Health inspection·July 10, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left palm dorsal surface bruise, right thumb bruise, and left shoulder bruise. No falls or injuries were reported. The resident denied pain and there were no signs of bone fractures. Review of a New Skin Observation Tool dated 06/08/23 revealed new bruising to left front shoulder, left top of hand, and right thumb. Cause is unknown. The resident was unable to tell writer cause. Will continue to monitor. All parties notified. Review of an Interdisciplinary Team (IDT) note dated 06/09/23 revealed on 06/08/23, Resident #44 presented with bruising and abrasions consistent with rolling out of bed. New intervention included mat to floor next to bed. Family and physician notified. Observation on 07/10/23 at 9:24 A.M. of Assistant Director of Nursing (ADON) #198 and STNA #108 assisting Resident #44 with transfer from bed to wheelchair, revealed STNA #108 assisted the resident with moving her legs over the side of the bed. ADON #198 and STNA #108 placed the lift sling around Resident #44 and connected the sling to the sit to stand lift. Utilizing the lift, STNA #108 provided Resident #44 with verbal cues to stand and STNA #108 guided the lift to the wheelchair while ADON #198 provided physical support to Resident #44. Interview at the time of the observation of ADON #198 and STNA #108 confirmed STNA #108 was the staff who noticed bruising on Resident #44 on the morning of 06/08/23. The source of the bruising was unknown. ADON #198 and STNA #108 were unaware of any falls or injuries that would have caused the bruising. Interview on 07/10/23 at 9:24 A.M. of the DON revealed bruising discovered on Resident #44 on 06/08/23 was consistent with the resident rolling out of bed and a new intervention to place a fall mat bedside was implemented. The DON confirmed, to the best of her knowledge, Resident #44 would have required assistance with getting up off the floor had she rolled out of bed and there were no reports the resident had fallen or rolled out of bed. Interview on 07/10/23 at 11:14 A.M. of Licensed Practical Nurse (LPN) #190 confirmed Resident #44 had bruising to her left hand, right thumb, and left shoulder. LPN #190 stated the bruise to the right thumb was bad. LPN #190 verified the source of the bruising was unknown. While LPN #190 stated it was possible Resident #44 could have rolled out of bed, she would not have been able to get herself off the floor without staff assistance. LPN #190 confirmed there was no documentation related to Resident #44 falling or rolling out of bed. Interview on 07/10/23 at 3:04 P.M. of the Administrator and DON confirmed the bruising discovered on 06/08/23 was not reported to the Ohio Department of Health (ODH) as an injury of unknown origin because the facility conducted an investigation and concluded the bruising was consistent with the resident falling out of bed. The Administrator stated the facility did not believe the bruising met criteria for an injury of unknown origin because they believed Resident #44 had an unreported fall, which explained the cause of the injuries. While staff who had worked on the memory care unit in the 24 to 48 hours prior to the discovery of the bruises were interviewed, there was no evidence Resident #44 had a fall or rolled out of bed. The Administrator and DON stated the facility conducted an investigation and on 06/21/23, provided staff education on falls. Review of CALS (system for facility reporting of incidents) on 06/10/23 confirmed the facility did not report an injury of unknown origin for Resident #44. Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, revised 10/25/22, revealed an injury is classified as an injury of unknown (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 2 of 5 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 07/10/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few source when all the following conditions are met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Allegations involving neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source will be reported to the Ohio Department of Health immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00144354. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 3 of 5 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 07/10/2023 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 0610 Respond appropriately to all alleged violations. 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, observation, staff interview, and review of the facility investigation, the facility failed to obtain sufficient evidence to support the outcome of an investigation involving an injury of unknown origin. This affected one (Resident #44) of three residents reviewed for injuries. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #44's medical record revealed an admission date of 01/08/21. Diagnoses included Alzheimer's disease, contracture right knee, contracture left knee, dysphagia, muscle weakness, atrial fibrillation, hypertension, chronic kidney disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 was severely cognitively impaired, required extensive assistance with bed mobility, locomotion, dressing, and personal hygiene and required total dependence for transfers and toilet use. In addition, Resident #44 had no falls. Review of a plan of care focus area, revised 06/24/23, revealed Resident #44 was at risk for falls. Interventions included mat to floor next to bed, ensure the resident was wearing proper footwear, wheelchair for mobility, standing lift for transfers, call light in reach, and if resident falls, assess, treat any injury, and notify family and physician. Review of Fall Risk Screenings dated 04/03/23 and 07/04/23 revealed Resident #44 was at risk for falls with no falls during each of the previous 90 days. Review of a nursing progress note dated 06/08/23 at 8:43 A.M. revealed during morning care, a State Tested Nurse Aide (STNA) notified nursing of a large bruise to the resident's left shoulder, left top of hand, and bruising to her right thumb. Bruising was significant and from unknown origin. The resident stated she did not know how it happened and it was painful. The Director of Nursing (DON), family, and physician notified. Review of a nursing progress note dated 06/08/23 at 5:34 P.M. revealed a head-to-toe assessment was completed. Areas of concern were documented under new skin assessment. Review of a Nurse Practitioner (NP) progress note dated 06/08/23 revealed Resident #44 was seen for an acute visit due to new bruises and need to be evaluated for possible injuries. The resident had left palm dorsal surface bruise, right thumb bruise, and left shoulder bruise. No falls or injuries were reported. The resident denied pain and there were no signs of bone fractures. Review of a New Skin Observation Tool dated 06/08/23 revealed new bruising to left front shoulder, left top of hand, and right thumb. Cause is unknown. The resident was unable to tell writer cause. Will continue to monitor. All parties notified. Review of an Interdisciplinary Team (IDT) note dated 06/09/23 revealed on 06/08/23, Resident #44 presented with bruising and abrasions consistent with rolling out of bed. New intervention included mat to floor next to bed. Family and physician notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 4 of 5 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 (X3) DATE SURVEY COMPLETED A. Building 07/10/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 07/10/23 at 9:24 A.M. of Assistant Director of Nursing (ADON) #198 and STNA #108 assisting Resident #44 with transfer from bed to wheelchair, revealed STNA #108 assisted the resident with moving her legs over the side of the bed. ADON #198 and STNA #108 placed the lift sling around Resident #44 and connected the sling to the sit to stand lift. Utilizing the lift, STNA #108 provided Resident #44 with verbal cues to stand and STNA #108 guided the lift to the wheelchair while ADON #198 provided physical support to Resident #44. Interview at the time of the observation of ADON #198 and STNA #108 confirmed STNA #108 was the staff who noticed bruising on Resident #44 on the morning of 06/08/23. The source of the bruising was unknown. ADON #198 and STNA #108 were unaware of any falls or injuries that would have caused the bruising. Interview on 07/10/23 at 9:24 A.M. of the DON revealed bruising discovered on Resident #44 on 06/08/23 was consistent with the resident rolling out of bed and a new intervention to place a fall mat bedside was implemented. The DON confirmed, to the best of her knowledge, Resident #44 would have required assistance with getting up off the floor had she rolled out of bed and there were no reports the resident had fallen or rolled out of bed. Interview on 07/10/23 at 11:14 A.M. of Licensed Practical Nurse (LPN) #190 confirmed Resident #44 had bruising to her left hand, right thumb, and left shoulder. LPN #190 stated the bruise to the right thumb was bad. LPN #190 verified the source of the bruising was unknown. While LPN #190 stated it was possible Resident #44 could have rolled out of bed, she would not have been able to get herself off the floor without staff assistance. LPN #190 confirmed there was no documentation related to Resident #44 falling or rolling out of bed. Interview on 07/10/23 at 3:04 P.M. of the Administrator and DON confirmed the bruising discovered on 06/08/23 as an injury of unknown origin. The facility conducted an investigation and concluded the bruising was consistent with the resident falling out of bed. The Administrator stated the facility did not believe the bruising met criteria for an injury of unknown origin because they believed Resident #44 had an unreported fall, which explained the cause of the injuries. While staff who had worked on the memory care unit in the 24 to 48 hours prior to the discovery of the bruises were interviewed, there was no evidence Resident #44 had a fall or rolled out of bed. The Administrator and DON stated the facility conducted an investigation and on 06/21/23, provided staff education on falls. Review of the facility investigation, including five (STNA #181, STNA #108, LPN #193, LPN #190, and LPN #154) staff statements dated 06/08/23, revealed no evidence Resident #44 sustained a fall or had rolled out of bed. There were no additional investigations completed. This deficiency represents non-compliance investigated under OH00144354. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 5 of 5