Health inspection·October 3, 2019

F 0679 her roommate and family that visit. Level of Harm - Minimal harm or potential for actual harm However, no specific interest were listed on the card that included specific individualized self guided points of interest. Residents Affected - Few According to activity participation documentation between 09/01/19 to 10/02/19 the resident was offered four opportunities of participation. Of the four opportunities the resident refused once. The documentation did not indicate what activity the resident refused or the specific detail of the three activities of participation. On 10/02/19 at 10:40 A.M. interview with the Activity Director (AD) #159 verified the plan of care and care card lacked specific activity interest for the resident. Further interview confirmed the resident was in her room sleeping in a recliner with no meaningful activity being provided and the room also lacked individual or self driven activity items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 2 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician orders, review of wound care notes, resident interview, staff interviews, and policy review, the facility failed to clarify physician orders for a pressure relieving cushion and wound treatments. This affected one (#71) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 87. Residents Affected - Few Findings include Review of the medical record revealed Resident #71 revealed the resident was admitted on [DATE]. Diagnoses included pulmonary fibrosis, delusional disorders, and hypertension. Review of a wound care physician Initial Wound Evaluation and Management Summary, dated 05/08/19 revealed Resident #71 had an unstageable deep tissue injury (DTI) to the sacrum. The area measured 4.3 centimeters (cm) in length by 1.8 cm in width by zero cm in depth. The resident was ordered daily dressing changes. Physician recommendations included to off-load the wound and reposition the resident per facility protocol. The physician also recommended a low air loss mattress and a gel cushion to the resident's chair. The physician noted the resident was oriented to person, place and situation. The physician noted the resident was calm and co-operative. Review of a physician order dated 05/08/19 revealed Resident #71 was ordered a pressure reducing chair cushion. Review of the physician's weekly wound care notes dated 05/15/19, 05/22/19, 05/30/19, 06/05/19, 06/12/19, 06/19/19, 06/26/19, 07/03/19, 07/10/19, 07/17/19, 07/24/19, 07/31/19, 08/07/19, 08/14/19, 08/21/19, 08/28/19, 09/04/19, 09/11/19, 09/18/19, 09/25/19 revealed there was a physician recommendation for a gel cushion to the resident's chair. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a stage four pressure ulcer. Review of a physician wound evaluation and management summary dated 09/11/19 revealed the residents wound had improved. The physician ordered a hydrocolloid sheet twice a week for nine days, change on Sunday and Wednesday. Also, apply calcium alginate twice a week for 16 days under duoderm, change on Sunday and Wednesday. Review of a physician wound evaluation dated 09/18/19 revealed the resident's wound had improved. The physician ordered a hydrocolloid sheet and calcium alginate twice a day but also stated to change on Sundays and Wednesdays. Review of the nurses notes dated 09/11/19 through 09/25/19 revealed no documentation the wound care dressing change orders were clarified with the physician. Review of the Treatment Administration Record (TAR) from 09/11/19 through 09/27/19 revealed the twice a week and twice a day ordered hydrocolloid and calcium alginate treatments were only completed once daily on 09/12/19, 09/19/19 and 09/26/19. Further review of the weekly wound evaluation and management summary dated 09/25/19 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 3 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0686 Level of Harm - Minimal harm or potential for actual harm resident's wound measured two cm in length by one cm in width by 0.6 cm in depth with undermining. The wound had light serous drainage with 10% granulation tissue. No change in the wound was noted. A new wound treatment was ordered. The physician noted the resident chronically slept in the reclining chair. The resident refused a pressure reduction mattress. The resident wondered why the wound was not healing faster. The resident wanted everything done to maximize healing. Residents Affected - Few Review of the nurses' notes dated 05/08/19 through 09/30/19 revealed no documentation the facility initiated the use of a gel cushion in the resident's chair. There was no documentation the resident had refused a gel cushion to her chair. Observations on 09/30/19 at 12:06 P.M., on 10/01/19 at 9:20 A.M. and on 10/02/19 at 11:14 A.M. revealed Resident #1 had a foam pressure reducing cushion in her recliner chair. Telephone interview on 10/01/19 at 3:54 P.M. with the Wound Care Physician (WCP) #500 revealed the resident's wound had no change at her last evaluation. WCP #500 revealed she had recommended a gel cushion to the resident's recliner. WCP #500 revealed a gel cushion would be better than a foam cushion. WCP #500 revealed she would have expected the wound to heal faster with a gel cushion. Interview on 10/01/19 at 11:07 A.M. with Licensed Practical Nurse (LPN) #207 verified the resident had a foam pressure reliving cushion. LPN #207 revealed the resident refused to sleep in a bed. The resident slept in her recliner. Interview on 10/02/19 at 11:14 A.M. with Resident #71 revealed she chose to sleep in her recliner. Resident #71 revealed the staff had never talked to her about using a gel cushion in her recliner. Resident #71 revealed she always had the foam cushion in her recliner. Resident #71 stated she would use the gel cushion if it would help her wound heal. Interview on 10/02/19 at 11:46 A.M. with the Director of Nursing (DON) revealed the physician wrote an order for a pressure reducing cushion and had not specified a foam cushion or gel cushion in the order. The DON revealed the gel cushion was only a recommendation. The DON revealed the facility had not clarified the recommendation with the physician. Further interview on 10/02/19 at 12:30 P.M. with the DON revealed the physician should have told them if the resident needed a different type of cushion. Interview on 10/02/19 at 2:36 P.M. with LPN #207 revealed she reviewed the physician's wound care notes and orders. LPN #207 revealed the physician never specified the type of cushion. LPN #207 revealed she never clarified the type of cushion with the physician because the facility used foam cushions and the resident preferred a foam cushion. LPN #207 verified there was no documentation the resident had tried a gel cushion. LPN #207 verified there was no documentation the resident had refused a gel cushion. LPN #207 was not aware of any gel cushions in the facility. Interview on 10/03/19 at 09:58 AM with LPN #207 revealed the treatment changes the physician referenced in the treatment plan notes dated 09/11/19 and 09/18/19 were never clarified with the physician. LPN #207 revealed the physician had not wrote any orders for the treatment changes. LPN #207 further revealed there was no documentation the physician had decided not to follow the new wound treatment plan. Telephone interview on 10/03/19 at 12:46 P.M. with WCP #500 revealed on 09/11/19 and 09/18/19 she made her recommendations and it was up to the facility to follow up with the attending physician. WCP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 4 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #500 revealed she could not recall if she wrote an order for the wound dressing treatment recommendations dated 09/11/19 and 09/18/19. Review of the policy, Prevention of Pressure Ulcers/Injuries, last revised 07/17, revealed to select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, preferences and overall risk factors. Further review of the policy revealed for staff to review pressure ulcer interventions and strategies for effectiveness on an ongoing basis. Event ID: Facility ID: 365430 If continuation sheet Page 5 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, facility urinary incontinence protocol, the facility failed to ensure urinary continence was promoted. This affected one resident (#2) reviewed for urinary incontinence. Facility census 87. Findings include: Resident #2 admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, insomnia, dysphagia, blindness, peripheral vascular disease, Parkinson's disease, hypertension, obesity, venous insufficiency, major depression, cerebral vascular disease, inflammatory liver disease, and chronic obstructive pulmonary disease. A bowel and bladder evaluation dated 06/19/19 and 09/19/19 noted the resident to not always void appropriately without incontinence daily, always aware of need to toilet, with no identified type of incontinence and no need for a toileting program due to being continent of bowel and bladder. Review of the most current minimum data set (MDS) assessment dated [DATE] identified the resident with severely impaired vision, adequate hearing, understood/understands, alert, oriented and able to make needs known. No rejection of care was recorded on the assessment. Further review noted the resident to require extensive physical assistance of one staff with toileting, dressing, transfer, bed mobility, and frequently incontinent of urine without the use of a toileting program. On 09/19/19, a plan of care was revised addressing Resident #2's bladder incontinence due to decreased attention to bladder cues. Interventions included staff to assist with incontinence as needed, apply moisture barrier cream with incontinence care, clean peri-area with each incontinence episode as Resident #2 will allow, and monitor for signs and symptoms of urinary tract infection, including blood tinges urine, foul smelling urine, urinary frequency. According to Resident #2's bladder function documentation recorded between 07/01/19 and 09/30/19 the resident was identified to be incontinent of urine daily. Further review of the medical record lacked documentation to determine the origin of urinary incontinence of strategies to promote bladder continence. Observation were noted as follows; on 10/01/19 at 7:43 A.M., a pervasive, strong urine odor was detected in Resident #2's room. A large yellow stain was on the bed sheet, with brown/yellow stain to the floor next to the bed and a urinal hanging on trash can at bedside empty. At 9:48 A.M., the resident was laying on the bed with the stained bed and floor. A strong urine odor was continued inside the room. At 12:10 P.M., the Resident was sitting in the dining room. The top sheet on the bed was soiled with large yellow damp liquid. A strong urine odor was pervasive inside the room and a urinal containing a small amount inside was hanging from the trash can next to bed. At 3:13 P.M., the Resident was on the bed with brown/yellow residue to the floor with a strong urine odor pervasive inside the room. On 10/02/19 at 7:47 A.M., the room was with a strong urine odor with the floor remaining soiled with a brown/yellow substance. On 10/02/19 8:35 A.M. interview with the resident revealed they were unaware of the odor at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 6 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedside and confirmed wearing adult briefs due to urinary incontinence. The resident stated facility staff assist with changing the briefs. On 10/02/19 at 8:45 A.M. interview with state tested nurse aide(STNA) #104 revealed the residents urinary status had been declining over time, approximately the past four years. STNA #104 confirmed the odor at the bedside and soiled linen. STNA #104 stated Resident #2 would not allow staff to assist but once during a 12 hour shift to cleanse and change brief related to associated urinary incontinence. Further interview revealed occurrences of urinary incontinence while sitting in the dining room. On 10/02/19 at 10:14 A.M. interview with the Director of Nursing (DON) and Assessment Nurse (AN) #217 verified bladder assessment documentation listed the resident as continent of bladder and identified no type of incontinence. No strategies were placed on the incontinence plan of care to promote bladder continence or address the urinary odor contained inside the residents room. The DON and AN #217 confirmed they were noted aware the resident had experienced bladder incontinence episodes inside the dining room, the decline in urinary status or recognized nurses aides were recording bladder incontinence daily. According to the urinary incontinence clinical protocol revised September 2012, nurses shall assess and document/report changes in urinary status including, identifying circumstances related to incontinence. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve individual's continence status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 7 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure appropriate technique for tracheostomy care and failed to wear a face mask and eyewear when performing tracheostomy care. This affected one (Resident #89) resident of one reviewed for tracheostomy care. The facility census was 87. Residents Affected - Few Findings Include: Review of Resident #85's medical record revealed an admission date of 08/18/15 with diagnoses including encounter for attention to tracheostomy, chronic respiratory failure, anoxic brain damage and disturbances of salivary secretions. Review of the care plan revealed the resident had a tracheostomy related to respiratory failure and vegetative state following an accident. Interventions included to use universal precautions per facility policy and provide trach care every shift and as needed. Observation on 10/02/19 at 11:37 A.M., of tracheostomy care with License Practical Nurse (LPN) #205 and LPN #207 revealed during tracheostomy care LPN #205 picked up a towel that was draped over Resident #89 and wiped off mucous secretions from the tracheostomy when doing tracheostomy care. Then LPN #207 picked up the same towel and wiped away mucous from the tracheostomy. Interview on 10/02/19 at 11:43 A.M., with LPN #205, LPN #207 verified they did use the towel to wipe off mucous secretions and did not wear mask or eyewear while performing tracheostomy care. Review of the facility policy titled Tracheostomy Care, undated, the purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. A mask and eyewear must be worn if splashes, splattering, or spraying of blood or body fluids is likely to occur when performing this procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 8 of 9 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 365430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and policy review, the facility failed to ensure food temperature was obtained before serving from the steam table and failed to ensure staff wore proper hair covers while serving food from the dementia unit. This had the potential to affect twenty (Resident #14, #23, #27, #28, #29, #30, #36, #41, #49, #60, #61, #65, #67, #79, #81, #88, #91, #242, #244, #292), residents identified by the facility that ate in the Maple and dementia unit dining rooms. The facility census was 87. Findings Include: 1. Observation on 10/01/19 at 12:02 P.M., of the dining in the dementia unit revealed Activity Director (AD) #159 walking behind the steam table getting a cup and accessing the refrigerator without a hair net. Interview 10/01/19 at 12:08 P.M., with AD #159 verified not wearing a hair net while in the area of the the steam table and getting food and drinks from the refrigerator. Review of facility policy titled Hair Restraints, undated, revealed hair shall be restrained to prevent physical contamination of food. 2. Observation on 10/02/19 at 12:03 P.M., of the steam table food temperatures located in the dementia unit revealed the temperature of the puree beef was 122 degrees and the steam table was cold to touch. Observation 10/02/19 12:31 P.M., of the Maple dining room steam table revealed no food temperatures were taken once food was placed on the steam table before serving meal. Interview on 10/02/19 at 12:35 P.M., Dietary Aide (DA) #158 the food was only temped in the kitchen and not after placing on the dining rooms steam tables. Review of facility policy titled Food Temperature Maintenance During Holding, dated 09/2019, revealed food temperatures were held at temperatures to promote palatability and maintain quality of meals, prevent bacterial growth and retain nutritional value. Food temperatures were held upon completion of cooking, prior to start of meal serve, and whenever a new pan of food was put in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 9 of 9