Health 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). Page 1 of 4 366406 366406 03/06/2025 Lakes of Monclova Health Campus The 6935 Monclova Road Maumee, OH 43537

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the admission MDS assessment, dated 01/28/25, revealed a BIMS score of 13, indicating Resident #35 was cognitively intact. Concurrent review of the MDS for Resident #35 revealed he was dependent for personal hygiene. Review of the facility shower schedule revealed Resident #35 was supposed to receive showers every Monday and Thursday in the evening. Review of the facility shower schedule for 01/22/25 through 03/05/25 revealed Resident #35 was supposed to receive 12 showers or baths. The resident only received showers or baths on eight dates, 01/24/25, 01/30/25, 02/26/25, 02/28/25, 02/18/25, 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 #35 only received eight baths or showers from 01/22/25 through 03/05/25. Interview on 03/05/25 at 2:45 P.M. with Resident #35 revealed he does not feel that he received adequate baths or showers. Resident #35 states he would prefer to have showers, but he receives baths more often than showers. 3. Review of the medical record for Resident #52 revealed an admission date of 09/23/24 with diagnoses of hypertensive heart disease, acute kidney failure, peripheral vascular disease, pleural effusion, protein-calorie malnutrition, anemia, chronic respiratory failure, rheumatoid arthritis, atrial fibrillation, generalized muscle weakness, hypomagnesemia, and heart failure. Review of the most recent quarterly MDS assessment, dated 02/14/25, revealed a BIMS score of 13, indicating Resident #52 was relatively cognitively intact. Concurrent review of the MDS assessment revealed Resident #52 required substantial/maximal assistance with showers/bathing. Review of the facility shower schedule revealed Resident #52 was supposed to receive showers every Monday and Thursday in the morning. Review of the facility shower schedule for 01/01/25 through 03/05/25 revealed Resident #52 was supposed to receive 18 showers or baths. The resident only received showers on 15 dates, 01/02/25, 01/06/25, 01/10/25, 01/13/25, 01/16/25, 01/20/25, 01/22/25, 01/23/25, 01/27/25, 01/30/25, 02/03/25, 02/06/25, 02/10/25, 02/13/25, 02/24/25, 02/27/25, and 03/03/25 during this time. Review of the facility shower schedule revealed Resident #52 did not receive a shower or a bath for 9 days during the period of 02/14/25 through 02/23/25. Interview on 03/05/25 Interview on 03/05/24 at 2:22 P.M. with the Director of Nursing (DON) and Regional Nurse #241 verified that Resident #52 only received 15 showers from 01/01/25 through 03/05/25 and that Resident #52 went 9 days between showers form 02/14/25 through 02/23/25. Review of the facility policy titled, Guidelines for Bathing Preference, dated 05/11/16, revealed the resident shall determine their preference for bathing upon admission. Bathing shall occur at least twice a week unless resident states otherwise. This deficiency represents non-compliance investigated under Complaint Number OH00158264. 366406 Page 2 of 4 366406 03/06/2025 Lakes of Monclova Health Campus The 6935 Monclova Road Maumee, OH 43537

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the medical record, and review of facility policy, the facility failed to ensure there were appropriate receptacles placed inside of the doorway to resident rooms to doff (remove) personal protective equipment (PPE) into. This affected two residents (#7 and #20) who were in Enhanced Barrier Precaution (EBP) isolation of five residents reviewed for isolation. The facility identified 11 residents (#1, #3, #5, #6, #7, #10, #16, #20, #24, #35, #52) residents in EBP isolation. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 01/04/24 with diagnoses of dementia, Alzheimer's disease, bipolar disorder, protein-calorie malnutrition, hypertensive chronic kidney disease (CKD), anxiety, hyperlipidemia, Vitamin D deficiency, white matter disease, seizures, restlessness and agitation, weakness, benign prostate hyperplasia (BPH), edema, malaise, dry eye syndrome, insomnia, difficulty in walking, and generalized muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was unable to be obtained due to Resident #7 being unable to complete the interview. Observation on 03/05/25 at 8:14 AM revealed a sign outside Resident #7's room indicating the resident was in EBP. Observation on 03/05/25 at 8:14 A.M. of Resident #7's room revealed there was no receptacle inside to discard used PPE into. Interview on 03/05/25 at 8:18 A.M. with LPN #158 verified there was no receptacle in Resident #7's room to discard used PPE into. 2. 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 (PVD), 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 (HTN), anemia, chest pain, cardiomyopathy, tachycardia, hyperkalemia, orthostatic hypotension, embolism and thrombosis of other arteries, stricture of artery, fecal impaction, oropharyngeal dysphagia, hypomagnesemia, malaise, nicotine dependence, urinary retention, hyperlipidemia, other signs and symptoms concerning food and fluid intake, hypo-osmolality and hyponatremia, acidosis, pneumonia, and sepsis. Review of the admission MDS assessment, dated 01/23/25, revealed a BIMS score of 06, indicating Resident #20's cognition was severely impaired. Observation on 03/05/25 at 7:09 A.M. revealed a sign outside Resident #20's room indicating the resident was in EBP. Observation on 03/05/25 at 7:47 A.M., when exiting Resident #20's room, revealed there was no 366406 Page 3 of 4 366406 03/06/2025 Lakes of Monclova Health Campus The 6935 Monclova Road Maumee, OH 43537

F 0880 receptacle to discard used PPE into. Level of Harm - Minimal harm or potential for actual harm Interview on 03/05/25 at 7:47 A.M. with Licensed Practical Nurse (LPN) #175 verified there was no receptacle in Resident #20's room to discard used PPE into. Residents Affected - Few Interview on 03/06/25 with Registered Nurse (RN) #151 revealed staff is required to doff PPE prior to exiting a resident's room who is in isolation. Concurrent interview with RN #151 revealed there should be a receptacle inside of every resident who is in isolation to doff used PPE into. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 04/01/24, revealed EBP will be in place during high-contact care activities for residents with the following conditions: - all residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. - all residents with indwelling medical devices, including but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes. 366406 Page 4 of 4