Inspection visit
Inspection
22 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 22 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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, resident and staff interview, review of medical records, review of a behavior contract, review of
facility equipment logs, and review of facility policies, the facility failed to ensure emergency crash carts
were completely stocked per facility policy. This had the potential to affect 33 (#1, #3, #4, #5, #10, #12, #13,
#14, #16, #17, #18, #19, #20, #21, #23, #24, #27, #28, #29, #30, #31, #32, #33, #35, #38, #39, #40, #41,
#44, #45, #46, #48, and #50) residents identified by the facility as being full code (the resident wishes to
receive resuscitation and all live saving measures in the event of a cardiac or respiratory arrest). In addition,
the facility failed to ensure smoking materials were stored safely for one (#28) of one residents reviewed for
smoking and failed to ensure one (#43) of one residents reviewed for accidents and hazards was
transferred with the appropriate level of assistance to prevent falls. The facility census was 44.
Findings Include:
1. Interview and observation on 12/18/24 at 2:21 P.M. of the emergency crash cart at the North nurse's
station with Licensed Practical Nurse (LPN) #702 revealed no oxygen tubing and no oxygen mask were
available in the cart. Additionally, LPN #702 confirmed the oxygen tank was empty, but stated the regulator
needed to be adjusted to show if there was oxygen available.
Continued observation on 12/18/24 at 2:27 P.M. revealed LPN #702 and Registered Nurse (RN) #515
attempting to adjust the regulator and determine if oxygen was in the tank.
Interview on 12/18/24 at 2:29 P.M. with RN #515 confirmed they could not determine if the oxygen tank
located with the crash cart contained oxygen. RN #515 stated if she needed oxygen she would go to the
closet located inside the dining room to get another tank.
Interview and observation on 12/18/24 at 2:33 P.M. with RN #515 of the crash cart at the South nurse's
station revealed no oxygen tank was with the cart. RN #515 confirmed no oxygen tank was with the cart.
Continued observation on 12/18/24 at 2:33 P.M. revealed RN #515 could not unlock or open the crash cart.
Corporate Risk Management Nurse (CRMN) #700 approached the cart and attempted to open it. After
several attempts, CRMN #700 was able to turn the key and successfully open the cart. CRMN #700 noted
something was jammed against the inside lock causing the delay in accessing the cart. CRMN #700
demonstrated hidden levers on every drawer required sliding before the drawers would open.
Observation and interview on 12/18/24 at 3:53 P.M. with LPN #701 revealed she could not open the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
365952
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
12/19/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
crash cart at the South nurse's station. LPN #701 turned the key but was unable to open the drawers of the
cart. LPN #701 further confirmed she could not find the crash cart checklist. LPN #701 stated she
previously worked in the facility on night shift and stated the night shift nurse was responsible for
conducting a nightly inventory on the crash cart.
Interview on 12/19/24 at 9:02 A.M. with the Director of Nursing (DON) confirmed she could not find the
crash cart book for the South nurse's station crash cart.
Review of the document titled, Crash Cart Equipment, revealed a list of all items to be included in the crash
cart. Review of the Crash Cart Equipment form from the notebook with the North nurse's station crash cart
revealed all items were present in the crash cart on 12/16/24, including an oxygen mask and a full oxygen
tank.
Review of the policy titled, Emergency Crash Cart, copyright 2024, revealed the emergency crash cart is
checked every 24 hours and after every use. Additionally, equipment/supplies used from the emergency
crash cart are noted and replaced promptly.
2. Review of the medical record for Resident #28 revealed an admission date of 10/10/24 with diagnoses of
heart disease, congestive heart failure, and depression.
Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed
Resident #28 had intact cognition and used tobacco.
Review of the current care plan revealed Resident #28 was a smoker. Interventions included storing
Resident #28's smoking supplies at the nursing station.
Review of a progress note dated 10/11/24 at 4:27 P.M. revealed Resident #28 was educated on the
smoking policy. Further review revealed Resident #28's cigarettes and lighter were confiscated and placed
in the smoke box.
Review of a progress note dated 10/11/24 at 5:39 P.M. revealed Resident #28 was educated to smoke only
in designated areas and smoking materials were not to be kept in his room. Further review revealed
Resident #28 stated understanding and agreed to give cigarettes to the nurse to be locked up.
Interview on 12/16/24 at 9:26 A.M. with Resident #28 revealed he kept his cigarettes and lighter in his
pocket. Concurrent observation revealed a cigarette pack in Resident #28's left pocket. Further observation
revealed a cigarette burn in his jacket and another on his pants.
Observation on 12/17/24 at 10:08 A.M. revealed Resident #28 lying in bed watching television. A cigarette
pack was on his bedside table. Concurrent interview with Resident #28 stated he was allowed to keep his
cigarettes and lighter in his room because he was allowed to smoke independently.
Interview on 12/19/24 at 11:25 P.M. with Social Services Director (SSD) #643 revealed she was familiar
with Resident #28. SSD #643 stated Resident #28 should not have cigarettes or lighters in his room.
Interview on 12/19/24 at 11:29 A.M. with SSD #643 and Resident #28 revealed Resident #28 confirmed he
had cigarettes and lighters in his room. Resident #28 gave permission to look in a shopping bag hanging
from the arm of his wheelchair. Observation with SSD #643 confirmed two packs of cigarettes
(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
12/19/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
were in the bag. Continued observation revealed Resident #28 removing two lighters from his jacket
pockets and handing them to SSD #643.
Review of the Behavior Contract for Resident #28, signed 12/11/24, revealed Resident #28 understood
cigarettes and smoking materials (i.e., lighters) may not be kept on his person.
Residents Affected - Some
3. Review of the medical record for Resident #43 revealed an admission date of 07/31/24 with diagnoses
including Alzheimer's disease, hypothyroidism, anxiety disorder, dysphagia, cachexia, and dementia.
Review of the most quarterly recent MDS assessment dated [DATE] revealed the resident was rarely/never
understood. Further review of the MDS assessment revealed the resident was dependent for all functional
care areas.
Review of the most recent care plan for Resident #43 revealed she required a mechanical lift with two staff
assistance for transfers.
Observation on 12/18/24 at 1:09 P.M. revealed one staff member, Certified Nurse Aide (CNA) #601, was
transferring Resident #43 from her Broda chair (a chair that provides comfort, support, positioning, and
mobility) to her bed unassisted by another staff member and without a mechanical lift.
An interview on 12/18/24 at 1:11 P.M. with CNA #601 confirmed she transferred Resident #43 from her
Broda chair to her bed unassisted from another staff member and without a Mechanical Lift.
An interview on 12/18/24 at 1:19 P.M. with MDS RN #517 confirmed Resident #43's plan of care revealed
the resident required a mechanical lift with two staff assistance for transfers.
This deficiency represents non-compliance investigated under Complaint Number OH00160151.
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
12/19/2024
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, medical record review, review of a medication manufacturer package insert, the
facility failed to ensure residents received insulin as ordered which resulted in a significant medication error.
This affected one (#13) of three residents observed during medication administration. The facility identified
10 residents with orders for insulin in a facility census of 44.
Residents Affected - Few
Findings Include:
Review of Resident #13's medical record revealed an admission date of 10/26/18. Diagnoses included
epilepsy, iron deficiency anemia, heart failure, primary osteoarthritis, insomnia, hyperlipidemia,
hypertension, atrial fibrillation, type two diabetes mellitus, post-traumatic stress disorder, and major
depressive disorder.
Review of Resident #13's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE]
revealed the resident was cognitively intact.
Review of Resident #13's current physician orders as of 12/18/24 revealed the resident was to receive
Novolog insulin eight (8) units subcutaneously (SQ) before meals for blood sugar control. Review of an
additional order for Novolog insulin per sliding scale was to be administered SQ with meals and at bed time.
Observation and interview on 12/18/24 at 8:14 A.M. of Licensed Practical Nurse (LPN) #701 administering
medication for Resident #13 revealed the nurse obtained a blood glucose level for Resident #13 of 224
milligrams per deciliter (mg/dL), which required four (4) units of Novolog insulin from the sliding scale order.
LPN #701 stated she would be administering 12 units total of Novolog insulin to Resident #13. LPN #701
then was observed to attach an administration needle to the insulin administration pen, turned the dose
selector dial to 12 units, and proceed to administer the insulin to Resident #13 without first priming the
Novolog insulin administration pen.
Interview on 12/18/24 at 8:37 A.M. with LPN #701 confirmed she administered the ordered 12 units of
Novolog insulin to Resident #13, but did not prime the pen needle prior to administration.
Review of the Novolog FlexPen package insert, dated 2023, revealed before each injection, to avoid
injecting air and ensure proper dosing, turn the dose selector to two (2), hold the Novolog FlexPen with the
needle pointing up, and press the push button all the way in until the dose selector returns to zero (0). A
drop of insulin should be seen at the tip of the needle. The dose selector then can be dialed to the correct
dose of insulin for administration.
Review of the facility policy titled, Administering Medications, revised 2012, revealed medications will be
administered in a safe and timely manner, and as prescribed.
This deficiency represents non-compliance investigated under Master Complaint Number OH00160513 and
Complaint Number OH00160203.
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
12/19/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, medical record review, review of medication manufacturer package inserts, and
review of facility policy, the facility failed to ensure that insulin was labeled appropriately. This affected two
(#17 and #46) of 10 residents with orders for insulin. The facility census was 44.
Findings Include:
1. Review of Resident #17's medical record revealed an admission date of 05/27/24. Diagnoses included
nonrheumatic aortic stenosis, hyperlipidemia, type two diabetes mellitus, hypertension, mild protein-calorie
malnutrition, obstructive sleep apnea, major depressive disorder, anxiety disorder, insomnia, and bilateral
primary osteoarthritis.
Review of Resident #17's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] the
resident was cognitively intact.
Observation on 12/16/24 at 9:11 A.M. of a medication cart on the South Hall revealed a Basaglar insulin
KwikPen that was open and approximately one-quarter used. There was no date documented on the
Basaglar insulin KwikPen indicating when it was opened.
Interview on 12/16/24 at 9:13 A.M. with Licensed Practical Nurse (LPN) #551 confirmed the Basaglar
insulin KwikPen was for Resident #17. LPN #551 verified the pen had been used and was not labeled with
a date that it was first opened.
Review of the manufacturer's package insert for Basaglar KwikPen revealed that when the pen is stored at
room temperature after opening it should be thrown away after 28 days.
2. Review of Resident #46's medical record revealed an admission date of 10/22/24. Diagnoses included
hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, diabetes
mellitus type II, major depressive disorder, glaucoma, hyperlipidemia, hypertension, and muscle weakness.
Review of Resident #46's admission MDS assessment dated [DATE] revealed the resident was moderately
cognitively impaired.
Observation on 12/16/24 at 10:05 A.M. of a second medication cart revealed an open vial of Humalog
insulin for Resident #46. There was no date documented on the vial of Humalog insulin indicating when it
was opened.
Interview on 12/16/24 at 10:07 A.M. with LPN #551 confirmed the vial of Humalog insulin for Resident #46
was open and was not labeled with a date that it was opened.
Review of the manufacturer's package insert for Humalog insulin revealed that when stored at room
temperature, after opening Humalog insulin can only be used for a total of 28 days.
Review of the facility policy titled, Storage of Medication, revised April 2007, revealed the
(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
12/19/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
facility shall store all drugs and biologicals in a safe manner. When opening a multi-dose container, the date
opened shall be recorded on the container.
This deficiency represents non-compliance investigated under Complaint Number OH00160203.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365952
If continuation sheet
Page 6 of 6
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Back to topCitations
22 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0223GeneralS&S Fpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362GeneralS&S Fpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the December 19, 2024 survey of RIDGEWOOD MANOR?
This was a inspection survey of RIDGEWOOD MANOR on December 19, 2024. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RIDGEWOOD MANOR on December 19, 2024?
Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.