Inspection·November 30, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 11/30/23 at 4:49 P.M. with Licensed Practical Nurse (LPN) #150 confirmed she contacted NP #200 following Resident #45's fall. LPN #150 verified NP #200 offered a telehealth visit due to the resident's previous fall injuries, but she did not have access to the telehealth software, had received no training on the telehealth software, and was unable to facilitate the visit. As a result, LPN #150 stated she declined the telehealth visit for NP #200 to assess Resident #45 after falling out of bed. LPN #150 stated she would appreciate the same treatment resources being available to agency staff as available to facility staff. This was an incidental finding discovered during the investigation of Complaint Number OH00148457. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 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 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, review of an Emergency Medical Services (EMS) Run Report and staff interview, the facility failed to ensure timely and accurate documentation in the resident medical record. This affected one (#46) of of three reviewed for change in condition. The facility census was 42. Findings include: Review of Resident #46's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), diabetes, atrial fibrillation, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #46 was cognitively impaired and required moderate partial assistance for mobility. Review of a nursing progress note, dated [DATE], revealed resident expired at 6:45 P.M. at the facility. The family, management staff and on-call Nurse Practitioner (NP) were informed and Resident #46's body was released to the funeral home. No additional information related to Resident #46's death was documented on [DATE]. Further review of a late entry nursing progress note, entered [DATE] for [DATE], revealed at 5:05 P.M., Licensed Practical Nurse (LPN) administered dinner medications and obtained the resident's blood sugar. The resident was sitting on the edge of the bed at that time with no complaints. At 5:40 P.M., State Tested Nurse Aide (STNA) informed the LPN the resident was not feeling well and wanted to see the nurse. The LPN was in the process of administering medications to another resident and stated she would be in shortly to see Resident #46. At 5:45 P.M., the LPN entered the resident's room. The resident was sitting in her reclining chair, leaning over to the left side. The nurse called out to the resident, without response, touched the resident's shoulder, without her becoming alert, and felt for a pulse at her wrist and throat, with no pulse noted. The LPN called a code. Unable to physically move Resident #46 from the recliner to the floor, the LPN pulled the resident into a flat position in the recliner and began to administer Cardiopulmonary Resuscitation (CPR). A second nurse arrived with the crash cart and assisted with moving the resident to the floor to continue CPR while the STNA contacted 911. CPR continued until EMS arrived at 6:05 P.M. and took over the resident's care. At 6:45 P.M., EMS informed staff they were discontinuing CPR and called time of death. Review of the EMS Run Report, dated [DATE], revealed dispatch received the call from the facility at 6:02 P.M., arrived to the facility at 6:11 P.M. and arrived to Resident #46's room at 6:12 P.M. The report revealed Resident #46 was found laying on the floor, receiving CPR from facility staff. Per facility staff, Resident #46 was last seen at 5:30 P.M. and found unresponsive at 6:00 P.M. Staff had been performing CPR for about 15 minutes. Resident #46 remained pulseless and apneic (not breathing) for the remainder of the code. Time of death was 6:42 P.M. Interview on [DATE] at 2:21 P.M., and follow-up interview at 5:50 P.M., with LPN #101 revealed she was Resident #46's assigned nurse on [DATE]. LPN #101 verified she did not enter a nursing progress note detailing the resident's change in condition and care provided on [DATE] until [DATE]. Additionally, LPN #101 verified the note entered on [DATE] for [DATE] was an estimated timeline of events, as best as she could remember, from the previous week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 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 366242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 4:35 P.M. with the Director of Nursing (DON) revealed she noticed the nurse had not documented the details of Resident #46's change in condition on [DATE] and requested she enter a note on her next shift. The DON verified progress notes should be entered timely to ensure an accurate timeline of events and the timeline provided in the progress note dated [DATE], five days after the event, did not match the time-stamped timeline in the EMS report. Residents Affected - Few This was an incidental finding discovered during the course of the investigation for Master Complaint Number OH00148499. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366242 If continuation sheet Page 4 of 4