Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, policy review, and staff interview, the facility failed to ensure call lights were
within reach and accessible. This affected one (Resident #318) of 31 residents reviewed for call light
placement. The facility census was 71.
Residents Affected - Few
Findings include:
Record review for Resident #318 revealed Resident #318 was admitted to the facility on [DATE]. Diagnoses
included systemic inflammatory response syndrome of non-infectious origin without acute organ
dysfunction, abdominal pain, diarrhea, congestive heart failure (CHF), weakness, end stage renal failure,
chronic obstructive pulmonary disease (COPD), multiple sclerosis, and morbid obesity due to excess
calories.
Review of the Minimum Data Set (MDS) assessment, dated 11/15/21, revealed Resident #318 was alert
and oriented to person, place and time and required substantial and/or maximal assistance for activities of
daily living (ADLs).
Review of the care plan, dated 11/15/2,1 revealed Resident #318 had a ADL self-care performance deficit
related to CHF, COPD, generalized weakness, obesity, pain and shortness of breath. Interventions included
two-person assist for bed mobility, toileting, transfers, and to encourage Resident #318 to use call light
when assistance was needed.
Observation and interview on 11/15/21 at 10:07 A.M. revealed Resident #318 was lying in bed with her
eyes open. The call light was noted to be laying across the recliner, approximately six feet away and out of
reach of Resident #318. Resident #318 was moving her hands around the bed. Resident #318 stated she
was trying to locate her call light for assistance regarding dialysis.
Interview on 11/15/21 at 10:16 AM with Social Service Director (SSD) #279 and Licensed Practical Nurse
(LPN) #288 confirmed the call light was out of reach and Resident #318 would not be able to reach it if she
required assistance. LPN #288 revealed Resident #318 was a two-person assist for ADLs.
Review of the facility's document titled Answering the Call Light, revised October 2010, revealed the facility
had a policy in place to respond to the resident's request and needs. When a resident was in bed or
confined to a chair, the call light should be within easy reach of the resident.
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 7
Event ID:
365430
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
11/18/2021
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 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, and staff interview, the facility failed to ensure Residents #169's wanderguard
(device used to alert staff of resident movement and potential exit seeking behaviors) was in place for a
valid medically necessary reason. This affected one (Resident #169) of one residents reviewed for
restraints. The facility identified there were zero residents with physical restraints. The facility census was
71.
Residents Affected - Few
Findings include:
Review of Resident #169's medical record revealed Resident #169 was admitted to the facility on [DATE].
Diagnoses included dementia.
Review of the census records for Resident #169's from 10/28/21 to 11/18/21 revealed Resident #169 had
never resided on the facilities locked behavioral unit.
Review of the Elopement section of the nursing admission assessment, dated 10/28/21, revealed Resident
#169 was not capable of leaving the building.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 11/05/21, revealed Resident
#169 was severely cognitively impaired and required extensive assistance for his activities of daily living.
Resident #169 exhibited no behaviors including wandering, hallucinations or delusions.
Review of the Elopement Risk assessment, dated 11/18/21, revealed the resident was at a low elopement
risk.
Review of the physicians orders for November 2021 revealed there were no orders for a wanderguard.
Review of the care plan for Resident #169 revealed no care plan indicating the need for a wanderguard.
Observation of Resident #169 on 11/18/21 at 9:45 A.M. revealed a wanderguard bracelet to the right ankle.
Interview with the Director of Nursing on 11/18/21 at 10:10 A.M. verified there was no order or care plan for
the wanderguard and that all clinical documentation indicated Resident #169 was not an elopement risk.
Follow up interview with the Director of Nursing on 11/18/21 at 10:20 A.M. revealed the wanderguard was
removed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 2 of 7
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
11/18/2021
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 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview, and review of the facility's policy, the facility failed to ensure residents were
provided bed hold notices when transferred to the hospital. This affected two (#66 and #67) of four
residents reviewed for hospitalization. The facility census was 71.
Findings include:
1. Review of the medical record for Resident #67 revealed Resident #67 had an admission date of
10/08/21. Diagnoses included sepsis, type two diabetes mellitus and acute kidney failure.
Review of a nursing note, dated 10/21/21 at 12:19 P.M. revealed Resident #67 was admitted to the hospital.
There was no documentation the resident or the resident representative was provided with a bed hold
notice.
2. Review of the medical record revealed Resident #66 revealed an admission date of 08/21/21. Diagnoses
included dementia, falls, wandering and chronic obstructive pulmonary disease.
Review of the nursing notes dated 10/03/21 through 11/08/21 revealed Resident #66 was transferred to the
hospital on [DATE], 10/18/21, and 11/07/21. Further review of the medical record revealed the resident and
the resident representative were not provided bed-hold notices.
Interview on 11/18/21 at 8:26 A.M. with the Administrator verified Resident #66 and Resident #67 were not
provided bed hold notices at the time of transfers to the hospital.
Review of the facility's policy titled Bed-Holds and Returns, revised 03/2017, revealed prior to transfers and
therapeutic leaves, residents or resident representatives would be informed in writing of the bed-hold and
return policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 3 of 7
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
11/18/2021
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on record review, observation, staff interview and review of the facility's policy, the facility failed to
ensure a medication cart and treatment cart were locked. This had the potential to affect nine residents (#7,
#17, #19, #23, #37, #38, #43, #63, and #217) residing in the secured unit who were independently mobile
with cognitive impairment. The facility census was 71.
Findings include:
Observation on 11/17/21 at 3:55 P.M. on the secured unit revealed the medication cart and the treatment
cart at the nursing station room were not locked. No staff were present in the nursing station room.
Resident #19 was standing in the nursing station room with his hand on top of the unlocked medication
cart.
Interview on 11/17/21 at 4:00 P.M. with the Director of Nursing (DON) verified the medication and treatment
carts were unlocked and should have been locked.
Record review revealed the facility identified Residents #7, #17, #19, #23, #37, #38, #43, #63, and #217
resided in the secured unit who were independently mobile with cognitive impairment.
Review of the facility's policy titled Storage of Medications, revised 04/2007, revealed compartments
(including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and
biologicals shall be locked when not in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 4 of 7
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
11/18/2021
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, and review of the facility's recipes, the facility failed to ensure food
was prepared in a way that was flavorful and palatable. This had the potential to affect all 71 residents who
received food from the kitchen.
Residents Affected - Many
Findings include:
Observation on 11/15/21 at 1:04 P.M. revealed a test tray had the following items on the tray: cranberry
juice, tapioca pudding, citrus grilled chicken, green beans, and mashed potatoes with gravy. The foods
items located on the test tray appeared appetizing in nature.
Evaluation on 11/15/21 at 1:04 P.M. of the food items on the test tray revealed the mashed potatoes with
gravy and green beans were without flavor and bland. Mashed potatoes and green beans appeared to have
no seasonings or condiments added to the tray for flavor.
Observation and interview on 11/15/21 at 1:05 P.M. revealed Dietary Staff (DS) #219 evaluated the test tray.
DS #219 confirmed the mashed potatoes with gravy and green string beans were absent of seasonings
and/or flavor.
Interview on 11/15/21 at 1:10 P.M. with DS #233 revealed during lunch trayline, she was required to prepare
more mashed potatoes. DS #233 revealed the first batch of the mashed potatoes contained butter, salt,
pepper, and garlic for seasoning. DS #233 revealed she did not add seasonings for flavoring to the second
batch of mashed potatoes or green beans.
Review of the facility's document for recipes for mashed potatoes and green beans revealed both food
items were to be seasoned with margarine, salt, and pepper. Review of the recipes revealed the facility did
not follow the recipes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 5 of 7
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
11/18/2021
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 0807
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides drinks consistent with resident needs and
preferences and sufficient to maintain resident hydration.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, policy review, and staff interviews, the facility failed to ensure residents request
and preferences for hydration were honored. This affected one (Resident #22) of one resident reviewed for
preferences honored. The facility census was 71.
Findings include:
Record review for Resident #22 revealed Resident #22 was admitted to the facility on [DATE] with
diagnoses including Type II diabetes mellitus without complications and hypertension.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 09/29/21, revealed Resident
#22 was moderately cognitively impaired.
Review of the care plan, dated 09/01/21, revealed Resident #22 was at risk for altered nutritional status
related to therapeutic diet and varied intake of current diet. Interventions included to encourage and/or
provide intake of fluids throughout the day, notify physician of any signs or symptoms of dehydration, and to
provide fluids based on preferences.
Review of the medical record for Resident #22 revealed there were no dietary restrictions.
Observation on 11/15/21 at 4:00 P.M. revealed Dietary Staff (DS) #219 informed Resident #22 he could not
have an extra can of soda.
Interview on 11/15/21 at 4:08 P.M. with DS #219 confirmed she told Resident #22 he could not have an
extra can of soda. DS #219 revealed Resident #22 could not have an extra can of soda due to him
receiving a can of soda with the lunch meal. DS #219 stated the residents were only allowed one can of
soda over the course of the day with each meal (breakfast, lunch, and dinner). DS #219 confirmed this was
normal protocol.
Interview on 11/15/21 at 4:10 P.M. with Dietary Manager (DM) #261 revealed if a resident requested an
extra drink, they should receive it until the item was depleted unless dietary restrictions were in place.
Interview on 11/18/21 at 10:31 A.M. with Dietitian #291 revealed Resident #22 weights and nutrition were
stable and required no diet restrictions. Dietitian #291 revealed Resident #22 was allowed snacks and soda
from the kitchen per his preference.
Review of the facility's policy titled Resident Rights, revised December 2016, revealed the facility had a
policy in place to treat all residents with kindness, respect, and dignity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 6 of 7
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
11/18/2021
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 - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, policy review, and staff interviews, the facility failed to store food and kitchen
equipment in accordance with professional standards for food service safety. This had the potential to affect
all 71 residents who receive food from the kitchen.
Findings include:
1. Observation on 11/15/21 at 8:30 A.M., during initial tour of the kitchen, with Dietary Manager (DM) #261
revealed three bags of cereal (Cornflakes, Cheerios, and [NAME] Krispies) opened and undated on the
bottom shelf in the dry storage area located near the rear of the kitchen adjacent to the walk-in refrigerator
and freezer.
Interview on 11/15/21 at 8:30 A.M. with the DM #261 confirmed three bags of cereal (Cornflakes, Cheerios,
and [NAME] Krispies) were opened and undated.
Observation on 11/15/21 at 8:32 A.M. revealed DM #261 removed the three bags of cereal from the shelf to
seal and date.
Observation on 11/15/21 at 11:38 A.M., during follow-up tour of the kitchen, revealed one bag of cereal
(Cornflakes) opened on the bottom shelf in the dry storage area located near the rear of the kitchen
adjacent to the walk-in refrigerator and freezer.
Interview on 11/15/21 at 11:39 A.M. with Dietary Staff (DS) #272 confirmed one bag of cereal was open
and located on the shelf. DS #272 revealed she forgot to seal the bag of cereal close.
2. Observation on 11/15/21 at 8:50 A.M. during initial tour of the kitchen also revealed a flour canister,
located near the kitchen door, with a flour scoop placed inside the canister.
Interview on 11/15/21 at 8:51 A.M. with DM #261 confirmed the flour scoop was placed inside the flour
canister. DM #261 revealed the flour scoop should not have been inside the flour canister.
Observation on 11/15/21 at 8:51 A.M. revealed DM #261 remove the flour scoop from flour canister.
Review of the facility's undated document titled Dry Storage and Supplies revealed the facility had a policy
in place that all non-perishable foods shall be stored in a manner that optimized food safety and quality. The
opened boxes or cans shall be stored in resealed containers and food bags that were labeled and dated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365430
If continuation sheet
Page 7 of 7
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F807 - Food and drink
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
FAQ · About this visit
Common questions about this visit
What happened during the November 18, 2021 survey of Carecore at Gaymont?
This was a inspection survey of Carecore at Gaymont on November 18, 2021. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Carecore at Gaymont on November 18, 2021?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.