Inspection·June 4, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left foot or ankle. Further observation revealed the resident had a border dressing on the left lower shin dated 05/28/25. Interview on 06/02/25 at 10:36 A.M., LPN #435 verified the resident had a wound dressing on the left lower shin dated 05/28/25. LPN #435 verified physician orders for the wound were not entered into the treatment administration record and the daily wound treatments had not been completed. LPN #435 also verified the resident had no wounds on his left foot/ankle and no physician orders for treatment. 2. Review of the medical record for Resident #37 revealed an admission date of 08/04/16. Diagnoses included cerebral infarction, spinal stenosis, and dementia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a nurse practitioner skin and wound note dated 05/14/25 at 1:18 P.M. revealed the resident had a skin tear to the left knee from a recent fall. The area measured two centimeters (cm) by 1.6 cm in width with no depth. Treatment recommendations included to cleanse with wound cleanser, apply bacitracin ointment to base of the wound and leave open to air. Review of a nurses note dated 05/20/25 at 3:02 P.M. revealed the resident had a skin tear on his right leg. The wound was cleansed and measured seven cm in length and four cm width. An abdominal pad was placed and wrapped with a gauze dressing. Wound care notified of the skin tear. Review of a wound nurse practitioner skin and wound note dated 05/21/25 at 11:42 A.M. revealed the resident had a skin tear improving to the left knee and a new skin tear to the right lateral lower leg. The wound to the left knee measured 1.7 cm in length by 1.5 cm in width by zero cm in depth. The wound to the right lateral lower leg measured 7.5 cm in length by 4.2 cm in width x 0.1 cm in depth. The wound NP treatment orders included to cleanse the skin tear to the left knee with wound cleanser, apply bacitracin and leave open to air. The treatment order for the right lateral lower leg skin tear was to cleanse with wound cleanser, apply non-adhering dressing to base of wound, secure with abdominal pad and rolled gauze, and change daily and as needed. Review of physician orders dated 05/21/25 revealed to cleanse the left knee with soap and water, pat dry, apply bacitracin ointment to wound bed and leave open to air every day shift. Also to cleanse the right lower extremity with wound cleanser, pat dry, apply oil emulsion non-adhering dressing to wound bed, cover with abdominal padding, then wrap with rolled dry gauze daily. Review of a nurse practitioner skin and wound note dated 05/28/25 at 7:07 P.M. revealed the skin tears to the right lower leg and left knee were healed and to continue preventative recommendations for daily emollients and prevent use of adherent tape directly to skin. The physician orders for the wound treatment for the skin tear to the left knee and right lower extremity skin tear had not been discontinued. Review of the Treatment Administration Record (TAR) from 05/22/25 through 06/01/25 revealed the wound treatments were documented as completed per physician orders. Observation on 06/02/25 at 2:06 P.M. revealed Resident #37 had an exposed scabbed area on the left knee. Further observation revealed the resident had an undated loosely wrapped gauze dressing around the lower left leg near the ankle. Further observation revealed the resident had an exposed scabbed area on the right lateral lower extremity and a loosely wrapped gauze wound dressing dated 05/31/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 2 of 3 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 06/04/2025 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 0684 around the right ankle. Level of Harm - Minimal harm or potential for actual harm Interview on 06/02/25 at 2:06 P.M., LPN #435 revealed the resident's wounds were healed but the physician orders had not been discontinued. LPN #435 verified the treatment to the left knee was to cleanse wound, apply bacitracin and leave open to air. LPN #435 verified there were no physician orders for a wound dressing to the left knee and should not have been wrapped with gauze. LPN #435 verified the dressing on the resident's right lower extremity skin tear had slid down and was not in place over the wound. LPN #435 also verified the wound dressing for the right lower extremity skin tear was dated 05/31/25 and wound care had not been completed as documented on 06/01/25. Residents Affected - Few Interview on 06/04/25 at 10:30 A.M., the Director of Nursing (DON) revealed after a wound was healed, the wound nurse practitioner wanted healed wounds to be padded and protected for an additional week. The DON verified there were no physician orders to pad and protect Resident #37's skin tear wounds. Interview on 06/04/25 at 11:15 A.M., Certified Wound Nurse Practitioner (CWNP) #700 revealed wound orders were continued for one additional week after a wound had healed. CWNP #700 verified she should have clarified with the facility when to discontinue Resident #37's wound care orders. Review of the facility policy Wound Care, dated 10/2010, revealed to verify a physician order for wound care. Also record in the medical record the type of wound care given, the date and time the wound care was given, and assessment data obtained when inspecting the wound. This deficiency represents non-compliance investigated under Complaint Number OH00165739. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365952 If continuation sheet Page 3 of 3