Health inspection·November 18, 2021

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. Page 1 of 7 365430 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 2 of 7 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 3 of 7 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 4 of 7 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 5 of 7 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 6 of 7 365430 11/18/2021 Gaymont Care and Rehabilitation 66 Norwood Ave Norwalk, OH 44857

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. 365430 Page 7 of 7