Inspection·June 6, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm room and verify the refusal. Further interview with RN #485 revealed the documentation of a refused shower was required in the nurse's notes as well as in the caregiver charting in the electronic medical record. Continued interview with RN #485 revealed they have encountered several residents who stated they were dissatisfied with not getting showers and who were not offered showers and staff were instead documenting the residents refused their showers. Residents Affected - Few Interview on 06/04/24 at 3:26 P.M., with the Director of Nursing (DON) and Regional Clinical Support Registered Nurse (RN) #610 revealed Resident #48 has had two showers since his admission on [DATE]. Review of policy titled, Guidelines for Bathing Preference, revised on 12/31/23, revealed bathing would occur at least twice a week unless resident preferences stated otherwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 2 of 11 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 06/06/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review of staff schedules, review of posted staffing, and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 56 residents residing in the facility. The census was 56. Findings include: Review of facility staffing schedules and posted staffing information from 05/02/24 to 06/02/24 revealed there was no Registered Nurse (RN) coverage in the facility on 05/18/24 or 05/19/24. Interview on 06/06/24 at 2:04 P.M., with the Director of Nursing (DON) verified there was no RN on duty in the facility on 05/18/24 and 05/19/24. The DON reported they had RN's on call but not in the facility. This deficiency represents non-compliance investigated under Complaint Number OH000154300. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 3 of 11 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 06/06/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 and staff interviews, the facility failed to timely obtain laboratory test as ordered by the physician. This affected one (#25) of two residents reviewed for hospitalization. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 01/11/21, with diagnoses of type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease stage 3, and hypokalemia (low potassium). Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 had severely impaired cognition and required supervision or touching assistance for eating, and substantial/maximal assistance for all other activities of daily life. Review of a progress note dated 05/10/24, by Certified Nurse Practitioner (CNP) #600, revealed Resident #25 was evaluated after a fall without injury or pain and after recently elevated blood sugars, and CNP #600 requested laboratory tests thyroid stimulating hormone (TSH), hemoglobin A1c (HbA1c), complete blood count (CBC) and a comprehensive metabolic panel (CMP). Review of a physician order dated 05/12/24 revealed a Comprehensive Metabolic Panel (CMP) laboratory test was ordered for Resident #25. Review of a progress note dated 05/16/24 by CNP #600 revealed the laboratory tests were still pending. Review of a progress note dated 05/21/24, by CNP #600, revealed the laboratory tests ordered 05/10/24 had not been drawn. Further review revealed CNP #600 reminded the facility to draw labs ordered 05/10/24: HbA1c, TSH, CMP, CBC. Review of a physician order dated 05/21/24 revealed a CMP laboratory test was ordered for Resident #25. Review of the CMP laboratory test drawn 05/28/24, with results available on 05/30/24, revealed Resident #25's BUN was critically high at 78 milligrams per deciliter (mg/dL) (normal range of 6-21 mg/dL), her creatinine (an indicator of kidney function) was high at 2.4 mg/dL (normal range 0.5-0.9 mg/dL) and her potassium was high at 5.6 millimoles per liter (mmol/L) (normal range of 3.5-5.1 mmol/L). Review of a physician order dated 05/30/24 revealed Resident #25's order for bumetanide was on hold. The order was discontinued on 06/02/24. Review of a progress note dated 05/31/24 at 7:13 A.M., by CNP #600, revealed Resident #25's laboratory tests were reviewed, and CNP #600 requested the facility send the laboratory tests with medication list and vital signs to Resident #25's nephrology clinic. Interview on 06/05/24 at 3:08 P.M., with the Director of Nursing (DON) revealed the laboratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 4 of 11 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 06/06/2024 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 0770 tests ordered on 05/12/24 and 05/21/24 for Resident #25 were not entered into the electronic system correctly and therefore were not drawn as ordered. 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 5 of 11 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 06/06/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, review of resident diet list, and review of the menu spreadsheet, the facility failed to provide adequate portions of protein and mashed potatoes to residents on a mechanical soft diet. This had the potential to affect all 10 residents on a mechanical soft diet (#10, #16, #19, #20, #27, #30, #44, #262, #309, and #310). Additionally, the facility failed to provide adequate portions of protein and vegetables to residents on a pureed diet. This affected all four residents on a pureed diet (#4, #18, #37, and #40). The facility census was 56. Findings include: Observation during meal service on 06/04/24, between approximately 12:00 P.M. and approximately 12:25 P.M., revealed staff used a #12 scoop (2 2/3 ounce) to serve mechanical soft Salisbury steak, pureed Salisbury steak, and mashed potatoes. Further observation revealed staff used a #16 scoop (2 ounce) for pureed peas. Review of the the menu spreadsheet revealed the mechanical soft Salisbury steak portion should be 5 1/3 ounces and the mashed potatoes portion should be 4 ounces. The pureed Salisbury steak portion should be 4 ounces and the pureed peas portion should be 3 ounces. Review of a facility provided list of diets revealed 10 residents (#10, #16, #19, #20, #27, #30, #44, #262, #309, and #310) were on a mechanical soft diet and 4 residents (#4, #18, #37, and #40) on a puree diet. Interview on 06/04/24 at approximately 12:33 P.M., with the Director of Food Service (DFS) #459 confirmed the scoops sizes used to serve the mechanical soft and pureed Salisbury steak, and the mashed potatoes were 2 2/3 ounces and the scoop used to serve the pureed peas was 2 ounces. Further interview and concurrent review with the the menu spreadsheet revealed the mechanical soft Salisbury steak portion should be 5 1/3 ounces and the mashed potatoes portion should be 4 ounces. Additionally, DFS #459 confirmed the pureed Salisbury steak portion should be 4 ounces and the pureed peas portion should be 3 ounces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 6 of 11 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 06/06/2024 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Some Based on medical record review, review of medication administration records, review of staffing assignments, and review of Certified Registered Medication Aide (CRMA) licenses, the facility failed to ensure licensed staff were administering medications. This affected 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) of 24 residents reviewed for medication administration. The facility census was 56. Findings include Review of the CRMA licenses for State Tested Nursing Assistant (STNA) #433 and STNA #407 revealed their CRMA licenses for administering medications had expired on [DATE]. Review of the staff assignment sheets revealed STNA #433 administered medications with an expired license on [DATE], [DATE], [DATE], and [DATE]. STNA #407 administered medications with an expired license on [DATE], [DATE], [DATE], and [DATE]. Review of the medication administration records for 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) revealed STNA #433 and/or STNA #407 had administered the residents' medications while working with expired medication certification licenses. Interview on [DATE] at 8:44 A.M., the Administrator revealed the facility had identified the two medication technicians working with expired licenses. Interview on [DATE] at 11:40 A. M.,with Regional Clinical Support Registered Nurse (RCSRN) #610 revealed the facility reviewed all events for all the residents, removed the two medications technicians from the schedule for administering medications, and verbally educated the two staff members to renew their licenses. RCSRN #610 revealed ongoing assessments of residents were completed by the nurses and a daily check of the administration compliance report for all residents showed no medication errors. As a result of the incident, the facility took the following actions to correct the deficient practice by [DATE]: • On [DATE], STNA #433 and STNA #407 were removed from the schedule as administering medications and remain of the CRMA schedule. • On [DATE], the Director of Nursing assessed the 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) and there were zero change in condition events. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 7 of 11 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 06/06/2024 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 0839 • Level of Harm - Minimal harm or potential for actual harm On [DATE], all CRMA licenses were verified to be active on [DATE], by the staffing scheduler. • Residents Affected - Some Beginning on [DATE], the staffing scheduler/designee would verify via the Ohio Board of Nursing all CRMAs licenses were active monthly. The Director of Nursing will be mointoring this to ensure it is completed monthly. • On [DATE], review of the CRMA licenses for the four medication aides in the facility revealed the licenses for STNA #433 and STNA #407 remained expired. Review of the licenses for CRMA #436 and CRMA #480 were active through [DATE]. • On [DATE] at 1:09 P.M., interview with STNA #433 revealed she had been educated by the facility to renew her medication administration certification license. STNA #433 verified she had administered medications with an expired license. • On [DATE] at 12:08 P.M., interview with STNA #407 verified she had administered resident medications with an expired license. STNA #407 verified the facility had educated her to renew her medication administration certification license. This deficiency represents non-compliance investigated under Complaint Number OH000154300. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 8 of 11 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 06/06/2024 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 2. Review of the medical record for Resident #26 revealed an admission date of 05/02/24. Diagnoses included congestive heart failure, type two diabetes mellitus with foot ulcer, atrial fibrillation, malignant neoplasm of the colon, and hypertension. Residents Affected - Some Review of plan of care dated 05/03/24 revealed the resident required enhanced barrier precautions during high-contact care related to presence of wound with dressing change. Review of a physician order dated 05/03/24 revealed staff to use enhanced barrier precautions, wear a gown and gloves at minimum during high-contact care activities. Observation on 06/03/24 at 12:42 P.M., revealed Resident #26 had no enhanced barrier precaution sign posted on her door or in her room. Interview on 06/03/24 at 12:57 P.M., with Registered Nurse (RN) #485 verified Resident #26 was on enhanced barrier precautions and no sign was posted regarding the enhanced barrier precautions. Review of the policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, last revised 04/02/24, revealed no guidelines for sign placement for a resident on enhanced barrier precautions. Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure personal protective equipment (PPE) was worn by staff while performing care for a resident in contact precautions. This affected one (#307) of one resident reviewed for transmission based precautions and had the potential to affect all residents on the 100-hall (#20, #30, #39, #41, #47, #311, #312, #313, and #314). Additionally, the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted appropriately for residents. This affected one (#26) of four residents reviewed for EBP. The facility census was 56. Findings include: Review of the medical record for Resident #307 revealed an admission date of 05/28/24, with a diagnosis of Clostridium difficile (C. diff). Review of the admission Observation and Data Collection completed 05/28/24 revealed Resident #307 was alert and oriented to person, place and time and had no impaired cognition. Further review revealed Resident #307 was continent of bladder and bowel. Review of the baseline careplan dated 05/28/24 revealed Resident #307 had a current infection of C. diff and was in isolation for C. diff and isolation precautions would be implemented. The type of isolation (contact/droplet) was not identified on the assessment. Review of the physician order dated 05/29/24 to 06/03/24 revealed Resident #307 was in contact precautions due to C. diff. Observation on 06/03/24 at 8:40 A.M., revealed Resident #307's room with a Contact Precautions sign posted outside the room and a plastic PPE cart was outside the room next to the doorway. The Contact Precautions sign stated providers and staff must put on gloves before room entry, put on gown (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 9 of 11 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 06/06/2024 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 Residents Affected - Some before room entry and discard gloves and gown before exiting the room. Further observation revealed Licensed Practical Nurse (LPN) #460 in Resident #307's room not wearing PPE. LPN #460 exited the room and used hand sanitizer. Interview on 06/03/24 at 8:42 A.M., with LPN #460 confirmed Resident #307 was in contact precautions for C. diff and further stated no PPE was required when providing care unless staff were coming in contact with areas that may have been soiled by stool, such as bedding or brief changes. LPN #460 confirmed he was in Resident #307's room to provide her a glass of water and was not wearing PPE. LPN #460 further confirmed the expected hand hygiene after exiting her room was hand sanitizer. Observation on 06/03/24 at 9:03 A.M., revealed State Tested Nurse Aide (STNA) #445 in Resident #307's room. Resident #307 was dressed and sitting in a chair with her breakfast tray on the overbed table in front of her. STNA #445 was not wearing PPE in the room while she removed a napkin from Resident #307's lap, moved her meal tray from the overbed table to the dresser, moved her tray table, picked up Resident #307's tennis shoes and tied the shoes on Resident #307's feet. STNA #445 then brought Resident #307's walker within reach and stood by while Resident #307 walked to the bathroom, entered the bathroom alone and closed the door. Interview on 06/03/24 at 9:06 AM., with STNA #445 confirmed Resident #307 was in contact precautions. STNA #445 confirmed she did not wear any PPE while providing assistance to Resident #307. STNA #445 stated PPE was only required when providing toileting hygiene assistance to Resident #307. Upon prompting by the surveyor during the interview, STNA #445 performed hand hygiene by using hand sanitizer. Observation on 06/03/24 at 3:04 P.M., revealed Resident #307 in her room with Occupational Therapy Assistant (OTA) #630. A Contact Precautions sign and PPE cart remained outside Resident #307's room. OTA #630 was not wearing PPE in the room. Interview on 06/03/24 at 3:05 P.M with OTA #630 confirmed Resident #307 was in contact precautions, and confirmed she did not wear PPE while providing care to Resident #307. OTA #630 stated PPE was only required if staff provided care after Resident #307 had a bowel movement. Observation on 06/04/24 at 5:52 A.M., revealed STNA #511 in Resident #307's room, not wearing PPE. A Contact Precautions sign and PPE cart was outside Resident #307's room. STNA #511 closed the door. Continued observation at 6:02 A.M., revealed STNA #511 exited Resident #307's room carrying a bag of trash. STNA #511 confirmed she did not wear PPE when providing care to Resident #307. STNA #511 stated she touched Resident #307's hand to assist her up to her walker, then Resident #307 walked herself to the bathroom and was in the bathroom during the interview. STNA #511 confirmed Resident #307 was in contact precautions and stated PPE was only required when providing care after a stool. STNA #511 carried the trash to the soiled utility room. STNA #511 confirmed she had not washed her hands since exiting Resident #307's room and proceeded to the bathroom on the 100-hall nurses station to wash her hands. Interview on 06/04/24 at 7:42 A.M., with the Assistant Director of Nursing (ADON)/Infection Preventionist confirmed Contact Precautions means a gown and gloves should be donned prior to entering the room for any reason. Additionally, hand hygiene after potential contact with C. diff should be soap and water, not just hand sanitizer. Review of policy titled, Guidelines for Contact Precaution, revised 02/28/24, revealed Contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366406 If continuation sheet Page 10 of 11 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 06/06/2024 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Precautions are indicated to prevent and control transmission of C. diff, among other healthcare-associated infections. PPE guidance included wearing gloves before contact with the resident or environmental objects. Hands should be washed after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects. Additionally, a fluid resistant gown should be worn when entering the room when there is likelihood that organisms from blood, urine, stool or wound drainage may be on surfaces or items in the resident's room. Event ID: Facility ID: 366406 If continuation sheet Page 11 of 11