Inspection·September 30, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident Council Meeting Minutes, dated 06/22/21, revealed residents voiced concerns with plastic silverware stating they are unable to cut meats and food being cold when passed in the hall. Residents present included Resident #9, #10, #19, #30, #37, #38, #44, and #48. Review of Resident Council Meeting Minutes, dated 07/27/21, revealed residents voiced concerns with plastic silverware. Residents present included Resident #5, #13, #10, #19, #38, #44, and #48. Review of Resident Council Meeting Minutes, dated 08/25/21, revealed residents voiced concerns with cold food. Residents present included Resident #2, #9, #30, #38, and #48. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 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 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 resident record review, observation, and staff interview; the facility failed to ensure fall interventions were in place in accordance with the plan of care. This affected one (#37) of three resident's reviewed for falls. The census was 52. Findings include: Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anorexia, Parkinson's disease, chronic obstructive pulmonary disease, heart disease, and hypertension. Review of a document titled, 48 Hour Baseline Care Plan dated 05/21/21, revealed Resident #37 was at risk for falls or lacks safety awareness. The history/observed triggers included placement in a new environment, takes medications that could potential adverse effects such as cathartics, analgesics, psychotropic, and/or hypoglycemic agents, diagnoses of disease or condition that increases risk for falls, and requires staff assistance and/or assistive devices for safe transfers and mobility. Interventions include assess for fall risk at admission and as needed until comprehensive care plan completed, provide assistive devices and ensure accessibility, keep call light within reach and encourage use of it, observe medications for side effects that could affect balance, cognition, or gait, and encourage and educate resident to utilize safety measures if applicable. Review of a physician order dated 05/27/21, revealed Resident #37 was not to be left unattended in the bathroom. Review of a care plan dated 06/04/21, revealed Resident #37 was at risk for falls related to assistance needed for transfers and a history of falls. Interventions included dycem to wheel chair, perimeter mattress to bed, ensure the floor is dry after shower. Observation on 09/27/21 at 4:54 P.M., of fall interventions for Resident #37, revealed the resident was sitting up in the wheel chair. There was no dycem located in the resident's wheel chair. Further observation revealed there was no perimeter mattress on the residents bed. Observation on 09/28/21 at 9:55 A.M., revealed Hospice Employee (HE) #369 was in the bathroom with Resident #37, assisting the resident with care. Continued observation revealed the HE #369, exited the bathroom leaving the resident in the bathroom, closed the door, and exited the resident's room. The HE #369 entered the hallway and walked down towards the nurse station to find a facility staff member to assist with the resident care. HE #369 and a staff member returned to Resident #37's room , entered the bathroom, and closed the door. Interview on 09/28/21 at 9:59 A.M., with HE #369 revealed HE #369 was in the bathroom with Resident #37 to assist the resident with a shower. HE #369 reported the resident was left unattended in the bathroom while the staff left the room to find someone to assist with transferring the resident off of the toilet. Continued interview with the staff revealed the reason HE #369 needed help with the transfer was because the drain on the bathroom floor was not draining the shower water very fast and the floor was covered with water, pooling in some areas. Further interview with HE #369 revealed the staff had attempted to dry the bathroom floor but there was to much water and the floor was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few able to be dried properly. Interview with HE #369 verified Resident #37 was left unattended in the bathroom with a wet floor. Observation on 09/28/21 at 10:02 A.M., of Resident #37's bathroom/shower area revealed the drain for the shower was located towards the middle of the room. The area of the shower was wet, there was water pooling in front of the sink, and the floor was wet surrounding the toilet. Interview and observation on 09/28/21 at 10:04 A.M., with Licensed Practical Nurse (LPN) #335 of Resident #37 revealed the resident was sitting in a broda wheel chair, there was no dycem in the wheel chair. Continued observation revealed there was no perimeter mattress on the residents bed. LPN #335 verified there was no dycem on the broda chair, on the standard wheel chair, or on the resident's recliner chair. An attempt was made to verify the type of mattress on the resident's bed but the LPN did not know if the mattress was a perimeter mattress or a regular mattress. Interview on 09/28/21 at 10:08 A.M., with Assistant Director of Nursing (ADON) #368 and observation of Resident #37's mattress verified the current mattress on Resident #37's bed was not a perimeter mattress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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, resident and staff interviews, the facility failed to ensure a resident was seen by a physician as required. This affected one (#38) of three residents reviewed for physician visits. The facility census was 52. Residents Affected - Few Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity, hypertensive heart and chronic kidney disease with heart failure, type two diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage three, hypothyroidism, sleep apnea, anxiety disorder, gout, hyperlipidemia, dysphagia, auditory hallucinations, delusional disorders, unspecified osteoarthritis, cervicalgia, and schizoaffective disorder depressive type. Review of the Minimum Data Set (MDS) assessment, dated 08/27/21, revealed Resident #38 was moderately cognitively impaired. Review of physician visits revealed Resident #38 met with a nurse practitioner monthly but has not met with a physician since 01/26/21. Interview on 09/28/21 at 9:32 A.M., with Resident #38 revealed the resident had not met with a primary care physician. Resident #38 stated he meets with a nurse practitioner but has not met with a physician at the facility. Interview on 09/29/21 at approximately 3:00 P.M., with the Director of Nursing verified Resident #38 has not met with physician since January 2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview; the facility failed to ensure a resident's environment was free from electrical wires being exposed. This affected one (#33) of 24 residents observed for the environment. The census was 52. Finding include: Observation on 09/27/21 at 3:25 P.M., of Resident #33 and the resident's room revealed wires were coming out of a hole in the wall in the resident's room. The hole in the wall and exposed wires appeared to be in the spot were a call light box and call light cord should be located. There was a bell placed on the resident's bed side table. Interview on 09/30/21 at 10:34 A.M., with the Director of Maintenance (DOM) verified there were wires hanging out of a hole in the wall in Resident #33's room. The DOM revealed the wires were for the call light box, which, should be affix to the exterior of the wall. The DOM revealed the call light box was laying on a shelf next to the wall and the call light cord was wrapped around the side rail on the resident's bed. The DOM reported call lights were a priority to be fixed. The DOM reported he/she was not notified of Resident #33's call light being broken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 6 of 6