Health inspection·January 15, 2025

F 0684 vomiting, diarrhea, or treatment for symptoms related to the Norovirus. Level of Harm - Minimal harm or potential for actual harm Interview on 01/15/25 at 9:21 A.M., Resident #34 revealed she became very ill with a stomach virus around Christmas. She reported she was throwing up violently and had extreme nausea and diarrhea. She reported she asked nursing for something to help with the vomiting and was told they did not have a physician's order to give her anything. She reported she remembered crying out and asking for help due to being extremely ill and having pain while vomiting related to her fractured ribs. Residents Affected - Few Interview on 01/15/25 at 11:57 A.M., Therapy Director #100 reported he recalled Resident #34 having the Norovirus around Christmas time, limiting their therapy. He stated he could remember responding to her when he heard her scream out from her room, she complained of having stomach pain when he responded. He stated the nurse was aware. Interview on 01/15/25 at 1:57 P.M. Registered Nurse (RN) #101 reported she was working in Resident #34's area on 12/21/24 and 12/22/24, but she could not remember if she was one of the residents who had symptoms of the Norovirus, or if she requested nausea medications. She reported when someone became symptomatic, it was the facility policy to complete a change of condition assessment, notify the physician, and obtain orders to evaluate symptoms. Interview on 01/15/25 at 2:05 P.M. Certified Nursing Assistant (CNA) #102 reported she was usually scheduled to work the hallway of Resident #34. She reported around Christmas 2024, the resident became very ill with a stomach virus. She reported she recalled the resident having nausea, vomiting, and bad diarrhea. She stated she was sick for several days and her nurse, Registered Nurse (RN) #101 was aware. Interview on 01/15/25 at 2:42 P.M. CNA #103 revealed she recalled Resident #34 getting sick with a stomach virus around Christmas 2024. She reported she was ill for several days with nausea, vomiting, and diarrhea. Interview on 01/15/25 at 3:55 P.M. with Regional Director of Nursing #104 revealed the facility had an outbreak of the Norovirus that started on 12/18/24. He reported that nursing staff were instructed to complete a change of condition assessment, notify the physician, and obtain medication orders to alleviate symptoms. He confirmed the facility did not follow their procedure related to a change in condition for Resident #34, including notifying the physician and obtaining medication to help relieve symptoms. Phone interview on 01/15/25 at 6:20 P.M., Family Member #105 stated a few days before Christmas 2024, Resident #34 became ill with a stomach virus. She was in a lot of stomach pain and was vomiting. She stated she attempted to contact the nurses, but was not able to get through. She revealed she was able to speak with the Administrator and reported her concerns to him and asked if the resident could please have some nausea medication. Phone interview on 01/16/25 at 10:41 A.M. with the facility Administrator revealed he did get call in December 2024 from Family Member #105. He reported she was concerned that Resident #34 was ill and requesting nausea medication. He continued that he reported the concern to the nurse managers in their morning meeting. Review of the facility policy, Change in a Resident's Condition or Status last revised December 2016 revealed the facility shall promptly notify the resident, his or her attending physician, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365324 If continuation sheet Page 2 of 3 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 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 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 0684 Level of Harm - Minimal harm or potential for actual harm representative of changes in the residents medical/mental condition and/or status. The Nurse would notify the residents attending physician or physician on-call when there had been a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement in the resident status that impacted more than one area of the resident's health status. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00160682. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365324 If continuation sheet Page 3 of 3