Health inspection·August 13, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/09/21 at 2:44 P.M. of Resident #13's room revealed a sign hanging on the resident's shelves, visible from the hall, which read SHOES Please keep shoes off floor so [resident] can reach. Interview on 08/09/21 at 2:58 P.M. with Licensed Practical Nurse (LPN) #449 verified the sign in Resident #13's room. LPN #449 stated the sign was placed by therapy to remind staff to keep Resident #13's shoes up because the resident would lean over to pick them up and fall. Interview on 08/10/21 at 2:02 P.M. with Clinical Support Resident Assessment (CSRA) #488 revealed signs placed in resident rooms were provided as reminders to residents for various reasons, such as to use their walker. The signs were discussed with residents and representatives and were care planned. CSRA #488 verified the signs in Residents #39 and #13 were written as instructions to staff on care needs of residents and not as reminders to residents. Review of facility policy titled Resident Rights Guidelines, revised 05/11/17, revealed residents have a right to be treated with dignity, respect and privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 2 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, and review of facility policy, the facility failed to complete a self-administration of medication assessment, and failed to obtain a physician orders for a resident who preferred to have medications left at bedside. This affected one (#9) resident reviewed for self-administration of medication. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 04/06/18 and a readmission date of 01/22/21. Diagnoses included hypertensive heart disease, end stage renal disease, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/10/21, revealed Resident #9 was cognitively intact. Additional review of Resident #9's medical record revealed no evidence of a self-administration of medication assessment, a physician order for self-administration of medication, and there was no plan of care interventions for self-administration of medication. Observation on 08/09/21 at 10:13 A.M. of Resident #9's room revealed a medication cup on the resident's tray table with four pills in the cup. Interview with Resident #9 at the time of the observation revealed the pills were prescription medications that were left on her tray table by the nurse. Resident #9 stated the nurse was called away before she was able to take them all. Resident #9 picked up the medications and took them. Interview on 08/09/21 at 10:16 A.M., Licensed Practical Nurse (LPN) #449 verified she left Resident #9's medications in her room. LPN #449 stated Resident #9 did not like to take all of her medications at one time because they caused her to have an upset stomach. LPN #449 stated she always went back to the resident's room to make sure she took them. Interview on 08/10/21 at 10:47 A.M., the Director of Nursing (DON) revealed the facility did not have any residents who self-administered medications. The DON stated a self-medication assessment would be completed in the resident's medical record if they were able to self-administer medications. The DON verified Resident #9's medical record did not contain a self-medication assessment. Interview on 08/12/21 at 7:25 A.M. with Resident #9 revealed she preferred to have nursing leave her medications in her room so she could take them one or two at a time. Resident #9 stated taking too many medications at once upset her stomach and the nurses would frequently leave her medications with her in her room. Review of facility policy titled Guidelines for Self-Administration of Medications, revised 05/22/18, revealed residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record (EHR). Results of the assessment will be presented to the physician for evaluation and an order for self-medication. Additionally, medication will be kept in a locked drawer in the resident's room, the self-medication plan of care will be initiated and updated as indicated and the assessment will be documented in the EHR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 3 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 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 Based on observation, medical record review, and resident and staff interview the facility failed to assist residents with shaving. This affected two (#2 and #50) of two residents reviewed for grooming. The facility census was 56. Residents Affected - Few Findings include: 1. Review of Resident #2's medical record revealed an admission date of 12/18/20 and a readmission date of 07/09/21. Diagnoses included fracture of neck of right femur, chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, macular degeneration; and disorientation. Review of the significant change in status Minimum Data Set (MDS) assessment, dated 07/19/21, revealed Resident #2 was moderately cognitively impaired, rejection of care occurred one to three days of the seven day look back period and the resident required extensive two person assistance with personal hygiene. Review of the plan of care, initiated 12/29/20, revealed Resident #2 required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Review of the Point of Care (POC) documentation and progress notes in the electronic health record (EHR) from 07/13/21 to 08/10/21 revealed Resident #2 had no refusals of care documented Observation on 08/09/21 at 9:49 A.M. of Resident #2 revealed significant hair growth on her chin. Interview of Resident #2 at the time of the observation revealed she required assistance with shaving and would like to have her chin shaved. Resident #2 was unsure when she was last assisted with shaving and stated staff told her they would assist her today. Interview on 08/09/21 at 3:38 P.M. with Licensed Practical Nurse (LPN) #449 verified Resident #2 had not been assisted to shave and had significant hair growth on her chin. LPN #449 stated she was unsure when the resident was last assisted to complete this task and Resident #2 sometimes refused care. Observations on 08/10/21 from 7:02 A.M. to 11:59 A.M. of Resident #2 revealed she still had significant hair growth on her chin. Interview on 08/10/21 at 11:29 A.M. with the Director of Nursing (DON) verified Resident #2's electronic health record (EHR) was silent for documentation of refusals of care. Interview on 08/10/21 at 11:59 A.M. of LPN #404 verified Resident #2 had not been assisted with shaving. LPN #404 stated Resident #2 sometimes refused care but, generally, if staff re-approached later, the resident may accept assistance. LPN #404 stated she was unsure when Resident #2 was last assisted to shave. Interview on 08/10/21 at 4:09 P.M. with State Tested Nurse Aide (STNA) #441 revealed Resident #2 could be resistive to care but usually if re-approached, even a couple of hours later, she was more accepting of assistance with care. STNA #441 stated any refusals of care should be documented in the comments section of the POC STNA documentation in the Resident's EHR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 4 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 2. Review of Resident #50's medical record revealed an admission date of 04/15/21. Diagnoses included type two diabetes mellitus, Parkinson's disease, heart failure, chronic kidney disease stage 3, major depressive disorder, and altered mental status. Review of the quarterly MDS assessment, dated 07/17/21, revealed Resident #50 was moderately cognitively impaired. Resident #50 was an extensive, one person assist with personal hygiene. Observation on 08/09/21 at 9:51 A.M. of Resident #50 revealed facial hair on the face and neck. Interview on 08/09/21 at 9:54 A.M. with Resident #50 revealed the facial hair was itching him and would like for it to be shaved. He stated it has been a few weeks since his facial hair had been trimmed or shaved. Interview on 08/10/21 at 11:29 A.M. with Resident #50 revealed no one has offered to shave or trim his facial hair. Interview on 08/10/21 at 11:36 A.M. with LPN #486 verified Resident #50 required assistance with shaving. Interview on 08/10/21 at 11:41 A.M. with STNA #442 verified Resident #50 required assistance with shaving. STNA #442 revealed shaving Resident #50 a few weeks ago and did not know if Resident #50 had been shaved since that time. Interview on 08/10/21 at 11:45 A.M. with STNA #442 and Resident #50 verified his facial hair is long and over due to be shaved or trimmed. Resident #50 stated it had been a few weeks or longer. Interview on 08/11/21 at 9:29 A.M. with Resident #50 again revealed no one has offered to shave or trim his facial hair. Interview on 08/11/21 at 1:02 P.M. with STNA #472 verified Resident #50 required extensive assistance with shaving facial hair. Observation on 08/12/21 at 9:50 A.M. of Resident #50 revealed no changes to the facial hair on the face and neck. Interview on 08/12/21 at 9:52 A.M. with Resident #50 revealed no one has offered to shave or trim his facial hair. Resident #50 reported the facial hair is very itchy and he wanted to be shaved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 5 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and resident and staff interviews, the facility failed to provide assistance to repair or replace broken glasses for one (Resident #50) of one resident reviewed for vision. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #50's medical record revealed an admission date of 04/15/21. Diagnoses included type two diabetes mellitus, Parkinson's disease, heart failure, chronic kidney disease stage 3, major depressive disorder single episode, and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/17/21, revealed Resident #50 was moderately cognitively impaired. Resident #50's vision was highly impaired. Observation on 08/09/21 at 9:51 A.M. of Resident #50 wearing broken eyeglasses with the left lens completely missing. Interview on 08/09/21 at 9:54 A.M. with Resident #50 revealed his eyeglasses had been broken for a long time, possibly prior to admission to the facility. Resident #50 was not aware of having access to an optometrist or having his eyeglasses fixed. Resident #50 reported no one had inquired regarding his vision needs. Interview on 08/12/21 at 12:59 P.M. with Clinical Support Resident Assessment (CSRA) #488 revealed the facility does not have information whether Resident #50 was admitted with broken glasses, if the glasses broke recently or if the resident had refused vision services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 6 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure an air mattress was in place and functioning for a resident with a pressure ulcer. The affected one (#7) of one resident reviewed for pressure ulcers. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record for the Resident #7 revealed an admission date of 04/16/21. Diagnoses included gastro paresis, chronic obstructive pulmonary disease, and type II diabetes. Resident #7 had an unstageable pressure ulcer to the left hip present upon admission. Review of the minimum data set (MDS) assessment, dated 08/03/21, revealed has unhealed pressure, pressure reducing device to bed. Review of the order dated 04/16/21 revealed order for air mattress. On 05/04/21 the resident readmitted from the hospital with pressure wound to the left hip and right heel ulcer. Review of the care plan 05/14/21 revealed Resident #7 has left hip pressure ulcer. Interventions included the use of pressure reducing mattress. Review of the current skin assessments revealed the left hip ulcer to be improving and the right heel ulcer to be healed. This was verified with Registered Nurse (RN) #425. RN #425 revealed the air mattress is to be on at all times. Observation of Resident #7's wound care on 08/11/21 7:53 A.M. revealed the resident lying in bed with the air mattress deflated. This was verified with Registered Nurse (RN) #425. RN #425 revealed the air mattress is to be on at all times. She didn ' t know how it got turned off but could have been when he was last changed and repositioned. Review of the facility policy titled Guidelines for General Wound and Skin Care, dated 08/01/16, revealed to provide measures to promote and maintain good skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 7 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 observation, medical record review, resident and staff interview and review of facility policy, the facility failed to ensure medications were not left unattended at resident bedside and failed to maintain a safe environment as care planned for fall prevention. This affected three residents (#11, #13 and #29) who were identified by the facility as being cognitively impaired, independently mobile, and one (#2) of two residents reviewed for fall precautions. The facility census was 56. Findings include: 1. Observation on 08/09/21 at 10:13 A.M. of Resident #9's room revealed a medication cup on the resident's tray table with four pills in the cup. Interview Resident #9 at the time of the observation revealed the pills were prescription medications that were left on her tray table by the nurse. Resident #9 stated the nurse was called away before she was able to take them all. Resident #9 picked up the medications and took them. Interview on 08/09/21 at 10:16 A.M. with Licensed Practical Nurse (LPN) #449 verified she left Resident #9's medications in her room. LPN #449 stated Resident #9 did not like to take all of her medications at one time because they caused her to have an upset stomach. LPN #449 stated she always went back to the resident's room to make sure she took them. The facility identified three residents (#11, #13 and #29) who as being cognitively impaired, independently mobile and resided on the same unit as Resident #9. 2. Review of Resident #2's medical record revealed an admission date of 12/18/20 and a readmission date of 07/09/21. Diagnoses included fracture of right femur, spinal stenosis, schizophrenia, bipolar disorder, orthostatic hypotension; macular degeneration; and disorientation. Review of the Minimum Data Set (MDS) assessment, dated 07/19/21, revealed Resident #2 was moderately cognitively impaired. The resident required extensive two person assistance with bed mobility, transfers and personal hygiene and extensive one person assistance with dressing and toilet use. There was a history of a fall with injury. Review of the plan of care, initiated 12/29/20, revealed Resident #2 was at risk for falling related to weakness, incontinence, history of falls, psychotropic medication use, orthostatic hypotension and recent right femur fracture. Interventions, with the initiated dates, included: 12/29/20 ensure the floor is free of liquids and foreign objects, 03/09/21 room was rearranged for increased mobility, 06/29/21 Resident's recliner was decluttered to allow her to sit in it, and 07/20/21 re-arrange the room. Observation on 08/09/21 at 9:49 A.M. of Resident #2's room revealed a fall mat next to the resident's bed. Next to the fall mat, pushed against the front of the resident's recliner, were three boxes, a pillow and two grocery store bags with items in them. There was approximately a six inch space between the fall mat and the boxes in order to walk through the area. Interview of Resident #2 at the time of the observation revealed she was not able to safely get out of her bed. Resident #2 stated the mat and boxes were ridiculous and the nursing staff were not able to walk through without tripping. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 8 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 Interview on 08/09/21 at 3:38 P.M. with Licensed Practical Nurse (LPN) #449 verified the boxes, pillow and grocery store bags with items in them pushed against Resident #2's recliner. LPN #449 stated Resident #2's family brought the boxes, containing personal items, and dropped them off without organizing the contents. LPN #449 stated she was not sure how long the boxes had been in the room or when they were going to be moved. Residents Affected - Some Interview on 08/10/21 at 11:29 A.M. of the Director of Nursing (DON) revealed Resident #2 had a fall on 07/06/21, resulting in a fractured hip. Upon the Resident's return from the hospital on [DATE], Resident #2 was moved to a room where staff could provide closer supervision. The DON stated the boxes were items that had been moved from the resident's previous room. The family had been contacted to pick them up, but the resident's son was unresponsive to the request. Interview on 08/10/21 at 11:59 A.M. LPN #404 revealed Resident #2 often attempted to get out of bed unassisted and walk or crawl on the floor in her room. Review of facility policy titled Fall Management Program Guidelines, revised 05/31/17, revealed the purpose was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. In addition, care plan interventions should be implemented that address the resident's risk factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 9 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 Based on medical record review, staff interview, and review of facility policy, the facility failed to follow physician orders for obtaining a resident's weekly weight to monitor nutritional status. This affected one (#9) resident reviewed for physician orders. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 04/06/18 and a readmission date of 01/22/21. Diagnoses included hypertensive heart disease with heart failure, end stage renal disease, and type II diabetes mellitus. The resident received hemodialysis three times a week. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/10/21, revealed Resident #9 was cognitively intact. Review of the plan of care, initiated 02/13/20, revealed Resident #9 was malnourished/at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and or/metabolic demands. Interventions included obtain weight as ordered/needed. Review of a physician order, dated 02/28/20, for Resident #9 revealed an order for weekly weight on Tuesdays, 6:00 A.M. to 6:00 P.M. Review of Medication Administrator Record (MAR) from June 2021 to August 2021 revealed Resident #9 was unavailable for the weekly weight on the following dates and times: 06/08/21 at 7:08 A.M.; 06/15/21 at 8:25 A.M.; 06/29/21 at 8:07 A.M.; 07/06/21 at 8:00 A.M.; 07/13/21 at 7:57 A.M.; 07/27/21 at 7:27 A.M.; and 08/03/21 at 7:24 A.M. Interview on 08/10/21 at 11:35 A.M. with Licensed Practical Nurse (LPN) #404 verified Resident #9 was out of the facility on Tuesdays, Thursdays and Saturdays from approximately 7:45 A.M. to 12:00 P.M. each week for dialysis. Interview on 08/12/21 at 7:00 A.M. with the Director of Nursing (DON) verified Resident #9 had an order for weekly weights. Documentation on the MAR indicated the Resident was unavailable on Tuesdays for the weekly weight and weights were not done as ordered. The DON verified Resident #9 was out of the facility at the time of the documentation on the MAR but the order was written for weights to be completed on the day shift and could have been taken at anytime from 6:00 A.M. to 6:00 P.M. The DON verified there was no documentation weights were attempted at any other time on the indicated Tuesdays except during the early morning when Resident #9 was out of the facility for dialysis. Review of facility policy titled Guidelines for Weight Tracking, revised 05/22/18, revealed the purpose was to ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration. Additionally, resident weights would be taken and recorded monthly or as indicated or ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 10 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure residents were educated and offered access to routine dental care. This affected one (Resident #15) of one residents reviewed for dental care in a skilled nursing facility. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #15 medical record revealed an admission date of 06/03/21. Diagnoses included Parkinson's disease, hypertensive heart disease with heart failure, hypothyroidism, hyperlipidemia, dysarthria and anarthria, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 06/06/21, revealed Resident #15 was cognitively intact. No dental concerns were identified. Interview on 08/09/21 at 3:30 P.M. with Resident #15 revealed the resident had a desire to schedule with a dentist and did not know there was access to a dentist through the facility. Resident #15 revealed for a variety of reasons she had not been to the dentist for a couple of years and would like to have her natural teeth checked. Resident #15 indicated the facility had not informed her of the availability of dental services. Interview on 08/12/21 at 12:59 P.M. with Clinical Support Resident Assessment (CSRA) #488 revealed the facility does not have any information that Resident #15 was educated and either offered or declined dental services following admission. Review of facility policy titled Dental Services Including Repair and Replacement, effective 11/08/17, verified the facility will assist residents in obtaining routine and emergency dental care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 11 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure residents were educated and offered access to replace missing dentures. This affected one (Resident #50) of one residents reviewed for dental care in a nursing facility. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #50's medical record revealed an admission date of 04/15/21. Diagnoses included type two diabetes mellitus, Parkinson's disease, stage 3 chronic kidney disease, major depressive disorder, gastro-esophageal reflux disease, altered mental status, and dysphagia oropharyngeal phase. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/17/21, revealed Resident #50 was moderately cognitively impaired. Interview on 08/09/21 at 9:54 A.M. with Resident #50 revealed he had dentures but had lost them prior to entering the facility. Resident #50 was not aware a dentist came to the facility and does not recall having been informed or provided the opportunity to have his dentures replaced. Interview on 08/12/21 at 12:59 P.M. with Clinical Support Resident Assessment (CSRA) #488 revealed the facility does not have information whether Resident #50 ever had dentures. The facility does not have documentation of Resident #15 being educated and either offered or declined dental services to aid in replacing his missing dentures. Review of facility policy titled Dental Services Including Repair and Replacement, effective 11/08/17, verified the facility will assist residents in obtaining routine and emergency dental care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 12 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to change contaminated gloves before touching food items when serving resident meals. This had the potential to affect all residents who received food from the kitchen. Resident #7 was identified by the facility as receiving nothing by mouth. The facility census was 56. Findings include: Observations on 08/09/21 from 11:40 A.M. to 11:55 A.M. of lunch service revealed Dietary Aide (DA) #478 plating resident meals. DA #478 gloved her hands, picked up a plate, touched the serving utensils for the chopped steak, mashed potatoes and California blend vegetables. Then without changing the gloves, picked up a dinner roll with a gloved hand and placed the roll on a plate. DA #478 repeated this process ten times without changing her gloves. In addition, observation of DA #464 revealed she donned gloves and proceeded to touch serving tongs, french fries, a metal pan, opened a refrigerated drawer, and then picked up a hot dog and placed it on the grill. DA #464 then removed her gloves and donned a new pair. DA #464 picked up a loaf of bread, reached inside and removed two slices of bread, buttered the bread and placed the bread on the grill on the grill. Without changing her gloves DA #464 opened a refrigerated drawer and removed slices of deli meat with her gloved hand, placed the deli meat on the grill, opened a refrigerator and removed a package of sliced cheese and a bottle of salad dressing. DA #464 then opened the package of cheese and removed a slice. DA #464 then removed her soiled gloves and donned a clean pair. DA #464 placed the cheese slice on the deli meat on the grill, opened a refrigerated drawer, picked up fish fillets and placed them on the grill and then removed her gloves and donned a new pair. Interview, at the time of the observation with Dietary Manager (DM) #461 and Assistant Dietary Manager (ADM) #490 verified DAs #478 and #464 touched food and non-food items using the same gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 13 of 14 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 366452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Sylvania, The 5351 Mitchaw 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the COVID-19 screening log, staff interview, and review of the facility policy, the facility failed to ensure proper screening procedures were in place for to assess visitors entering the facility for signs and symptoms of COVID-19. This had the potential to affect all 56 residents residing in the facility. Additionally, the facility failed to properly clean, sanitize and, store bed pans in resident bathrooms. This affected two (#33 and #41) residents, who reside in the same resident room. The facility census was 56. Residents Affected - Many Findings include: 1. Observation on 08/12/21 at 8:15 A.M. revealed the front entrance door was unlocked, allowing outside persons entrance to the building. Once inside, a posted sign indicated visitors are to be screened for signs and symptoms of COVID-19. No staff were available to provide visitor screening for signs and symptoms of COVID-19, allowing visitors to enter building unscreened. Review of the COVID-19 screening log revealed four visitor entries without initials, indicating screening was completed by staff. Interview on 08/12/21 at 8:50 A.M., with Director of Nursing (DON) revealed the business office staff screen visitors for signs and symptoms of COVID-19 upon entrance. Review of facility policy titled Guidelines for COVID-19, dated 03/11/20, revealed precautionary measures taken in all campuses included complete infection control education and screening questionnaires for all employees, visitors, outpatients, and contractors who attempt to enter the campus. The screening will include temperature monitoring. The facility should have designated campus employee at main entrance providing education and screening. 2. Observation on 08/09/21 at 11:00 A.M., of Resident #33 and #41's bathroom revealed two soiled bed pans filled with fluid stacked on top of each other on the bathroom floor. This was verified at the time of the observation with State Tested Nursing Assistant (STNA) #410. STNA #410 revealed bed pans were to be sanitized and placed in a plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366452 If continuation sheet Page 14 of 14