Health inspection·March 1, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident room ceilings were maintained in good repair. This affected five residents (#25, #45, #50, #59, #72) of six residents reviewed for the physical environment. The facility census was 71. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 03/05/21 with diagnoses including schizophrenia and dementia. Review of the annual Minimum Data Set (MDS) assessment for Resident #50 dated 01/10/24 revealed the resident had severe cognitive impairment. Review of the medical record for Resident #25 revealed an admission date of 09/03/22 with diagnoses including dementia and type two diabetes mellitus. Review of the annual MDS assessment for Resident #25 dated 12/19/23 revealed the resident had severe cognitive impairment. Observation on 03/01/24 at 10:37 A.M. in the shared room of Residents #25 and #50 revealed an area approximately two feet by one and half feet on the ceiling with 50 or more discolored brown circular areas. Interview on 03/01/24 at 10:40 A.M. with Dietary Manager (DM) #100 confirmed the presence of discolored areas on Resident #25 and #50's ceiling. Interview on 03/01/24 at 10:43 A.M. with Director of Maintenance (DOM) #101 confirmed the stains on Resident #25 and #50's ceiling were there from a water leak that occurred approximately a year ago. 2. Review of the medical record for Resident #72 revealed an admission date of 07/15/22 with diagnoses including dementia and type two diabetes mellitus. Review of the quarterly MDS assessment for Resident #72 dated 01/04/24 revealed the resident had severe cognitive impairment. Observation on 03/01/24 at 10:45 A.M. revealed there was a small brown discolored area on the (continued on next page) 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 2 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 03/01/2024 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)