Health inspection·March 10, 2022

F 0686 heels. Level of Harm - Minimal harm or potential for actual harm Review of a wound assessment dated [DATE] revealed Resident #142 developed a pressure ulcer to the left heel measuring 4.0 cm long by 3.0 cm wide by 0.1 cm depth with no stage documented. The wound was described as granulated (beefy red), with scant drainage, a pale pink peri-wound, and wound edges intact. Residents Affected - Few Interview on 03/09/22 on 10:38 A.M. with Licensed Practical Nurse (LPN) #268 stated Resident #142's skin was assessed on 03/02/22 and there were no pressure ulcers on her heels. LPN #268 stated she was off work for a couple of days and when she came back on 03/05/22 she noticed Resident #142 had a ruptured blister on her left heel. LPN #268 stated she did not know when the blister developed and verified staff were offloading Resident #142's heels while in bed to relieve pressure, but stated she nor any of the nurses were applying skin prep to Resident #142's heels. LPN #268 stated she measured the wound and contacted the wound nurse practitioner to order treatment. LPN #268 stated Resident #142's left heel wound was not staged on the initial assessment on 03/05/22 and stated the wound nurse practitioner had yet to observe the wound, but would stage the wound after her assessment. LPN #268 verified Resident #142 had an active order for skin prep to bilateral heels every day and night shift, but the staff member who put the order into the computer system never enabled the order to be seen by the nurses on their treatment orders. LPN #268 stated none of the nurses would have known the skin prep treatment was due because it was never alerted in the system. LPN #268 again stated she had not been applying skin prep to Resident #142's heels and verified there was no documentation in the medical record of skin prep ever being applied to Resident #142's heels. Observation on 03/10/22 at 7:24 A.M. revealed Resident #142 laying in bed with heels offloaded by pillows and a wound dressing in place to her left heel. Further observation revealed Wound Nurse Practitioner (WNP) #567 removed the old dressing and revealed a healing, ruptured blister on the skin surface with scant drainage, healthy surrounding skin, and no odors. WNP #567 measured the wound to be 6.0 cm long by 4.2 cm wide by 0.1 cm deep. Interview on 03/10/22 at 8:12 A.M. with WNP #567 verified 03/10/22 was the first she observed Resident #142's heel wound and stated it appeared to her as a ruptured blister and would stage the wound as a Stage Two pressure ulcer. WNP #567 stated she would continue the current treatments and encouraged to continue offloading bilateral heels. Review of a facility policy titled, Pressure Ulcer and Skin Management, dated 10/27/21, revealed residents who enter the facility without pressure ulcers do not develop pressure ulcer unless the resident's clinical condition demonstrates that they were unavoidable. The licensed nurse will review the pressure protocol to select the treatment appropriate for the resident and the type of pressure ulcer or wound. The licensed nurse will implement the wound care treatment in accordance with current standards of practice. 2. Review of the record for Resident #21 revealed an admission date of 06/25/21. Diagnoses included epilepsy, muscle weakness, and Alzheimer's disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. He was dependent on two staff for transfers, toileting, and hygiene. Review of an order for Resident #21 dated 02/08/22 revealed heel protectors were to be worn at all times due to the deep tissue injuries (DTI) to both heels. The heel protectors could be removed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 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 366184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabeth Scott Community 2720 Albon Rd 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 0686 personal hygiene. Level of Harm - Minimal harm or potential for actual harm Review of a wound assessment signed 02/09/22 for Resident #21 revealed a suspected DTI to his right heel presented on 02/08/22 and a suspected DTI to his left heel presented on 02/09/22. The recommended treatment was heel protector boots to both heels. Residents Affected - Few Observation on 03/07/22 at 3:08 P.M. revealed heel protector boots in Resident #21's chair, and Resident #21 lying in bed not wearing heel protector boots. Observation and interview on 03/08/22 at 4:53 P.M. revealed Resident #21 being pushed into dining room by State Tested Nursing Assistant (STNA) #230 while seated in Broda chair (a wheeled, cushioned, reclining chair). Heel protector boots were not on Resident #21 who wore only socks with his heels resting on the foot rests of the chair. Interview at that time with STNA #230 confirmed Resident #21 was not wearing heel protector boots, and she was unable to explain why he was not currently wearing boots. Observation on 03/09/22 at 2:38 P.M. revealed Resident #21 lying in bed without wearing heel protector boots, and heel protector boots were in his chair. Observation and interview on 03/09/22 at 2:42 P.M. with STNA #232 revealed Resident #21 was in bed lying on his back without wearing heel protector boots. Further interview revealed STNA #232 did not know when Resident #21 was supposed to wear the boots. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 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 366184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabeth Scott Community 2720 Albon Rd 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to provide restorative care as care planned. This affected two (#24 and #28) of two residents reviewed for range of motion. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnosis included anxiety disorder, displaced fracture of first cervical vertebra, subsequent encounter for fracture for fracture with routine healing, history of falling, dementia, hypertension, spinal stenosis cervical region, hyperlipidemia, atrial fibrillation, cardiomyopathy, major depressive disorder, morbid obesity, muscle weakness and unsteadiness on feet. Review of the minimum data set (MDS) assessment, dated 12/15/21, revealed the resident was severely cognitively impaired. Review of the care plan, revised 01/19/22, revealed Resident #28 was at risk for impaired weakness due to displaced fracture of first cervical vertebra, spinal stenosis, and muscle weakness. Interventions include active range of motion both lower extremities seated leg program with two pound weights, twenty reps all planes and active range of motion to bilateral extremity twenty to thirty reps all planes with no weights, raise arms shoulder height only not above head for six to seven days a week for at least fifteen minutes a day. Review of range of motion documentation, dated 01/25/22 to 03/08/22, Resident #28 had active range of motion restorative services provided as follows: 01/14/22 to 01/15/22 one out of two potential days, 01/16/22 to 01/22/22 four out of seven days; 01/23/22 to 1/29/22 four out of seven potential days; 01/30/22 to 02/05/22 five out of seven potential days; 02/06/22 to 02/12/22 six out of seven potential days; 02/13/22 to 02/19/22 two out of seven potential days; 02/20/22 to 02/26/22 one out of seven potential days; 02/27/22 to 03/05/22 three out of seven potential days; and 03/06/22 to 03/08/22 one out of three potential days. Interview on 03/09/22 at approximately 4:00 P.M. with the Director of Nursing (DON) verified restorative care was not provided as care planned for Resident #28. 2. Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnosis include muscle spasms, non-Hodgkin lymphoma, personal history of malignant neoplasm of breast, personal history of other malignant neoplasm of skin, cerebral infarction, unsteadiness of feet, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, epilepsy and osteoarthritis. Review of the MDS assessment, dated 01/21/22, revealed Resident #24 was cognitively intact. Review of the care plan, dated 01/20/22, revealed Resident #24 has impaired functional range of motion of left upper and lower extremities related cerebrovascular accident (CVA) with hemiplegia to the left side. Interventions include Active Range of Motion (AROM) program to right shoulder, elbow, wrist, hip, knee and ankle one time a day, six to seven days a week for at least 15 minutes a day in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 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 366184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabeth Scott Community 2720 Albon Rd 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at least one set of fifteen to twenty reps per joint. To the left aide perform Passive Range of Motion (PROM) to all above listed joints of upper and lower extremities, one set of fifteen reps per joint as tolerated. Review of range of motion documentation, dated 01/25/22 to 03/08/22, Resident #24 had active range of motion restorative services provided as follows: 01/25/22 to 01/29/22 three out of five potential days; 01/30/22 to 02/05/22 four out of seven potential days; 02/06/22 to 02/12/22 four out of seven potential days; 02/13/22 to 02/19/22 one out of seven potential days; 02/20/22 to 02/26/22 one out of seven potential days; and 02/27/22 to 03/05/22 three out of seven potential days. Interview on 03/08/22 at 4:23 P.M. with Licensed Practical Nurse (LPN) #261 verified Resident #24 has not received restorative care as care planned. LPN #261 reports restorative aides are at times reassigned to work as a hall aide when the facility is short staffed. Interview on 03/09/22 at 9:45 A.M. with State Tested Nursing Assistant (STNA) #202 verified working as a restorative aide. It was reported Resident #24 is cooperative and has not refused restorative services. STNA #202 reported a restorative aid is scheduled seven days a week but is often reassigned to work as an aide which results in not being able to provide the restorative program to residents. Review of the facility policy, Restorative Program, dated 03/01/10, revealed special restorative nursing program will be initiated as ordered and the restorative nurse, licensed nurse, along with floor aides or restorative aides will implement the program documenting on a daily basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 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 366184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabeth Scott Community 2720 Albon Rd 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 - Few 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, medical record review, staff interview, and review of a facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#142) of four residents reviewed for accidents. The census was 47. Findings include: Review of Resident #142's medical record revealed an admission date of 02/16/22. Diagnoses included displaced intertrochantric fracture of the left femur, cognitive communication deficit, unspecified dementia with behavioral disturbances, heart failure, muscle weakness, and unsteadiness on feet. Review of an admission nursing assessment dated [DATE] revealed Resident #142 was alert to person only and exhibited confusion. Review of an admission fall risk assessment dated [DATE] revealed Resident #142 was assessed at high risk for falls. Review of a baseline care plan dated 02/16/22 revealed Resident #142 was at risk for falls with a history of a falls at home with her daughter that required surgery. Review of a fall investigation report dated 03/02/22 revealed Resident #142 was found on the floor in her room beside her bed on her left side. Resident #142 was last observed in a low bed with her call light in reach and assessed with no injuries. Further review of the fall investigation revealed immediate interventions implemented were a mat placed on the floor and Resident #142 was given a body pillow. Review of a physician order dated 03/02/22 revealed Resident #142 was ordered a mat to the floor next to the bed while Resident #142 was in bed. Review of the comprehensive care plan dated 03/08/22 revealed Resident #142 was at risk for falling with an intervention to have a mat to the floor next to Resident #142's bed and utilize a body pillow in bed. Observation on 03/08/22 at 1:12 P.M. revealed Resident #142 sitting in her wheelchair in her bedroom. Observation on 03/08/22 at 2:28 P.M. revealed Resident #142 laying in bed on her right side with a body pillow at the edge of the right side of the bed mattress. The left side of Resident #142's bed was against the wall with a gray mat standing on end horizontally and wedged between the bed and the wall measuring approximately two inches thick. There was no mat noted to the floor next to Resident #142's bed. Interview on 03/08/22 at 2:39 P.M. with State Tested Nurse Aide (STNA) #203 stated Resident #142 was laid down in bed at approximately 1:30 P.M. on 03/08/22 but she was not one of the staff members that assisted with her transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 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 366184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabeth Scott Community 2720 Albon Rd 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 - Few Observation of Resident #142 on 03/08/22 at 2:41 P.M., with STNA #203, revealed Resident #142 laying in bed with no mat to the floor next to her bed. Interview on 03/08/22 at 2:42 P.M. with STNA #203 confirmed she was in Resident #142's bedroom at approximately 2:15 P.M. and verified Resident #142 was in bed but no mat was on the floor at that time either. STNA #203 stated the mat the was between the wall and the left side of the bed should have been on the floor on the right side to prevent injuries if Resident #142 were to fall out of bed. STNA #203 confirmed the active order for Resident #142 to have a mat to the floor next to her bed at this time. Review of a facility policy titled, Falls - Protocol, dated October 2021, revealed for an individual who has fallen, staff and the interdisciplinary team will attempt to define possible causes and analysis each incident to determine root causes. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366184 If continuation sheet Page 7 of 7