Inspection·March 6, 2025

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 Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure residents were provided with scheduled bathing. This affected three residents (#20, #35, and #52) of five residents observed for activities of daily living. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 01/17/25 with diagnoses of osteomyelitis of right ankle and foot, streptococcus, Pseudomonas aeruginosa (P. aeruginosa), unspecified open wound of right foot, peripheral vascular disease, atrial fibrillation, heart disease, heart failure, pericardial effusion, type two diabetes mellitus, nonrheumatic mitral valve insufficiency, nonrheumatic mitral valve insufficiency, protein-calorie malnutrition, low back pain, weight loss, hypertension, anemia, chest pain, cardiomyopathy, tachycardia, hyperkalemia, orthostatic hypotension, embolism and thrombosis of other arteries, stricture of artery, fecal impaction, orphoyngeal dysphagia, hypomagnesemia, malaise, nicotine dependence, urinary retention, hyperlipidemia, hypo-osmolality and hyponatremia, acidosis, pneumonia, and sepsis. Review of the admission Minimum Data Set (MDS) assessment, dated 01/23/25, revealed a Brief Interview of Mental Status (BIMS) score of 06, indicating Resident #20's cognition was severely impaired. Concurrent review of the MDS assessment revealed Resident #20 was dependent for personal hygiene. Review of the facility shower schedule revealed Resident #20 was scheduled to receive showers every Tuesday and Friday in the evening. Review of the facility shower schedule for 01/17/25 through 03/05/25 revealed Resident #20 was scheduled to receive 14 showers/baths. The resident only received showers or baths on seven dates, 01/22/25, 01/31/25, 02/03/25, 02/10/25, 02/13/25, 02/27/25, and 03/03/25 during this time. Interview on 03/05/24 at 2:22 P.M. with the Director of Nursing (DON) and Regional Nurse #241 verified that Resident #20 only received seven baths showers from 01/17/25 through 03/05/25. 2. Review of the medical record for Resident #35 revealed an admission date of 01/22/25 with diagnoses including metabolic encephalopathy, syncope and collapse, dehydration, acute kidney failure, type two diabetes mellitus, dementia, heart disease, occlusion and stenosis of bilateral carotid arteries, aortic valve stenosis, iron deficiency anemia, hypomagnesemia, fall, orthostatic hypotension, hyperlipidemia, hypertension, presence of cardiac pacemaker, old myocardial infarction , dizziness and giddiness, history of falling, thrombocytopenia, Vitamin B12 deficiency, benign prostatic hyperplasia (BPH), and gastro-esophageal reflux disease (GERD). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 366406 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 03/06/2025 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)