09/15/22, 09/27/22, 09/29/22, and 10/11/22 and indicated Resident #15 had thrill and bruit present for her fistula. LPN #345 verified this was inaccurate documentation as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 11 of 12 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Sunset Village 9640 Sylvania-Metamora Road Sylvania, OH 43560 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 0842 Level of Harm - Minimal harm or potential for actual harm Resident #15 had a port and not a fistula. RN #345 reported Resident #15's port was checked for infection and would not be checked for thrill and bruit as blood did not run through the port. LPN #345 reported Resident #15 may have had a fistula a long time ago but as long as she had worked with Resident #15 she only had a port. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 12 of 12