Health inspection·June 12, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few place during the day on 05/25/23. The night shift nurse did not check for placement until the morning of 05/26/23. It was at that time the patch was noted to be missing from Resident #70's left shoulder. The DON stated the resident's skin was seeping and he had poor skin integrity due to necrotizing fasciitis and they believed the patch just fell off of the resident. The DON stated Resident #70's sheets were changed frequently due to his skin seeping and it was unknown how many linen changes the resident had after the patch was applied. The DON stated staff looked for the patch in the garbage and on sheets but they were never able to locate the missing fentanyl patch. The DON confirmed hospice was contacted and the fentanyl patch was discontinued and new orders were received to increase other pain medications. While the DON stated she completed an investigation and provided staff education on controlled substances, she did not consider the missing fentanyl patch could be a misappropriation and verified it was not reported to the State Survey Agency. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the Administrator and other officials according to state law. In addition, the administrator or individual making the allegation reports to the state licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours for allegations that do not include abuse or serious bodily injury. This was an incidental finding discovered during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 2 of 5 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 06/12/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's investigation, staff interview, and review of the facility policy, the facility failed to complete a thorough investigation into a potential misappropriation of a resident's narcotics. This affected one (#70) of one resident reviewed for misappropriation. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #70's medical record revealed an admission date of 04/08/23 and a discharge date of 06/02/23. Diagnoses included necrotizing fasciitis, systemic inflammatory response syndrome, acute kidney failure, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact and received hospice care. Review of a plan of care focus area initiated 03/31/23 revealed Resident #70 had the potential for pain related to peripheral vascular disease, immobility, pressure ulcers, and osteoarthritis. Interventions included to administer medications per physician orders. Additional review of a plan of care focus area initiated 05/01/23 revealed Resident #70 had a terminal prognosis with hospice related to necrotizing fasciitis. Interventions included to administer medications per physician order and notify hospice if pain medication was ineffective. Review of the physician order dated 05/24/23, revealed Resident #70 was ordered fentanyl transdermal patch 75 micrograms/hour (mcg/hr) apply one patch transdermally every 72 hours. Review of the Controlled Substance Log revealed on 05/25/23 at 2:30 A.M., a 75 mcg/hr fentanyl patch was applied to Resident #70's left shoulder. Review of a nursing progress note dated 05/26/23 at 1:27 P.M. revealed a fentanyl patch was not present on Resident #70. The nurse was waiting on a return call from hospice to see about a new order. Review of the facility's investigation, completed 05/26/23, revealed staff interviews were conducted related to the missing fentanyl patch and staff education was conducted on the disposal of pain medication patches and controlled substances. The investigation did not include evidence of any additional investigation, including contacting the police, conducting staff toxicology screens, or resident interviews. Interview on 06/12/23 at 4:50 P.M. with the Director of Nursing (DON) revealed Resident #70 was on hospice services and was ordered a fentanyl patch for pain management. In the early morning hours of 05/25/23, a 75 mcg/hr patch was applied to the resident's left shoulder. The patch remained in place during the day on 05/25/23. The night shift nurse did not check for placement until the morning of 05/26/23. It was at that time the patch was noted to be missing from Resident #70's left shoulder. The DON stated the resident's skin was seeping and he had poor skin integrity due to necrotizing fasciitis and they believed the patch just fell off of the resident. The DON stated Resident #70's sheets were changed frequently due to his skin seeping and it was unknown how many linen changes the resident had after the patch was applied. The DON stated staff looked for the patch in the garbage and on sheets but they were never able to locate the missing fentanyl patch. The DON confirmed staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 3 of 5 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 06/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interviews were conducted and staff education was provided on controlled substances and the disposal of pain patches, but the police were not contacted regarding a potential controlled drug diversion, no staff were tested for controlled substances, and no residents were interviewed. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law, including, but not limited to, local law enforcement. In addition, the investigation must include, at a minimum, interviews of the person reporting the incident, interview of the resident or resident's representative, and interviews of other residents who may have been impacted. This was an incidental finding discovered during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 4 of 5 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 06/12/2023 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility job description, the facility failed to ensure Medication Technicians did not provide clinical assessment of resident needs. This affected one (#1) of three residents reviewed for clinical assessments. The facility census was 67. Residents Affected - Few Findings include: Review of the Resident #1's medical record revealed an admission date of 01/11/23. Diagnoses included schizoaffective disorder, dementia, osteoarthritis, atherosclerotic heart disease, and congestive heart failure (CHF). Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/26/23, revealed Resident #1 was severely cognitively impaired and received as needed pain medication. Review of the plan of care initiated 01/12/23 revealed Resident #1 was at risk for pain related to gastroesophageal reflux (GERD). Interventions included to administer medications as ordered, monitor for changes in behavior and mood that may indicate pain, and monitor for verbal and non-verbal signs and symptoms of pain. Additional review of a plan of care focus area initiated 02/09/23 revealed Resident #1 was at risk for abnormal bleeding or hemorrhage related to aspirin therapy. Interventions included to administer medications as ordered and monitor/document/report to the physician signs and symptoms of abnormal bleeding. Review of the physician orders revealed to monitor Resident #1 for signs and symptoms of bleeding every shift and monitor pain and document every shift. Review of the Treatment Administration Record (TAR) from 04/01/23 through 05/31/23 revealed Medication Technician (MT) #183 documented assessment of Resident #1's pain and signs and symptoms of bleeding on 04/22/23, 05/06/23, and 05/13/23. Interview on 06/12/23 at 2:02 P.M. with the Director of Nursing (DON) revealed a MT was like a nurse aide with a specialty to pass oral medications. The DON explained MTs passed oral medications and, in between, provided resident care. The DON stated if the MT believed there was a resident concern, such as pain, they were to get the nurse to complete a resident assessment. The DON stated any nursing activity outside of administering scheduled oral medication was outside the scope of practice for a MT. The DON verified on 04/22/23, 05/05/23, and 05/13/23, MT #183 documented pain levels and monitoring of signs and symptoms of bleeding for Resident #1. The DON confirmed there was no documentation indicating a licensed nurse had completed these assessments and verified the MT should not have documented the assessments were completed. Review of the Certified Medication Aide job description, dated 08/01/16, revealed the position was responsible for set up and administering medications under the supervision and direction of a Charge Nurse. This deficiency demonstrates non-compliance investigated under Complaint Number OH00143296. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 5 of 5