Inspection·June 13, 2024

F 0908 exposing the attic wooden trusses to the resident smoke compartment. Level of Harm - Minimal harm or potential for actual harm an incorrectly sealed penetration was found in the south hall central area. A two foot by two-foot piece of drywall was loosely screwed into the ceiling and not into studs or sealed. Residents Affected - Many room [ROOM NUMBER] was found to have a four foot by eight-foot section of drywall ceiling water damaged and sagging with cracks along the seam. Interview on 06/06/24 at 8:00 A.M., with Director of Maintenance #364 verified the north hall central ceiling collapsed on 05/19/24. 3. Record review on 06/06/24 at 2:30 P.M., found no evidence of a notification verification (fax, email or phone call) notifying the Ohio Department of Health (ODH) of the facility being on fire watch. Interview on 06/06/24 at 3:00 P.M., with the Director of Operations #1 could not provide proof of ODH notification of the fire watch. The Director of Operations #1 revealed a notification may have called the EIDC number. The Director of Operations #1 verified no followed up with written confirmation or a call to the number in the fire watch policy. 4. Record review on 06/06/24 at 2:20 P.M., revealed gaps in the Fire Watch on 05/25/24 from 11:00 P.M. until 8:45 A.M., on 05/26/24 for the north side of the building; and from 7:15 A.M. until 8:45 A.M. for the south side of the building, from 10:15 P.M. until 10:45 P.M. On 05/26/24, there were gaps in the watch for the south side of the building, from 10:15 P.M. until 10:45 P.M.; on 05/27/24, for the north side of the building and from 6:00 A.M. until 6:45 A.M.; on 05/29/24, for the south side of the building. Further review of the Fire Watch logs revealed two different watch sheets documented for the facility from 05/30/24 at 11:00 P.M. until 6:45 A.M. on 05/31/24; two different watch sheets documented on 05/25/24 for the north side of the building; two different watch sheets on 05/26/24 for the south side of the building; and two different watch sheets documented for the north side of the building on 06/02/24. Interview on 06/06/24 at 12:00 P.M., with ADON #505 verified the Fire Watches are being completed on the nursing units, offices, laundry, the kitchen and other nonpatient care areas are not being monitored during the 15-minute checks. ADON #505 stated maintenance and electrical rooms are locked, and the staff do not have keys. Interview on 06/06/24 at 3:00 P.M., with the Director of Operations #1 verified the missing Fire Watches and was unable to explain why there were two different documented fire watch logs for 05/25/24, 05/26/24, 05/30/24 and 06/02/24. The Director of Operations #1 further verified the Fire Watches being conducted included only patient care areas, the kitchen, dietary, laundry rooms, offices, mechanical and electric rooms were not being checked as the staff do not have keys to those areas and cannot observe them. Review of the undated policy titled Fire Watch stated the facility will incorporate a plan of action anytime the fire alarm or sprinkler system is not functioning, such as a malfunction or service/repair. Anytime this condition exists a fire watch will promptly be implemented. A fire watch is a periodic walking tour of the entire facility with direct observation of all rooms for signs of a fire. The Executive Director, Director of Clinical Services and Maintenance are to be contacted anytime the fire panel or sprinkler system malfunctions or is out of service for any reason. The Fire (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 2 of 6 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 06/13/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Department is to be notified if the fire protection system is not working completely. If the sprinkler or fire system is inoperable for a time period of more than 4 hours in a 24-hour period, notify the Department of Health District Office. The Fire Watch procedure will be performed by personnel solely dedicated to the fire watch and no other facility related activities. The personnel assigned to the Fire Watch will tour the facility, performing fire watch duties in all areas of the building and will keep a written log which records 15-minute intervals for all areas inspected, and the employees initials completing the 15-minute round. Fire Watch should occur 24 hours a day and should include a check on resident rooms, dietary and laundry rooms, mechanical and electric rooms. Review of the Facility Assessment, dated 05/03/24, stated the physical environment, the building and plant needs will be maintained to protect and promote the health and safety of residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00154624. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 3 of 6 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 06/13/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility assessment, the facility failed to maintain a safe and clean environment after the facility had a water leak causing damage. This has the potential to affect all residents in the facility. The facility census was 52. Findings include: Observation on 06/06/24, during the initial tour of the facility, between 6:45 A.M. and 7:30 A.M., revealed a missing section of the ceiling on the north hall approximately 8 feet wide by 8 feet long with plastic stabled loosely to the exposed wood trusses, an area approximately two feet wide by two feet long with loosely screwed drywall to a patched ceiling in the south hall just inside the fire doors and in room [ROOM NUMBER], several bath towels with brownish-yellow dried discoloration were noted on the floor of the unoccupied room (215), below a sagging ceiling with deep cracks approximately four feet wide by eight feet long. Interview on 06/06/24 at 12:00 P.M., with the Assistant Director of Nursing (ADON) #505 revealed the ceiling in room [ROOM NUMBER] started to leak after the sprinkler system was shut down and residents had to be moved. Additional observations on 06/06/24, during a facility tour, between 2:50 P.M. and 3:24 P.M., with the Director of Operations #1, verified the environment was in disrepair in the following locations: • an eight foot by eight-foot section of drywall was missing from the north hall central ceiling exposing the attic wooden trusses to the resident smoke compartment. • an incorrectly sealed penetration was found in the south hall central area. A two foot by two-foot piece of drywall was loosely screwed into the ceiling and not into studs or sealed. • room [ROOM NUMBER] was found to have a four foot by eight-foot section of drywall ceiling water damaged and sagging with cracks along the seam. Interview on 06/06/24 at 8:00 A.M., with Director of Maintenance #364 verified the north hall central ceiling collapsed on 05/19/24. Review of the Facility Assessment, dated 05/03/24, stated the physical environment, the building and plant needs will be maintained to protect and promote the health and safety of residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00154624 and Complaint Numbers OH00154571, OH00154576, OH00154189 and OH00154234. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 4 of 6 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 06/13/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, staff interview, review of facility assessment, review of the housekeeping daily cleaning reports, and review of the exterminator inspection report, the facility failed to maintain an effective pest control program. This directly affected one resident (#51) with the potential to affect all residents of the facility. The facility census was 52. Residents Affected - Many Findings include: Observation on 06/06/24 at 8:45 A.M., during the tour of the facility, revealed a snap trap (mouse trap) on the floor in the office of the Minimum Data Set (MDS) Nurse #500. The snap trap was along the wall on the left side of the office as you entered. Interview with the MDS Nurse #500, at the time of the observation, verified mice were seen in the building over the weekend of June 1st and June 2nd, 2024. MDS Nurse #500 added he killed a mouse earlier in the week in the office and have seen mice in the therapy room. Interview on 06/06/24 at 9:05 A.M., with Occupational Therapist #501 in the therapy room verified mice have been seen in the therapy room this week and a snap trap is placed each night in the room prior to leaving. Occupational Therapist #501 stated no mice have been caught in the trap. Observation on 06/06/24 at 9:45 A.M., of Resident #51's room revealed a dead gnat on the window ledge, two dead earwigs on the floor to the right of the bed. Interview with Resident #51, at the time of the observation, revealed a mouse was seen inside the resident's room over the past weekend. Resident #51 stated gnats, earwigs and centipedes have been seen in her room for several weeks. Resident #51 stated the facility offered to move rooms, however Resident #51 does not want to move rooms, just wants the bugs and rodent issue resolved. Resident #51 added inability to sleep at night due to the bugs. Resident #51 stated the bugs can be felt crawling on her and due to not being able to see them, Resident #51 is not sleeping at night. Resident #51 stated a collection of bugs were provided to the Director of Maintenance #364 in a cup and was told an exterminator would be in. Resident #51 stated no exterminator has been in to treat the room. Observation on 06/06/24 at 12:30 P.M. and again at 3:30 P.M., with the Executive Director present revealed black ants crawling on the conference room table. The Executive Director verified, at the time of the observation at 3:30 P.M., the black ant on the conference room table. Interview on 06/06/24 at 3:30 P.M., with the Director of Maintenance (DM) #364 revealed bugs have been reported in Resident #51's room and an exterminator is scheduled to be out on 06/07/24. Interview on 06/10/24 at 11:40 A.M., with Resident #51 revealed no exterminator came in on 06/07/24 to treat the room. Interview on 06/10/24 at 11:50 A.M., with DM #364 stated awareness of concerns related to bugs in Resident #51's room, DM #364 verified the exterminator did not come on Friday, 06/07/24 but is scheduled to come on 06/12/24. Review of the exterminator invoice dated 04/10/24 revealed fruit flies in the kitchen and ants in resident rooms on the 100 hall. Review of the exterminator invoice dated 05/08/24 revealed heavy fly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 5 of 6 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 06/13/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many activity in the kitchen. Open conditions listed on both the 04/10/24 and 05/08/24 invoices revealed the facility was not rodent proof due to the lobby entry doors having a gap between them at the bottom to allow rodents to enter, holes in the roof and soffit areas to allow for pest entry, employee hallway doorframe rusting out creating gaps on the side allowing for pests to enter, gap between the doors on the dining room door to the courtyard allowing for pest to enter and missing floor tiles in the kitchen collecting water for a potential fly breeding area. Further review of the exterminator invoice dates 05/24/24 recommended mice traps be placed in the drop the ceiling, which was declined due to work being completed in the area. Many other areas were unable to be serviced due to service animals present. The exterminator invoice dated 05/28/24 revealed several mice were captured. On 05/30/24 the Executive Director stated no further extermination visits were necessary. Open building conditions stating the facility was not rodent proof remained open on the 05/30/24 invoice. Review of the housekeeping daily cleaning for June 2024 revealed ants were cleaned up from the dining room. Review of the Facility Assessment, dated 05/03/24, stated the physical environment and physical plant is maintained to protect and promote the health and safety of residents. This deficiency represents non-compliance investigated under Complaint Numbers OH00154571, OH00154576, OH00154189, and OH00154234. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 6 of 6