Inspection·February 22, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a safe an orderly discharge. This affected one (Resident #65) of two residents reviewed for facility initiated discharges. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Former Resident (FR) #65 revealed an admission date of 12/20/23 and a discharge date of 02/13/24. Diagnoses included alcohol abuse, cocaine abuse, depression, transient cerebral ischemic attack, chronic obstructive pulmonary disease, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] for FR #65 revealed the resident was cognitively intact. FR #65 was independent to set-up/supervision for activities of daily living. Review of the care plan dated 01/05/24 for FR #65 revealed no care plan for behaviors/aggression or sexual misconduct. Review of the physician orders for FR #65 revealed 15-minute safety checks for behaviors, please call admin with any issues, Tylenol 325 milligrams (mg) every six hours as needed for pain, aspirin 81 mg daily, folic acid 1 mg daily, hydrocortisone (steroid) 10 mg daily, lasix (water pill) 20 mg daily, levothyroxine 25 mcg, magnesium oxide 400 mg daily (supplement), miralax 17 gm daily for constipation, multivitamin daily, omeprazole delayed release 20 mg (stomach), oyster shell calcium 500 mg daily, simvastatin 40 mg daily (cholesterol), thiamine 100 mg (alcohol abuse), trazodone 75 mg (sleeplessness), and ventolin inhalation 108 (90 base) mcg/act 2 puffs every six hours as needed . Review of progress notes revealed no documentation regarding an incident of sexual abuse regarding FR #65 reported on 02/03/24. Additionally, there was no documentation regarding the resident being discharged to the mission (homeless shelter). There was no documentation pertaining to the resident being discharged with medications or a follow up appointment with a primary care physician. Further review of progress notes revealed on 02/12/24, FR #65 had an altercation while in the dining room during mealtime with another resident. Residents were separated with no injuries noted. All parties updated. FR #65 was in good spirits and went on to finish his meal. FR #65 continued on with his usual daily activities with no evidence noted of physical or emotional distress. Review of the admission Agreement dated 12/20/23 revealed the resident was being conditionally admitted to the facility and agrees that, following 30 days written advance notice from the facility to the resident, the responsible party, and any government agencies when required by law, resident shall promptly remove himself or herself from the facility if such transfer or discharge is necessary because the safety and/or health of other residents is endangered. If arrangements are not timely made, then, following the giving of notice and compliance with other applicable regulatory requirements, the Administrator or any other designee of the facility is hereby granted the right to sign applications and any other necessary documents to admit resident to any suitable facility, local, state or otherwise, designated by the medical staff of the facility. Resident hereby agrees to assume full responsibility for the costs of the facility to which he or she is transferred, and that the facility shall have no financial responsibility in connection with any such costs. Interview on 02/20/24 at 11:15 A.M. with the Administrator revealed he was unaware FR #65 had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 2 of 7 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 365952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgewood Manor 3231 Manley Road Maumee, OH 43537 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 0624 Level of Harm - Minimal harm or potential for actual harm removed from a prior facility due to behaviors. The Administrator revealed while FR #65 was a resident at the facility, he became more aggressive towards other residents. The Administrator reported he started looking for placement after an incident on 02/03/24. The Administrator revealed the altercation on 02/12/24 was the last straw and they needed to get FR #65 out of the facility. The Administrator stated the resident was discharged back to the mission where he had stayed before. Residents Affected - Few Interview on 02/21/24 at 1:13 P.M. with State Tested Nursing Assistant (STNA) #616 verified FR #65 was independent for activities of daily living. STNA #616 verified they only sat with him while he took a shower and changed his sheets. STNA #616 verified FR #65 could walk and ambulate by himself. Interview on 02/21/24 at 2:15 P.M. with the Director of Nursing (DON) verified she was not a part of the discharge process for FR #65 and was not aware of any appointments set up for him with a primary care physician after discharge. The DON revealed FR #65 was cognitively intact and could have set them up for himself. The DON also verified FR #65 could walk but, he liked to be in the wheelchair and maneuver with his feet. The DON verified FR #65 was independent for activities of daily living and transfers. Interview on 02/21/24 at 3:45 P.M. with the Administrator and Assistant Director of Nursing (ADON) #649 verified the facility did not send any medications with FR #65 at discharge. Both verified the discharge summary for FR #65 revealed no prescriptions called to the pharmacy and no prescriptions were given to the resident or any follow-up appointment with a primary care physician was set up to obtain any prescriptions for medications. Review of policy titled, Discharging the Resident, revised December 2016 revealed no procedure noted for facility initiated discharges. This deficiency represents an incidental finding found over the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 3 of 7 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 365952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgewood Manor 3231 Manley Road Maumee, OH 43537 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, interview, medication admin audit report, and policy, the facility failed to administer medications in the time frame ordered by the physician. This affected twelve residents (#3, #8, #9, #10, #11, #16, #17, #18, #20, #23, #24, and #26) who resided on the north front hallway. The facility census was 64. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 01/30/24 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, type two diabetes, hypertension, cocaine abuse, and chronic pain. Review of the medication admin audit report dated 02/20/24 revealed antifungal powder two percent (%) for itching and Tylenol 325 milligrams (mg) two tablets for pain was given at 11:43 A.M. and was scheduled for 7:00 A.M. - 10:00 A.M. 2. Review of the medical record for Resident #8 revealed an admission date of 12/19/23 with diagnoses of COPD, repeated falls, bipolar, coronary artery disease, hyperlipidemia, anxiety, and major depressive disorder. Observation on 02/20/24 at 11:20 A.M. of medication administration for Resident #8 revealed the resident received airsupra aerosol 90-80 micrograms (mcg) two puffs for COPD, aripiprazole (bipolar) 15 mg, benzotropine (tremors) 0.5 mg, vitamin D 25 mcg five tablets, bupropion (depression) XL 300 mg, famotidine (stomach) 20 mg, folic acid 1000 mcg, isosorbide mononitrate ER (heart) 30 mg, oxybutynin ER (bladder) 15 mg, pantoprazole (stomach) 40 mg, vitamin B12 1000 mcg, clonazepam (bipolar) 1 mg, and ibuprofen 800 mg for pain. Medications were ordered for 7:00 A.M. - 10:00 A.M. and were administered at 11:30 A.M. 3. Review of the medical record for Resident #9 revealed an admission date of 01/21/24 with diagnoses including atrial fibrillation, type two diabetes, hypertension, and repeated falls. Review of the medication admin audit report dated 02/20/24 revealed clotrimazole cream 1% to groin, and lidocaine pain relief patch 4% to left shoulder on 12 hours and off 12 hours was applied at 11:51 A.M. and was scheduled for 7:00 A.M. - 10:00 A.M. 4. Review of the medical record for Resident #10 revealed an admission date of 07/19/23 with diagnoses including osteomyelitis, type two diabetes, alcohol abuse, and malignant neoplasm of transverse colon. Review of the medication admin audit report dated 02/20/24 revealed fluticasone nasal spray 50 mcg/act two sprays in both nostrils for allergies was administered at 11:56 A.M. and scheduled for 7:00 A.M. -10:00 A.M. 5. Review of the medical record for Resident #11 revealed an admission date of 12/08/23 with diagnoses including major depressive disorder, suicidal ideations, and hypertension. Review of the medication admin audit report dated 02/20/24 revealed lidocaine pain relief patch 4% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 4 of 7 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 365952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgewood Manor 3231 Manley Road Maumee, OH 43537 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 0755 to left shoulder was applied at 11:58 A.M. and was scheduled for 7:00 A.M.-10:00 A.M. Level of Harm - Minimal harm or potential for actual harm 6. Review of the medical record for Resident #16 revealed an admission date of 07/01/22 with diagnoses including COPD, cognitive communication deficit, diabetes, asthma, alcohol dependence, cocaine abuse, bipolar disorder, depression, and seizures. Residents Affected - Some Review of the medication admin audit report and Medication Administration Record (MAR) for 02/20/24 revealed keppra (seizure med) 1000 mg, losartan potassium (heart) 25 mg, ceririzine (allergies) 10 mg, apixaban (blood thinner) 5 mg, and oxybutynin (bladder) 10 mg were administered at 12:50 P.M. and scheduled for 7:00 A.M. - 10:00 A.M. 7. Review of the medical record for Resident #17 revealed an admission date of 10/18/23 with diagnoses including COPD, hypertension, malignant neoplasm of tongue and prostate, anxiety, and major depressive disorder. Review of the medication admin audit report and MAR for 02/20/24 revealed hydroxizine 25 mg (itching), atorvastatin 20 mg (cholesterol), incruse elipta 62.5 mcg/act (COPD), tamsulosin 0.4 mg (prostate), folic acid 1 mg, plavix 75 mg (blood), vitamin B12 100 mcg, volteran gel 75 mg to knees (pain), finasteride 5 mg (prostate), omeprazole 20 mg (stomach), losartan potassium 50 mg (heart), isosorbide mononitrate extended release 60 mg (heart), and sertraline 50 mg (depression) was administered at 12:27 P.M. and was scheduled for 7:00 A.M. - 10:00 A.M. 8. Review of the medical record for Resident #18 revealed an admission date of 09/29/23 with diagnoses including cerebrovascular disease, type two diabetes, COPD, dementia, hypertension, cocaine abuse, congestive heart failure, and syncope and collapse. Review of the medication admin audit report dated 02/20/24 revealed fluticasone nasal spray 50 mcg/act two sprays both nostrils, amlodipine 7.5 mg (heart), empagliflozin 12.5 mg (diabetes), metoprolol extended release 25 mg (heart) hold for blood pressure less than 100/60, and isosorbide mononitrate 25 mg (heart) hold for blood pressure less than 100/60 was administered at 12:44 P.M. and was scheduled at 7:00 A.M. 10:00 A.M. 9. Review of the medical record for Resident #20 revealed an admission date of 11/06/23 with diagnoses including Parkinson's disease, bipolar disease, schizophrenia, dementia, heart failure, and seizures. Review of the medication admin audit report dated 02/20/24 revealed triamcinolone 0.5 % cream to bilateral lower extremities and zinc oxide 10% ointment to bilateral buttocks was administered at 12:14 P.M. and scheduled for 7:00 A.M. - 10:00 A.M. 10. Review of the medical record for Resident #23 revealed an admission date of 01/23/24 with diagnoses including cerebral aneurysm, asthma, epilepsy, heart failure, anxiety, depression, migraine, and bipolar disorder. Review of the medication admin audit report dated 02/20/24 revealed magnesium oxide 400 mg, aspirin 81 mg, xarelto 20 mg (blood thinner), pantoprazole 40 mg, furosemide 20 mg (water pill), gabapentin 100 mg two capsules (pain), gabapentin 300 mg, keppra 1000 mg (seizures), lisinopril 5 mg (heart), lamictal 150 mg (seizures), and budesonide 0.5 mg/2 milliliters (ml) (asthma) was administered at 1:04 P.M. and was scheduled for 7:00 A.M. - 10:00 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 5 of 7 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 365952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgewood Manor 3231 Manley Road Maumee, OH 43537 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11. Review of the medical record for Resident #24 revealed an admission date of 01/29/24 with diagnoses including asthma, fusion of lumbar spine, mild cognitive impairment, fibromyalgia, major depressive disorder, anxiety, and hypertension. Review of the medication admin audit report dated 02/20/24 revealed cymbalta delayed release 20 mg (depression), ferrous sulfate 325 mg, fluticasone 50 mcg/act, zyrtec 10 mg (allergies), gabapentin 300 mg, tizanidine 4 mg (muscle spasms), furosemide 20 mg, and famotidine 20 mg was administered at 12:04 P.M. and was scheduled for 7:00 A.M. - 10:00 A.M. 12. Review of the medical record for Resident #26 revealed an admission date of 01/15/24 with diagnoses including cerebral infarction, hypertension, coronary artery disease, benign prostatic hypertrophy, and gastroesophageal reflux disease. Review of the medication admin audit report dated 02/20/24 revealed lidocaine pain patch 4% to right side on 12 hours and off 12 hours was applied at 1:58 P.M. and scheduled for 7:00 A.M. - 10:00 A.M. Interview on 02/20/24 at 11:05 A.M. with Licensed Practical Nurse (LPN) #626 verified the following residents had late medications: Resident #3, #8, #9, #10, #11, #16, #17, #18, #20, #23, #24, and #26. LPN #626 revealed the Nurse Practitioner (NP) was in the facility and she would have her look over late medications to see if they were ok to administer. Interview on 02/20/24 at 11:20 A.M. with LPN #626 verified she started passing late medications at 11:20 A.M. with surveyor observing. LPN #626 verified she still had eleven residents to pass morning medications to. Observation on 02/20/24 at 11:14 A.M. revealed the NP going through medications that were late and let LPN #626 know what medications to give. Some medications due at 2:00 P.M. were going to be held (not given) due to medications being late that morning. Review of the medication administration times revealed times 4:00 A.M. - 6:00 A.M., 5:00 A.M. - 7:00 A.M., 7:00 A.M. - 10:00 A.M., 10:30 A.M. - 12:30 P.M., 2:00 P.M. - 4:00 P.M., 4:00 P.M. - 6:00 P.M., 7:00 P.M. 11:00 P.M., and 12:00 A.M. Some medications are scheduled at 8:00 A.M. and 8:00 P.M. and 9:00 A.M. and 9:00 P.M. Review of the policy titled, Administering Medications revised December 2012 revealed medications must be administered in accordance with the orders, including any required time frame and medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). This deficiency represents non-compliance investigated under Complaint Number OH00151116. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 6 of 7 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 365952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgewood Manor 3231 Manley Road Maumee, OH 43537 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and policy review, the facility failed to ensure a medication error rate less than five percent with 13 medication errors out of 33 opportunities resulting in a medication error rate of 39.39%. This affected one (Resident #8) of four observed for medication pass. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed an admission date of 12/19/23 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), repeated falls, bipolar, coronary artery disease, hyperlipidemia, anxiety, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #8 required set-up/clean-up to supervision for activities of daily living. Observation on 02/20/24 at 11:20 A.M. of medication administration for Resident #8 revealed the resident received airsupra aerosol 90-80 micrograms (mcg) two puffs for COPD, aripiprazole (bipolar) 15 milligrams (mg), benzotropine (tremors) 0.5 mg, vitamin D 25 mcg five tablets, bupropion (depression) XL 300 mg, famotidine (stomach) 20 mg, folic acid 1000 mcg, isosorbide mononitrate ER (heart) 30 mg, oxybutynin ER (bladder) 15 mg, pantoprazole (stomach) 40 mg, vitamin B12 1000 mcg, clonazepam (bipolar) 1 mg, and ibuprofen 800 mg for pain. Medications were ordered for 7:00 A.M. - 10:00 A.M. and were administered at 11:30 A.M. (approximately at least an hour and a half late). Interview on 02/20/24 at 11:20 A.M. with Licensed Practical Nurse (LPN) #626 verified she started passing late medications at 11:20 A.M. with surveyor observing Resident #8 receiving medications late. Review of medication administration times revealed times 4:00 A.M. - 6:00 A.M., 5:00 A.M. - 7:00 A.M., 7:00 A.M. - 10:00 A.M., 10:30 A.M. - 12:30 P.M., 2:00 P.M. - 4:00 P.M., 4:00 P.M. - 6:00 P.M., 7:00 P.M. - 11:00 P.M., and 12:00 A.M. Some medications are scheduled at 8:00 A.M. and 8:00 P.M. and 9:00 A.M. and 9:00 P.M. Review of the policy titled, Administering Medications, revised December 2012 revealed medications must be administered in accordance with the orders, including any required time frame and medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). This deficiency represents non-compliance investigated under Complaint Number OH00151116 and is an example of continued noncompliance from the survey dated 01/25/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 7 of 7