Health inspection·December 19, 2024

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 Page 1 of 6 365952 365952 12/19/2024 Ridgewood Manor 3231 Manley Road Maumee, OH 43537

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 365952 Page 2 of 6 365952 12/19/2024 Ridgewood Manor 3231 Manley Road Maumee, OH 43537

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. 365952 Page 3 of 6 365952 12/19/2024 Ridgewood Manor 3231 Manley Road Maumee, OH 43537

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. 365952 Page 4 of 6 365952 12/19/2024 Ridgewood Manor 3231 Manley Road Maumee, OH 43537

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 365952 Page 5 of 6 365952 12/19/2024 Ridgewood Manor 3231 Manley Road Maumee, OH 43537

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 365952 Page 6 of 6