Inspection·March 21, 2019

F 0550 requested posted clinical information in the resident's room. Level of Harm - Minimal harm or potential for actual harm Observation of the resident's room on 03/18/19 at 12:23 P.M. revealed two signs posted above the resident's bed. One sign read, Patient has port and the other sign read, Do not use left arm for blood pressures, lab draws, IV's (intravenous), etc. Residents Affected - Few Interview with LPN #153 on 03/19/19 at 2:56 P.M. verified the resident had clinical information posted on her wall visible to anyone who came in the room. Interview with Regional Support Nurse #201 on 03/19/19 at 3:51 P.M. verified the resident did not have anything in her care plan indicating the resident's family requested clinical information be posted in her room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 2 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, resident council interview, and review of a facility policy, the facility failed to ensure resident's call lights were within reach for the residents. This affected two (Resident #13 and #22) of 24 residents observed during stage one of the survey. The facility census was 55. Residents Affected - Few Findings include: 1. Review of Resident #13's medical record revealed an admission date of 03/04/15. Medical diagnoses included peripheral vascular disease, dementia without behaviors, anxiety disorder, major depressive disorder, generalized muscle weakness, urinary incontinence, history of urinary tract infections, history of falls, and Alzheimer's disease. Review of the resident's Minimum Data Set (MDS) assessment, dated 01/08/19, revealed the resident required extensive assistance of one staff member for bed mobility, transfers, and toilet use. Review of the resident's activities of daily living (ADL) care plan revised on 01/10/19 revealed the resident was unable to complete ADL's independently and was at risk for falls due to balance difficulty, weakness and impaired cognition which could affect her safety awareness and decision making. She also received medications which could further affect her balance. Interventions included keeping her call light and other frequently used objects within easy reach. Observation of Resident #13 on 03/18/19 at 10:06 A.M. revealed the resident was in her recliner asleep. Her call light was attached to the bed and not within her reach. Interview with Licensed Practical Nurse (LPN) #137 on 03/18/19 at 10:10 A.M. verified the resident's call light was not in reach. LPN #137 stated the resident was able to use the call light. 2. Review of Resident #22's medical record revealed an admission date of 06/14/17. Medical diagnoses included dementia without behaviors, heart failure, sepsis, hypertension, metabolic encephalopathy, and myelodysplastic syndrome. Review of the resident's MDS assessment, dated 01/18/19, revealed the resident required extensive assistance of one staff member for bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. Review of the resident's care plan, revised on 01/10/19, revealed she was at risk for falls related to muscle weakness, dementia, and osteoporosis. Interventions included keeping the call light in reach at all times. Observation of Resident #22 on 03/18/19 at 10:13 A.M. revealed the resident had a pressure call button hanging on the back of her headboard with the head of the bed elevated. The resident was lying in bed but the call button was not within reach of the resident. Interview with State Tested Nursing Assistant (STNA) #127 on 03/18/19 at 10:18 A.M. verified the resident was not able to reach her call light. She stated the resident was able to use her call light. Interview with the resident council group on 03/19/19 at 4:11 P.M. revealed they complained of call lights being placed out of their reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 3 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0558 Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled Guidelines for Answering Call Lights reviewed on 05/22/18 revealed staff was to ensure the call light was plugged in securely to the outlet and in reach of the resident. If nothing else is needed, return the call light to within reach of the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 4 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure implementation of their abuse policy when an injury of unknown origin (IUO) was not reported timely to administrative staff and the survey State Agency. This affected one (Resident #36) of one resident reviewed for skin conditions. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed an admission date of 10/25/18. Medical diagnoses included dysphagia, heart failure, atherosclerotic heart disease, atrial fibrillation, anemia, anxiety, dementia, hypertension, rheumatoid arthritis, and repeated falls. The resident began receiving hospice services on 03/12/19. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of five, indicating severe impairment in cognition. Review of the resident's medical record revealed a nursing note dated 03/13/19 at 10:40 P.M. from Licensed Practical Nurse (LPN) #140 indicating bruising was noted in the resident's anal area when providing personal care this evening which was dark purple in color. No frank/fresh bleeding was noted from anus. Resident did not respond to questions of whether the area hurt or if she had any discomfort in that area. A bruise was also noted on lateral left forearm, yellow-green in color. There was no evidence the nurse notified the Administrator and/or Director of Nursing. Review of the facility's self-reported incidents from 03/13/19 through 03/21/19 revealed there were no IUO reported to the survey State Agency, the Ohio Department of Health. Interview with LPN #153 on 03/19/19 at 10:58 A.M. revealed she was responsible for weekly skin assessments for the resident. She verified she saw new bruising around the resident's anus on 03/14/19. She stated she did not report this to administration as she was not the one who discovered it. She stated the bruising was discovered on 03/13/19 by LPN #140. She stated she would have reported the bruising had she been the one who initially noted the bruising. Interview with Regional Support Nurse #173 and the Director of Nursing on 03/19/19 at 1:31 P.M. verified LPN #140 did not report the bruising to the resident's anal area and forearm in a timely manner. The DON called LPN #140 at home after reviewing the event on 03/14/19. LPN #140 was re-educated on the abuse, neglect, and misappropriation policy. They verified there were no SRI's reported involving Resident #36 and IUO. Review of a facility policy titled Abuse, Neglect and Exploitation Procedural Guidelines with an effective date of 10/10/17 revealed an IUO occurs when both of the following conditions were met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. 2. The injury was suspicious in nature because of the extent of the injury or the location of the injury. Reporting requirements included ensuring that all alleged violations involving abuse, neglect, exploitation or mistreatment, including IUO and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials, including the State (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 5 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0607 Survey Agency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 6 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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 report an injury of unknown origin (IUO) timely to administrative staff and the survey State Agency. This affected one (Resident #36) of one resident reviewed for skin conditions. The facility census was 55. Findings include: Review of Resident #36's medical record revealed an admission date of 10/25/18. Medical diagnoses included dysphagia, heart failure, atherosclerotic heart disease, atrial fibrillation, anemia, anxiety, dementia, hypertension, rheumatoid arthritis, and repeated falls. The resident began receiving hospice services on 03/12/19. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of five, indicating severe impairment in cognition. Review of the resident's medical record revealed a nursing note dated 03/13/19 at 10:40 P.M. from Licensed Practical Nurse (LPN) #140 indicating bruising was noted in the resident's anal area when providing personal care this evening which was dark purple in color. No frank/fresh bleeding was noted from anus. Resident did not respond to questions of whether the area hurt or if she had any discomfort in that area. A bruise was also noted on lateral left forearm, yellow-green in color. A nursing note, dated 03/14/19 at 9:20 A.M. from LPN #153, revealed the bruises continued to the resident's anal area and left lateral arm. The resident denied any pain or discomfort to the area. A late entry nursing note, dated for 03/14/19 at 11:00 A.M., and recorded on 03/18/19 at 5:34 P.M. from the interdisciplinary team, indicated the root cause of the resident's bruising was her dependence on staff for activities of daily living (ADL) and transfers, elevated international normalized ratio (INR) (ration used to determine the effectiveness of blood thinner medication), and thin and aging skin. The resident was noted to rest her arms next to arm rest of Broda chair. Another late entry nursing noted, dated for 03/14/19 at 4:45 P.M. and recorded on 03/18/19 at 5:10 P.M. from wound care nurse LPN #161, indicated the resident's perirectal area was assessed and area was noted to be dark, rusty in color which was within normal limits for the resident. No open areas were noted. Resident dependent on staff for ADLs including transfers via Hoyer lift. Resident receives Coumadin (anticoagulant) therapy. At present time, INR elevated and Coumadin on hold. Review of a weekly skin assessment completed by LPN #153, dated 03/19/19 at 1:13 P.M., revealed discoloration continued to anal area, right inner thigh and left arm. Excoriation areas continued to buttocks and coccyx with scarring. Review of the facility's self-reported incidents from 03/13/19 through 03/21/19 revealed there were no IUO reported to the survey State Agency, the Ohio Department of Health. Interview with LPN #153 on 03/19/19 at 10:58 A.M. revealed she was responsible for weekly skin assessments for the resident. She verified she saw new bruising around the resident's anus on 03/14/19. She stated she did not report this to administration as she was not the one who discovered it. She stated the bruising was discovered on 03/13/19 by LPN #140. She stated she would have reported the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 7 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0609 bruising had she been the one who initially noted the bruising. Level of Harm - Minimal harm or potential for actual harm Observation of the resident's anal area on 03/19/19 at 11:07 A.M. with LPN #153 revealed very faint scattered bruising continued around the resident's anus area. Residents Affected - Few Interview with Regional Support Nurse #173 and the Director of Nursing on 03/19/19 at 1:31 P.M. verified LPN #140 did not report the bruising to the resident's anal area and forearm in a timely manner. The DON called LPN #140 at home after reviewing the event on 03/14/19. LPN #140 was re-educated on the abuse, neglect, and misappropriation policy. They verified there were no SRI's reported involving Resident #36 and IUO. Review of a facility policy titled Abuse, Neglect and Exploitation Procedural Guidelines with an effective date of 10/10/17 revealed an IUO occurs when both of the following conditions were met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. 2. The injury was suspicious in nature because of the extent of the injury or the location of the injury. Reporting requirements included ensuring that all alleged violations involving abuse, neglect, exploitation or mistreatment, including IUO and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials, including the State Survey Agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 8 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notices of transfer/discharge to the resident and/or resident representative. This affected three (Resident #25, #40 and #59) of three residents reviewed for hospitalization. The facility census was 55. Findings include: 1. Record review revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included anxiety, Parkinson's Disease, dysphasia status post cerebral vascular accident, congestive heart failure, and bladder cancer with declined treatment. Review of the medical record revealed Resident #25 was discharged to the hospital on [DATE]. There was no evidence of a transfer/discharge document given to the resident or responsible party at the time of discharge. 2. Record review revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included restless leg syndrome, anxiety, gastroesophageal reflux disease, and arteriosclerotic heart disease. Review of the medical record revealed Resident #40 was discharged to the hospital on [DATE]. There was no evidence of a transfer/ discharge document given to the resident or responsible party at the time of discharge. 3. Review of the medical record for Resident #59 revealed an admission date of 01/26/19 and a discharge date of 02/18/19. Diagnoses included muscle weakness, spinal stenosis, thoracic region, rheumatoid arthritis, venous insufficiency, chronic peripheral, pneumonia, gastro-esophageal reflux disease without esophagitis, thrombocytopenia, unspecified atrial fibrillation, benign prostatic hyperplasia without lower urinary tract symptoms, and drug or chemical induced diabetes mellitus with hyperglycemia. Review of the progress notes revealed Resident #59 was admitted to the hospital on [DATE]. There was no evidence in the medical record of a transfer/discharge notice given to the resident or resident representative. Interview on 03/18/19 at 4:00 P.M. with Campus Clinical Support Registered Nurse (RN) #173 verified Resident # 25, #59 and #40 did not receive a written notice of transfer /discharge prior to hospital admissions. Interview on 03/20/19 at 6:20 A.M. with Licensed Social Worker (LSW) #167 revealed the facility has not been giving transfer/discharge notices to the residents, but have been sending a list of residents who were transferred/discharged to the Ombudsman's office at the end of each month. Interview on 03/21/19 at 10:20 A.M. with Corporate Clinical Support #173 verified the facility was in the process of finalizing their policy and do not have one yet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 9 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to provide written notices of bed hold information to residents. This affected three (Resident #25,#40 and #59) of three residents reviewed for hospitalization. The facility census was 55. Findings include: 1. Record review for Resident #25 revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety, major depression , Parkinson's Disease, dysphasia status post cerebral vascular accident, congestive heart failure, and bladder cancer with declined treatment. Review of the medical record revealed Resident #25 was discharged to the hospital on [DATE]. There was no evidence of a written notice of bed hold information given to the resident or responsible party prior to transfer to the hospital. 2. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with diagnoses including restless leg syndrome,dysphasia, hypertension, anxiety, gastroesophageal reflux disease, and arteriosclerotic heart disease. Review of the medical record revealed Resident #40 was discharged to the hospital on [DATE]. There was no evidence of a written notice of bed hold information given to the resident or responsible party prior to transfer to the hospital Interview on 03/18/19 at 4:00 P.M. with Campus Clinical Support Registered Nurse (RN) #173 verified Resident # 25 and #40 did not receive a written notice of bed hold information prior to transfer to the hospital from the facility. 2. Review of the medical record for Resident #59 revealed an admission date of 01/26/19 and a discharge date of 02/18/19. Diagnoses included muscle weakness, spinal stenosis, thoracic region, rheumatoid arthritis, venous insufficiency, chronic peripheral, pneumonia, gastro-esophageal reflux disease without esophagitis, thrombocytopenia, unspecified atrial fibrillation, benign prostatic hyperplasia without lower urinary tract symptoms and drug or chemical induced diabetes mellitus with hyperglycemia. Review of the progress notes revealed Resident #59 was admitted to the hospital on [DATE]. There was no evidence in the medical record of a bed hold notice given to the resident or resident representative. Interview on 03/20/19 at 11:58 A.M. with Business Office Manager #175 verified Resident #59 did not receive a bed hold notice. Review of the policy titled Bed Hold Notification, dated 11/23/16, revealed before transferring a resident to a hospital or allowing a resident to go on a therapeutic leave, the Nursing designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed hold and admission policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 10 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed when a resident began receiving hospice services. This affected one (Resident #22) of three residents reviewed for hospice services. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed an admission date of 06/14/16. Medical diagnoses included dysphagia, anemia, generalized anxiety disorder, restlessness and agitation, dementia with behaviors, insomnia, dehydration, insomnia, altered mental status, atrial fibrillation, and Parkinson's disease. She started receiving hospice services on 09/26/18. Review of the resident's MDS assessments revealed she did not have a significant change MDS assessment completed after the resident went under hospice services. Interview with MDS Coordinator #155 on 03/20/19 at 4:53 P.M. verified she did not complete a significant change MDS when the resident was placed on hospice on 09/26/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 11 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, anemia, arteriosclerotic heart disease, left kidney neoplasm, gangrene to bilateral toes due to arterial insufficiency, and unstageable pressure ulcer to left heel. Review of the baseline plan of care, dated 02/24/19, revealed a plan of care was developed for the resident. There was no evidence the resident received a written summary of the baseline plan of care. Interview with Resident #55 on 03/20/19 at 10:30 A.M. stated she did not receive a summary of her plan of care after admission. Interview with Clinical Support Registered Nurse #173 on 03/20/19 at 10:20 A.M. verified the resident and/or her representative did not receive a written summary of the resident's baseline care plan. Based on medical record review, review of facility policy and resident and staff interview, the facility failed to ensure residents and/or their representatives were provided with a summary of the resident's baseline care plan. This affected two (Resident #18 and #55) of three residents reviewed for baseline care planning. The facility identified 15 new admissions in the last 30 days. The facility census was 55. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 01/07/19. Medical diagnoses included osteoarthritis, major depressive disorder recurrent severe with psychotic symptoms, Alzheimer's disease, dementia with behaviors, visual hallucinations, atrial fibrillation, anxiety, hypertension, spinal stenosis, atherosclerotic heart disease, and urinary retention. Review of the resident's medical record revealed a baseline care plan created on 01/08/19. Further review revealed no indication the resident or the resident's representative received a written summary of the baseline care plan. Interview with Clinical Support Registered Nurse #173 on 03/20/19 at 10:20 A.M. verified the resident and/or her representative did not receive a written summary of the resident's baseline care plan. Review of a facility policy titled 48 Hour Baseline Care Plan Guideline, dated 05/22/18, revealed the Minimum Data Set (MDS) coordinator or MDS nurse will print the 48 hour baseline care plan and provide it to the resident or resident representative during the initial resident first meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 12 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive person centered plan of care regarding a pressure ulcer for a resident. This affected one (Resident #55) of 17 care plans reviewed. The facility census was 55. Findings include: Record review for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, gangrene to bilateral toes due to arterial insufficiency, and unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to left heel. Review of the admission Minimum Data Set (MDS) assessment, dated 03/02/19, revealed the resident has no cognitive deficits. She had a unstageable pressure ulcer to her left heel. Review of the Care Area Assessment (CAA) in section V of the admission MDS stated the pressure sore would be addressed in the plan of care. Review of the comprehensive plan of care dated 03/06/19 reveled a plan of care for skin integrity stating the resident was at risk for skin breakdown due to peripheral vascular disease, arterial ulcers wounds, and decreased mobility also the resident has arterial ulcers to bilateral toes with gangrene. The goals included the residents ulcers will not cause further complications, heal without complications, and residents skin will remain intact. The plan of care does not address where the residents unstageable ulcer is located. The interventions are generic in nature not addressing the specific interventions in place to promote healing, prevent infection, and prevent worsening of the unstageable pressure ulcer located on her left heel. On 03/21/19 at 3:00 P.M. during an interview with MDS Coordinator #162 verified she developed a comprehensive plan of care for Resident # 55. She verified the unstable pressure ulcer on Resident #55 left heel and interventions to promote healing, prevent infection, were not addressed in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 13 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, review of facility policy and staff interview, the facility failed to ensure resident care conferences were held as required. This affected three (Resident #7, #11 and #18) of 17 residents reviewed for care planning. The facility census was 55. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/18/18. Diagnoses included dysphagia, dementia with behavioral disturbance, muscle weakness, hyperlipidemia, anemia, hypothyroidism, other recurrent depressive disorder, anxiety disorder, essential hypertension and gastro-esophageal reflux disease without esophagitis. Review of the resident's medical record revealed no evidence of a care conference since 06/18/18. Interview with Clinical Support Registered Nurse #173 on 03/20/19 at 10:20 A.M. verified the resident did not have a care conference since 06/18/18. 2. Review of the medical record for Resident #11 revealed an admission date of 03/23/18. Diagnoses included chronic obstructive pulmonary disease, unspecified, type two diabetes mellitus with diabetic neuropathy, unspecified, muscle weakness, essential hypertension, morbid obesity due to excess calories, hyperlidemia, unspecified dementia without behavioral disturbance, infection and inflammatory reaction due to internal fixation device of left femur, major depressive disorder, recurrent, atrial fibrillation and osteoarthritis. Review of the resident's medical record revealed there was an initial care conference completed on 04/06/18 and on 8/03/18. There was no evidence another care conferences was held since 08/03/18. Interview with Clinical Support Registered Nurse #173 on 03/20/19 at 10:20 A.M. verified the resident did not have a care conference since 08/03/18. 3. Review of Resident #18's medical record revealed an admission date of 01/07/19. Medical diagnoses included osteoarthritis, major depressive disorder recurrent severe with psychotic symptoms, Alzheimer's disease, dementia with behaviors, visual hallucinations, atrial fibrillation, anxiety, hypertension, spinal stenosis, atherosclerotic heart disease, and urinary retention. Review of the resident's medical record revealed no evidence of a care conference. Interview with Clinical Support Registered Nurse #173 on 03/20/19 at 10:20 A.M. verified the resident did not have a care conference since admission to the facility. Review of a facility policy titled Resident First Meeting Guidelines, dated 03/07/19, revealed a resident first meeting should be scheduled and held within ten days of admission. Subsequent meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change. Subsequent meetings for Medicare residents should be conducted minimally quarterly and prior to discontinuing Medicare services or being discharged from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 14 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to ensure one resident Residents Affected - Few (#13) was cued and assisted during dining of 54 residents observed for dining. The facility identified one (resident (#25) as not eating with an order of nothing by mouth. The facility census was 55. Findings include: Review of Resident #13's medical record revealed an admission date of 03/04/15 with diagnoses including peripheral vascular disease, dementia without behaviors, anxiety disorder, major depressive disorder, generalized muscle weakness, urinary incontinence, history of urinary tract infections, history of falls, and Alzheimer's disease. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and the resident required limited assistance with one staff for eating. Review of the resident's care plan revised on 01/10/19 revealed the resident was on hospice with potential for unavoidable weight loss. The interventions included offering alternates and substitute items if needed. Review of the daily assignment sheet for the 200 hall revealed STNA #106 was to be in the dining room for breakfast and lunch. Observation of Resident #13 on 03/20/19 at 8:30 P.M. revealed she was at the dining room table with eggs, pancake, and sausage cut up on a plate. At 8:55 P.M., State Tested Nursing Assistant (STNA) #106 approached the resident and asked her if she was finished eating. The resident stated, yes and STNA #106 removed the resident from the dining room. Observation of dining in the main dining room on 03/20/19 at 12:05 P.M. revealed Resident #13 was served a regular diet with a coke. The resident sat at the table with her hands folded not attempting to eat or drink . Several different staff staff members walked by Resident #13. At 12:25 P.M., STNA #106 came into the dining room and approached Resident #13. She asked her if she wanted anything else to eat. The resident responded No and STNA #106 walked away. On 03/20/19 at 12:30 P.M. during an interview with STNA #106 she verified Resident #13 had not eaten any breakfast or lunch and verified the resident had not been assisted to eat breakfast or lunch on 03/20/19 She stated this was normal for the resident. She stated the resident likes sweets and she thinks the nurses give her a supplement. After the interview, STNA #106 left the dining room. At 12:50 P.M., STNA #106 returned to the dining room and removed Resident #13 from the dining room. On 03/20/19 at 1:30 P.M. during an interview with the Director of Nursing she stated an STNA from 100 and two STNA from the 200 hall hall was scheduled to be in the dining room for breakfast. An STNA from the 300 hall and two STNA from the 200 hall was scheduled to be in the dining room for lunch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 15 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on medical record review, observation, resident and staff interview, manufacturer recommendations and interview with the dressing manufacturer representative, the facility failed to ensure a resident received treatments consistent with professional standards of practice to promote healing and prevent infection to an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). This affected one (Resident #55) of one resident reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 55. Findings include: Record review for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, anemia, arteriosclerotic heart disease, left kidney neoplasm, gangrene to bilateral toes due to arterial insufficiency, and unstageable pressure ulcer to left heel. Review of the admission Minimum Data Set (MDS) assessment, dated 03/02/19, revealed the resident had no cognitive deficits. She required extensive assistance of two staff for bed mobility, extensive assistance of one staff for transfers, and limited assistance of one staff member for ambulation in her room. She has a unstageable pressure ulcer to her left heel. Review of the Care Area Assessment (CAA) in section V of the admission MDS stated the pressure sore would be addressed in the plan of care. Review of the comprehensive plan of care dated 03/06/19 reveled a plan of care for skin integrity stating the resident was at risk for skin breakdown due to peripheral vascular disease, arterial ulcers wounds, and decreased mobility also the resident has arterial ulcers to bilateral toes with gangrene. The goals included the residents ulcers will not cause further complications, heal without complications, and residents skin will remain intact. Review of the wound assessment, dated 02/26/19, revealed the resident's left heel had an unstageable pressure ulcer measuring 0.3 centimeters (cm.) in length by 0.3 cm. in width and unable to determine depth. There was eschar (dry black scab) covering the pressure ulcer. The treatment was to apply skin prep (liquid protective barrier) twice a day, cover with Allevyn (silicone adhesive) dressing, and change the dressing every three days. Review of the measurements of the left heel unstageable pressure ulcer on 03/12/19 revealed the ulcer measured 0.2 cm. by 0.2 cm. with eschar. There were no changes noted to the wound and the treatment was not changed. On 03/19/19, the ulcer measured 0.5 cm. by 0.5 cm. The wound was described as have slough (soft moist dead tissue) in the wound. The depth of the wound was not measured. There were no changes to the wound treatment. Observation and interview with Resident #55 on 03/19/19 at 2:30 P.M. revealed the resident was in bed with her right leg hanging off the side of the bed. Her left foot and lower leg was in a boot. The resident verified she had an ulcer to her left heel upon admission to the facility. She stated she has peripheral vascular disease with very little arterial flow to her feet. She states she has pain all the time. She stated she does get some relief of pain in her feet when she lets them hang down off the side of the bed. She stated the doctor in the hospital told her this would help with the limited blood flow to her feet. She stated she tries to keep her left foot in the boot to relieve (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 16 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0686 pressure off of her left heel as she wants the pressure sore to her left heel to heal. Level of Harm - Minimal harm or potential for actual harm Observation of Licensed Practical Nurse (LPN) #152 providing the treatment to Resident #55 left heel ulcer revealed she entered the room, washed her hands and donned gloves. She removed the top border of the Allevyn dressing while the bottom border was attached to the resident's heel. While LPN #152 was removing the top border of the dressing, the resident was complaining of severe pain. There was a dime sized area of serosanguineous drainage (yellow liquid) with a brown border around the drainage on the dressing. The wound on with the left heel appeared to have an open area with no evidence of eschar or slough. LPN #152 applied skin prep to the entire area on the left heel. She allowed the skin prep to air dry and reapplied the soiled dressing. Residents Affected - Few Interview with LPN #152 on 03/20/19 at 2:10 P.M. verified the dressing to the resident's left heel was soiled with drainage. When asked why she did not change the soiled dressing to Resident #55's heel, she stated she could have but verified she did not. Interview with Director of Nursing (DON) on 03/20/19 at 2:15 P.M. she stated that was the purpose of the Allevyn dressing to absorb drainage from wounds and did not need to be changed for three days. Further review of the nursing progress note dated 03/20/19 at 3:30 P.M. stated the Certified Nurse Practitioner (CNP) was notified of the drainage from the resident's left heel. The treatment to the left heel ulcer was changed on 03/20/19 at 3:33 P.M. by the CNP. Further interview with the DON on 03/20/19 at 4:00 P.M. verified the treatment to the left heel was changed. She verified the CNP had given a verbal order to change the treatment due to drainage from the wound. She stated the CNP did not look at the wound as she trusts LPN #161's judgement in her wound assessment. Interview on 03/21/19 at 9:50 A.M. with LPN #161 verified on 03/20/19 she was made aware of Resident #55's wound to the left heel was open and draining based on surveyor observation. She verified she did not reassess the wound prior to notifying the CNP of the drainage and requesting a treatment change to the area. She verified the CNP did not assess the wound prior to changing the treatment. During a phone interview with Product Representative #300 for Allevyn on 03/21/19 at 2:00 P.M. verified Allevyn dressing was a single use product. She stated the dressing could be pulled back and reapplied if the wound was dry without drainage as it serves a protective barrier to prevent infection. She verified if the wound was open and there was drainage on the dressing it should not be peeled back and reapplied due to risk of infection. Review of the manufactures instructions for Allevyn dressings under the heading of precautions stated the Allevyn dressing is a single use product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 17 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 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 observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure a resident received recommended services to maintain range of motion. This affected one (Resident #12) of one residents reviewed for limited range of motion. The facility identified three residents with contractures. The facility census was 55. Findings include: Review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Medical diagnoses included atherosclerotic heart disease, diabetes mellitus, major depressive disorder, nontraumatic subarachnoid hemorrhage, contractures of right and left hands, gastrostomy status, altered mental status, heart failure, and dementia. Review of the resident's Minimum Data Set (MDS) assessment, dated 01/02/19, revealed the resident had moderate impairment in cognition. The resident experienced no behaviors or rejection of care during the assessment period. She required extensive assistance with two plus staff members for bed mobility, transfers, and dressing. Review of the resident's care plan, revised on 01/18/19, revealed she had contractures to her left lower arm and left hand. Her goal was to have no complications from her contractures. Interventions included daily soaks to her left hand during evening care and range of motion (ROM) will be performed with daily care. There was no mention of a splint. Review of the resident's occupational therapy (OT) Discharge summary, dated [DATE], revealed the resident had a contracture of her right and and left hand. Her goal to tolerate bilateral hand passive range of motion (PROM) and donning of inflatable carrot splint for two to three hours to maintain ROM for ease of cleansing bilateral hands and avoiding skin breakdown was not met. She did not tolerate greater than 75 minutes of splint wear. At discharge, she was tolerating the carrot splint to her left hand for 60-75 minutes. She continued to report minimal pain with completion of PROM. She did show gains in splint wear tolerance and decreased pain which allowed for increased wear time of splint. Recommendation was for staff to continue with splint placement as resident tolerated. Continued record review revealed a recommendation to caregivers document dated 07/11/18 that was titled carrot splint for contracture. Tasks included soak bilateral hands with warm water, check skin, PROM as patient tolerates, place carrot splint between thumb and pointer finger to line five or six for 60 minutes, use pump to fill with air. Precautions included cleanse and check skin for redness/breakdown of skin. Review of the resident's physician's orders revealed an order, dated 01/17/17, for five minutes to clean/soak and apply gentle range of motion to bilateral hands, between fingers and palm. Pat dry, (May increase time as tolerated by resident) once daily. This order was on the resident's Treatment Administration Record and signed daily by the nursing staff. Further review of the medical record revealed no indication the resident had an order for a carrot splint or evidence the resident was provided an opportunity to wear the carrot splint since her discharge from occupational therapy in 07/2018. Interview and observation with Resident #12 on 03/18/19 at 11:04 A.M. revealed the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 18 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few limitation in range of motion of bilateral hands. She did not have any splints on and none were observed in the room. The resident stated she did not wear hand splints or receive range of motion services. Interview with State Tested Nursing Assistant (STNA) #109 on 03/19/19 at 2:41 P.M. revealed the STNA staff did not perform range of motion for the resident. He was not aware of any splint devices for the resident. Interview with Licensed Practical Nurse (LPN) #135 on 03/19/19 at 3:14 P.M. revealed the resident received gentle range of motion (ROM) daily with hand soaks. She stated the nursing staff were responsible for the ROM. She stated the resident had a carrot splint in the past, but would not allow its use anymore. Interview with LPN #138 on 03/20/19 at 10:42 A.M. revealed she was not aware of any splints for the resident. Interview with Occupational Therapy Assistant (OTA) #205 on 03/20/19 at 10:47 A.M. verified OT had not worked with the resident since 07/2018. She verified the resident was discharged with a recommendation to continue carrot splint to the left hand along with other recommendations. OTA #205 observed the resident's room with surveyor and verified the resident's carrot splint was in the resident's drawer, but the pump was not found in the resident's room. The splint was buried under several items. During this observation, the resident stated staff had not placed the carrot splint in her hand for a very long time. She stated she would allow them to place the splint in her left hand if they wanted to. Interview with the Director of Nursing on 03/20/19 at 11:30 A.M. verified they had not been applying the resident's carrot splint as recommended by OT. She verified there was no indication the physician had declined to follow the OT recommendations. Review of a facility policy titled Program Guidelines: Contracture Prevention and Management Program, revised 06/06/17, revealed the purpose was to prevent or reduce contractures and deformity, and/or preserve range of motion of residual limb to allow for use of prosthesis if needed through the provision of range of motion, stimulation of circulation, and muscle strengthening exercises. Procedures included evaluate the need for splint/brace/prosthetic device use and assistance and refer to therapy as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 19 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 Based on observation, medical record review, staff interview and review of a manufacturer guideline, the facility failed to ensure a medication was administered correctly, resulting in a significant medication error. This affected one (Resident #17) of 14 residents observed for medication administration. The facility identified five additional residents receiving insulin. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 09/21/18. Medical diagnoses included dementia and diabetes mellitus. Review of the resident's physicians orders revealed an order for Novolog Flexpen insulin per sliding scale. The resident was to receive six units for a blood sugar of 271. Observation of medication administration on 03/20/19 at 11:01 A.M. for Resident #17 revealed Licensed Practical Nurse (LPN) #138 obtained the resident's blood sugar level of 271. She then prepared the resident's Novolog insulin Flexpen by turning the dial to six units. She then administered the insulin to the resident. She did not prime the Flexpen prior to administration. Interview with LPN #138 immediately following the observation verified she did not prime the insulin Flexpen prior to administering six units of insulin. Review of an undated manufacturer guideline for Basaglar KwikPen (Flexpen) revealed priming ensures the KwikPen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime KwikPen before each injection, the patient may get too much or too little insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 20 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on review of the facility menu and spread sheets, observation, and staff interview, the facility failed to provide the appropriate portion sizes for therapeutic diets as ordered by the physician for five residents (#6, #11, #16, #17, and #214) of 36 residents who were served lunch in the dining room. Findings include: Review of the menu for lunch on 03/20/19 revealed main entree was fried shrimp, cauliflower, and peach cobbler. Review of the spread sheet for lunch on 03/20/19 revealed residents on carbohydrate consistent diets prescribed by their physician were to receive a half portion of the peach cobbler. Observation of the dessert cart located in the dining room during lunch on 03/20/19 revealed dishes with peach cobbler. All of the cobblers appeared to be the same size. Observation and interview on 03/20/19 at 12:55 P.M. revealed Dining Assistant #300 was serving peach cobbler to the residents in the dining room from the dessert cart. After serving over half of the resident's in the dining room, Dining Assistant #300 verified all of the peach cobbler servings were the same size. When asked if any of the resident in the dining room were on a carbohydrate controlled diet, she stated she did not know and she would have to check her sheet which she did not have with her. She verified at that time she had served over half of the residents in the dining room peach cobbler. After the interview, she served the other residents in the dining room peach cobbler. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 21 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview, review of manufacturer guidelines, interview with manufacturer representative, policy review and review of the Ohio Department of Health form named Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, the facility failed to ensure proper hand hygiene was performed during a clean dressing change for one resident (#55) of one dressing change observed. The facility also failed to report an outbreak of gastroenteritis to the local/state health department in a timely manner. This affected 23 of 55 residents. The facility census was 55. Residents Affected - Some Findings include: 1. Observation of Licensed Practical Nurse (LPN) #152 providing the treatment to Resident #55's left heel ulcer. She entered the room, washed her hands and donned gloves. She removed the top border of the Allevyn dressing while the bottom border was attached to the resident's heel. While LPN #152 was removing the top border of the dressing, the resident was complaining of severe pain. There was a dime sized area of serosanguineous drainage (yellow liquid) with a brown border around the drainage on the dressing. The wound on with the left heel appeared to have an open area with no evidence of eschar or slough. LPN #152 applied skin prep to the entire area on the left heel. She allowed the skin prep to air dry and reapplied the soiled dressing. She removed her gloves, donned new gloves, and applied skin prep to the right heel . The right heel was intact with no skin breakdown. Interview on 03/20/19 at 2:10 P.M. with LPN #152 verified the dressing to the resident's left heel was soiled with drainage. When asked why she did not change the soiled dressing to Resident #55 heel she stated she could have but verified she did not. Interview with Director of Nursing on 03/20/19 at 2:15 P.M. she stated that is the purpose of the Allevyn dressing to absorb drainage from wounds and did not need to be changed for three days. Review of the manufactures instructions for Allevyn dressings under the heading of precautions stated the Allevyn dressing is a single use product. During a phone interview with Product Representative #300 for Allevyn on 03/21/19 at 2:00 P.M. verified the Allevyn dressing was a single use product. She stated the dressing could be pulled back and reapplied if the wound was dry without drainage as it serves a protective barrier to prevent infection. She verified if the wound was open and and there was drainage on the dressing, it should not be peeled back and reapplied due to risk of infection. Review of the undated facility policy titled Dressing Changes under step eight, nine and 10 stated to dispose of gloves, wash hands with soap and water, and put on a second pair of gloves after discarding a soiled dressing. 2. Review of the facilities Long Term Care Acute Gastroenteritis Surveillance Line list revealed the first resident to have Gastrointestinal symptoms was on 03/01/19 and the last resident to have symptoms was on 03/18/19, with a total of 23 residents. The first staff member to have gastrointestinal symptoms was on 03/06/19 and the last to have symptoms was on 03/14/19 for a total of 15 staff affected by the outbreak. The facility did not report the gastrointestinal outbreak until 03/19/19. Interview on 03/21/19 at 11:16 A.M. with the Director of Nursing (DON) verified the facility did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 22 of 23 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 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakes of Monclova Health Campus The 6935 Monclova 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 0880 Level of Harm - Minimal harm or potential for actual harm not test any of the resident's or staff for norovirus and reported to the health department on 03/19/19 of the gastroenteritis outbreak. Interview on 3/21/19 at 2:05 P.M. with the [NAME] County Health Department Supervisor verified the facility did not report the gastrointestinal outbreak at the facility until 03/19/19. Residents Affected - Some Review of the Ohio Department of Health form titled Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, from the Ohio Administrative Code Chapter 3701-3; Effective March 22, 2018, revealed facilities should report when they suspect an outbreak within the next business day. Review of the policy titled Infection Prevention and Control General Guidelines, dated 11/10/17, revealed the facility shall establish an infection prevention and control program that enables the facility to analyze patterns of known infections. Review of the policy titled Infection Prevention and Control Program, dated 11/10/17, revealed the Infection Prevention and Control Program designee should report communicable disease that are reportable to the local/state public health authorities. This deficiency substantiates Complaint Number OH00103295. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 23 of 23