Inspection·April 25, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm had no way of calling for staff assistance as her call light was out of reach. She gestured to the bed where the call light was observed wrapped around the mobility bar on the side of the bed against the wall. Interview on 04/23/24 at 9:06 A.M., with the Administrator verified Resident #51's call light was not in reach. She returned the call light to Resident #51 and went to summon additional assistance from direct care staff. Residents Affected - Few Observation and interview on 04/23/24 at 12:57 P.M., revealed Resident #51 seated in her wheelchair eating lunch. She was facing the television in her room with her bed behind her. Resident #51 stated she was done eating and wanted to lie down but again did not have her call light. The call light was observed underneath blankets on the bed behind the resident. Observation and interview on 04/23/24 at 1:00 P.M., with State Tested Nurse Aide (STNA) #101 verified Resident #51's call light was not in reach. STNA #101 provided Resident #51 with her call light and verified she was able to use it to make her needs known. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 2 of 16 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 04/25/2024 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)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure a resident's preference for showers was honored. This affected one (#4) of one resident reviewed for choices. The facility census was 70. Findings include: Review of the medical record for Resident #4 revealed an admission date of 12/10/21. Diagnoses included chronic kidney disease, hypertension, and systolic heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bathing/showers. Review of the task documentation for scheduled bathing revealed the resident had received bed baths on 03/27/24 and 04/10/24. The resident received showers on 03/30/24, 04/03/24, 04/06/24, 04/13/24, 04/17/24, and 04/20/24. Review of the nurses notes dated 03/27/24 through 04/11/24 revealed no documentation the resident had refused her shower or wanted a bed bath instead of a shower on 03/27/24 and 04/10/24. Interview on 04/22/24 at 8:21 A.M., with Resident #4 revealed she preferred showers in the mornings on Wednesdays and Saturdays. Resident #4 revealed she was not given the choice of a shower twice in the last month because the staff were too busy. Interview on 04/23/24 at 4:09 P.M., with the Director of Nursing (DON) verified the resident was documented as having bed baths on 03/27/24 and 04/10/24. The DON was unaware why the staff gave the resident a bed bath instead of a shower. Review of the undated policy titled, Resident Rights, revealed all residents would be treated with kindness, respect, and dignity and the residents had a right to self-determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 3 of 16 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 04/25/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#53) of one resident reviewed for advanced directives. The facility census was 70. Findings include: Review of the medical record revealed Resident #53 had an admission date of [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, hypertension, type two diabetes mellitus, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care initiated [DATE] revealed the resident's code status was Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) meaning providers would treat patient as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. Review of the undated electronic medical record face sheet revealed the resident was listed with a full code status (cardiopulmonary resuscitation (CPR) measures). Review of the physician's orders dated [DATE] in the electronic medical record revealed the resident was listed with a full code status. Review of the paper chart revealed in the advance directives tab the resident had a signed Do Not Resuscitate (DNR) order for DNRCC-Arrest (DNRCC-A) dated [DATE]. Review of a Care Plan Meeting Attendance and Notes document dated [DATE] revealed the resident's code status was reviewed and the resident had chosen a DNRCC-A code status. Interview on [DATE] at 2:43 P.M., with Licensed Practical Nurse (LPN) #152 verified the resident's code status did not match in the electronic medical record and the paper medical record. Review of the undated policy titled, Advance Directives, revealed physician's orders would be consistent and updated with the resident's treatment preferences and/or advance directive. Code status would be determined based on physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 4 of 16 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 04/25/2024 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)

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 observations, medical record review, staff interview, and policy review, the facility failed to ensure a resident with a pressure ulcer was provided pressure ulcer prevention interventions. This affected one (#122) of two resident identified by the facility with pressure ulcers. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #122's medical record revealed an admission date of 04/03/24, with medical diagnoses including stroke, protein calorie malnutrition, anemia, and chronic obstructive pulmonary disease (COPD). Review of Resident #122's admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #122 had cognition impairment with a Brief interview for Mental Status (BIMS) score of 12. Resident #122's height was four feet eight inches and the weight listed was 75 pounds. The assessment additionally revealed Resident #122 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed, granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) to her coccyx. Review of Resident #122 wound evaluation notes dated 04/03/24 confirmed she was admitted with a stage III pressure ulcer located on the coccyx. The records identified a treatment was ordered. Review of Resident #122's admission physician orders dated 04/03/24 identified no pressure ulcer interventions, except for a wound treatment. Review of a 04/22/24 (first day of survey) physician order revealed an order for an alternating air mattress for wounds, check function every shift. The physician order did not list the settings the air mattress should be set on (ie; alternating/static; and weight settings) or in accordance with manufacture's instructions. Observation on 04/22/24 at 12:51 P.M., of Resident #122 in a wheelchair in the main dinning room. Resident #122 was observed sitting directly on the wheelchair seat with no cushion and or pressure relief devices. Resident #122 was observed to be placed into a soft recliner chair on 04/22/24 at 1:11 P.M. Resident #122 was again observed with no pressure relief cushions to the recliner chair in her room. Resident #122 was observed to have an alternating air mattress located on the bed. Interview on 04/24/24 at 10:17 A.M., with Resident #122 confirmed she mostly sleeps in her recliner. Observation and interview on 04/22/24 at 1:16 P.M., with Registered Nurse (RN) #162 confirmed there was no pressure relief devices located in Resident #122's wheelchair and or recliner and she had been up in both. The interview confirmed the physician order dated 04/22/24 does not have the settings the air mattress should be on or in accordance with the manufacture's instructions. Review of a wound evaluation completed by the facility Certified Wound Nurse #200 dated 04/15/24, revealed the wound evaluation identified recommendations to include Pressure reduction mattress per facility protocol, off load heels per facility protocol, wheelchair pressure reduction cushion per facility protocol, reposition per facility protocol, and nutritional consult per facility protocol. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 5 of 16 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 04/25/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Requests were made from 04/23/24 through 04/25/24 during the annual survey for the facility written pressure reduction mattress, offloading heel, wheelchair cushion and nutritional consults protocols. The facility was never able to provide these protocols. Review of the policy titled Prevention of Pressure Injuries dated April 2020, identified the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The Support Surfaces and Pressure Redistribution section identified; 1. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. Event ID: Facility ID: 365430 If continuation sheet Page 6 of 16 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 04/25/2024 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, staff interviews, and policy review, the facility failed to develop and implement a comprehensive, effective, and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as recommended, and/or to recognize and address severe resident weight loss. Actual Harm occurred when Resident #122, who was admitted with an unplanned significant weight loss and tested positive for COVID -19 two days after admission, experienced a severe weight loss of 17.6% pounds, within 21 days of admission. Upon admission on [DATE], Resident #122 weighed 75 pounds and on 04/25/24 Resident #122 weighed 61.8 pounds. The nutritional recommendations for Resident #122 that were made on 04/09/24 were not implemented and Resident #122 did not receive the recommended supplements of a frozen nutritional treat twice a day. This affected one (#122) of two residents reviewed for nutrition. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #122's medical record revealed an admission date of 04/03/24 with medical diagnoses including stroke, protein calorie malnutrition, anemia, and chronic obstructive pulmonary disease (COPD). Review of the admission nursing assessment dated [DATE], revealed Resident #122 was admitted from the hospital with significant weight loss that was unplanned. Review of Resident #122's written plan of care for nutrition dated 04/04/24 revealed provide nutritional supplements as ordered by the physician. Review of Resident #122's admission weight dated 04/04/24 revealed Resident #122's weight was 75.0 pounds. Review of the dietitian admission evaluation note completed on 04/09/24 revealed Resident #122 was admitted from another nursing home facility following a hospitalization. Resident #122 tested positive for COVID-19 on 04/05/24. The assessment revealed Resident #122 was able to feed herself on a regular diet. The notes revealed Resident #122's body mass index (BMI), a measurement of body fat based on height and weight, was 15.6 indicating the resident was underweight (healthy range is 18.5 to 24.9). The dietitian recommended a frozen nutritional treat two times a day to encourage protein and calorie intake and promote healing and gradual weight gain. Review of Resident #122's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 had cognition impairment with a Brief Interview for Mental Status (BIMS) score of 12. Resident #122's height was four feet eight inches and the weight listed was 75 pounds. Additionally, the assessment revealed Resident #122 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to her coccyx. Review of the Nutrition Care Area Assessment (CAA) dated 04/10/24 revealed the resident had a low BMI and there was a need for a plan of care for nutrition. Review of Resident #122's weight dated 04/11/24 revealed Resident #122's weight was 62.8 pounds. This was a 12.2-pound weight loss since admission which indicated a 16.3 percent severe weight loss. Review of the dietitian's note dated 04/16/24 revealed Resident #122's weight was 62.8 pounds on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 7 of 16 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 04/25/2024 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)

F 0692 Level of Harm - Actual harm 04/11/24 and this was a significant weight decrease. The dietitian's note stated to 'continue' frozen nutritional treat two times a day to encourage intake and promote healing. The dietitian's note did not address the nutritional interventions were not implemented as recommended on 04/09/24 and there were no new nutrition interventions recommended. Residents Affected - Few Review of Resident #122's weight dated 04/18/24 revealed Resident #122's weight was 64.2 pounds. Review of Resident #122's medication administration records, treatment administration records, and physician orders for April 2024, revealed no evidence of frozen nutritional treat started until 04/23/24. Review of the physician's orders dated 04/23/24 revealed an order to provide frozen nutritional treat, two times a day. Interview on 04/23/24 at 10:23 A.M. with Registered Dietitian (RD) #137 revealed she was not able to enter physician's orders into the resident's medical record. RD #137 has to give her nutrition recommendations to the nursing staff to enter into the resident's medical record. RD #137 confirmed on 04/09/24, when she made the recommendation for the frozen nutritional treat to be started twice a day to the nursing staff, the orders were not entered. RD #137 confirmed there was no evidence Resident #122 was receiving the recommended nutritional supplement until 04/23/24, when the physician order was placed into the computer. RD #137 confirmed the dietitian's progress notes dated 04/16/24 did not address Resident #122's severe weight loss from 04/04/24 through 04/11/24 at 62.8 pounds or any new interventions at that time. RD #137 confirmed she did not check to ensure her recommendations from 04/09/24 were actually entered and implemented for Resident #122. Review of a physician order dated 04/23/24 (following the interview with RD #137) revealed an order for additional nutritional interventions of Boost Breeze (a high calorie nutritional supplement drink) and weekly weights on Thursdays. Interview and observation on 04/23/24 at 12:46 P.M. revealed Resident #122 did have the frozen nutritional supplement offered. Resident #122 stated she could not remember if she had ever gotten a frozen nutritional treat before. Observation on 04/25/24 at 8:07 A.M. revealed Resident #122's weight was obtained by State Tested Nursing Aide (STNA) #106. Resident #122 weighed 61.8 pounds. This was a 2.2-pound weight loss (3.7%) in one week, and a 13.2-pound weight loss in 21 days, indicating a 17.6 percent severe weight loss since admission to the facility. Review of the policy titled, Weight Assessment and Interventions, dated 2001, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain, as appropriate, in light of the resident's right to refuse food/fluid, the resident's right to consume food/fluid of choice, and the resident's express wishes in Advanced Directive, if any. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss/gain = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight loss/gain. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 8 of 16 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 04/25/2024 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)

F 0692 3 months - 7.5% weight loss/gain. Level of Harm - Actual harm c. Residents Affected - Few 6 months - 10% weight loss/gain. The Dietitian or his/her designee should discuss undesired weight gain with the resident, resident's legal representative and/or resident's responsible party. Interventions for undesirable weight loss/gain may be based on any of the following (not all inclusive): a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may impact meal consumption; d. Environmental factors that may affect appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing or digestion; g. The use of supplementation as recommended by dietician and/or physician; h. The use of feeding tubes; i. End of life decisions and advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 9 of 16 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 04/25/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents receiving supplemental oxygen had complete physician's orders for oxygen administration. This affected three (#45, #62, and #224) of three residents reviewed for respiratory care. The facility identified 13 residents who required the use of supplemental oxygen. The facility census was 70. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 02/24/24. The resident was hospitalized from [DATE] to 04/19/24, for a spontaneous pneumothorax (collapsed lung). Medical diagnoses included malignant neoplasm of the lung and/or bronchus, chronic obstructive pulmonary disease (COPD), malnutrition, and weakness. Review of Resident #45's care plan, dated 02/27/24, revealed the resident to have impaired respiratory status related to COPD and cancer of the bronchus or lung. The interventions for the respiratory focus did not include an intervention of supplemental oxygen administration. Review of Resident #45's interdisciplinary progress notes revealed a note dated 04/19/24 at 12:00 P.M., indicating the resident had readmitted from a local hospital. The note indicated the resident was receiving supplemental oxygen. Review of Resident #45's physician's orders revealed no order for supplemental oxygen in the resident's record. Observation on 04/22/24 at 10:03 A.M., revealed Resident #45 lying in bed. The resident had a nasal cannula in place connected to an oxygen concentrator delivering supplemental oxygen at a rate of 3 liters per minute (lpm). There was an additional oxygen concentrator at the foot of the resident's bed, and a portable oxygen tank in a mobile stand in the resident's room. An interview with Resident #4, at the time of the observation, revealed the resident had a diagnosis of lung cancer, a recent hospitalization for a collapsed lung, and stated she had worn the oxygen since before she had gone to the hospital. Interview on 04/23/24 at 2:37 P.M., with Minimum Data Set (MDS) Nurse #162 verified Resident #45 had been using supplemental oxygen since her change in condition which led to her hospitalization. She verified Resident #45 did not have an order for supplemental oxygen until 04/22/24, when she placed the order into the electronic health record. MDS Nurse #162 identified the nurse who completed the readmission must have overlooked that the resident required supplemental oxygen upon the resident's return to the facility. Review of Resident #45's physician's orders revealed a new order dated 04/22/24 at 5:43 P.M., for continuous oxygen at 3 liters per nasal cannula every shift related to COPD. 2. Review of the medical record for Resident #62 revealed an re-admission date of 07/26/23. Medical diagnoses included COPD, emphysema, malignant neoplasm of the left lung or bronchus, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of Resident #62's care plan, dated as initiated 07/06/23 and revised on 07/10/23, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 10 of 16 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 04/25/2024 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident has an impaired respiratory status related COPD, emphysema, history of smoking, respiratory failure and shortness of breath. Care plan approaches include to administer oxygen as ordered by the physician. Review of Resident #62's physician's orders revealed an order dated 07/19/23 which stated liters received 2 L(liters) via nasal cannula. The order did not specify if the liters received were referring to oxygen, and there was no mention of whether the resident was supposed to receive continuous or intermittent oxygen administration. Observation on 04/22/24 at 1:26 P.M., revealed an oxygen concentrator in Resident #62's room, in the on position and set to 2 lpm, connected to nasal cannula tubing which was observed draped across Resident #62's bed. Resident #62 was seated in her recliner in her room. Observation on 04/23/24 at 9:10 A.M., revealed Resident #62 in her room, with her oxygen tubing draped over the left armrest of her recliner. Resident #62 states she is sometimes short of breath but wasn't sure if she was supposed to wear the oxygen all the time or not. Interview on 04/23/24 at 2:37 P.M., with MDS Nurse #162 verified Resident #62's order for oxygen did not specify oxygen or whether it should be administered continuously or on an intermittent basis. MDS Nurse #162 verified the order should specify whether supplemental oxygen should be administered on a continuous or an intermittent basis so it is clear to staff. 3. Review of the medical record for Resident #224 revealed an admission date of 04/11/24. Medical diagnoses included COPD, diabetes mellitus, and orthopedic aftercare. Resident #224 was discharged to home on [DATE]. Review of Resident #224's care plan, dated 04/12/24, revealed the resident had impaired respiratory status related to COPD with an intervention which included to provide oxygen as needed for difficulty breathing. Review of Resident #224's interdisciplinary progress notes revealed orders dated 04/13/24 at 10:13 A.M., 04/14/24 at 2:28 P.M. and 04/19/24 at 9:47 A.M., referencing Resident #224 requiring the use of supplemental oxygen. Review of Resident #224's physician's orders revealed an order dated 04/22/24 at 6:14 P.M., for continuous supplemental oxygen per nasal cannula at 2 lpm. Observation on 04/22/24 at 12:50 P.M., of Resident #224 revealed the resident in bed, with supplemental oxygen in place per nasal cannula. An interview with Resident #224, at the time of observation, revealed she had worn oxygen since her admission to the facility. Interview on 04/23/24 at 2:37 P.M., with MDS Nurse #162 verified Resident #224 had received supplemental oxygen since admission, but did not have a physician's order until the evening of 04/22/24. MDS Nurse #162 stated she did not believe the resident wore oxygen at home but had worn it off and on since admission to the facility. Review of the undated policy titled, Oxygen Administration revealed the purpose is to provide guidelines for safe oxygen administration. The first step listed in the policy was to verify that there is a physician's order for this procedure. The policy additionally states to review the physician's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 11 of 16 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 04/25/2024 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)

F 0695 orders pr the facility's protocol for oxygen administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 12 of 16 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 04/25/2024 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)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, record review, and policy review, the facility failed to comply with the requirements for binding arbitration agreements of allowing up to 30 days to rescind the agreement and allow for a neutral arbitrator according to policy This affected three (#04, #37, and #52) of three residents reviewed for binding arbitration. The facility identified ten residents who had signed the facility's binding arbitration agreement. The facility census was 70. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #04 had an original admission date of 04/23/20 and a re-admission date of 12/10/21. Diagnoses included chronic kidney disease, hypertension, and systolic heart failure. Review of a form titled Arbitration Agreement, dated 04/24/20, revealed Resident #04 signed the form as agreeing to the facility's binding arbitration agreement on 04/24/20. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. 2. Review of the medical record for Resident #37 revealed an admission date of 04/11/20. Medical diagnoses included chronic pain, hyperlipidemia, anxiety, and depression. Review of a form titled Arbitration Agreement, dated 04/11/20, revealed Resident #37 signed the form as agreeing to the facility's binding arbitration agreement on 04/11/20. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. 3. Review of the medical record for Resident #52 revealed an admission date of 06/24/21. Medical diagnoses included hypertensive heart disease, heart failure, diabetes mellitus and depression. Review of a form titled Arbitration Agreement, dated 06/25/21, revealed Resident #37 signed the form as agreeing to the facility's binding arbitration agreement on 06/25/21. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. An attempted interview on 04/24/24 at 9:09 A.M., to reach the arbitration firm as listed on the facility's arbitration agreement was unsuccessful, with the website identified as not having an active server and an attempt to phone the number listed on the form revealed it led to an unrelated business. Interview on 04/24/24 at 10:24 A.M., with the Administrator verified the facility's arbitration form contained outdated contact information and provided new contact information for the listed arbitration firm. Interview on 04/24/24 at 2:38 P.M. with Receptionist #163 revealed she is responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 13 of 16 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 04/25/2024 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)

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completing admission paperwork upon admission. Receptionist #163 verified that residents are not required to sign the arbitration agreement as a condition of admission, and most of them don't. Receptionist #163 verified the current form the facility was using listed an arbitration firm who would be used and the form did not acknowledge or provide an option to use a neutral arbitrator. Additionally, Receptionist #163 verified the form stated the resident would have only 14 days to revoke the arbitration agreement, and was unaware the regulatory requirement specified the resident had 30 days to rescind the agreement. Interview on 04/24/24 at 3:55 P.M., with [NAME] President of Clinical Services (VPCS) #310 verified the facility had been using the wrong form for binding arbitration agreements. VPCS #310 provided a copy of the new form which indicated the arbitration process allowed for a selection of a neutral arbitrator and for residents to rescind the binding arbitration within 30 days of signing the form. Review of the policy titled Binding Arbitration Agreements, revised November 2023, revealed the residents or representatives are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether or not to enter into such agreements. Arbitration agreements provide for the selection of a neutral arbitrator who is an impartial and unbiased third-party decision maker. Upon admission, or any time during the resident's stay, the resident or representative may be presented with the opportunity to utilize a binding arbitration agreement to resolve disputes, as long as the terms and conditions of the agreement comply with federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 14 of 16 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 04/25/2024 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were timely cleaned and maintained in good repair. This affected four (#11, #53, #38, #21) of six residents reviewed for environment. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #11 had an admission date of 01/07/11. Diagnoses included type two diabetes mellitus and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Observation on 04/22/24 at 7:47 A.M., in Resident #11's room revealed the cord on the call light cord had a frayed area exposing the inner wire. Further observation revealed the resident's window shade was broken and there were several stained areas on the tile floor. Interview on 04/22/24 at 2:54 P.M., State Tested Nursing Assistant (STNA) #142 verified the stains on Resident #11's floor and the frayed call light cord. STNA #142 revealed she would notify maintenance. Observation on 04/23/24 at 3:25 P.M., revealed the resident's floor was stained and the window shade was broken. Interview on 04/23/24 at 3:25 P.M., with the Laundry and Housekeeping Supervisor (LHS) #127 verified the broken shade and the stains on the resident's floor. LHS #127 revealed the tile floor needed stripped in the resident's room. 2. Review of the medical record for Resident #53 revealed an admission date of 09/27/23. Diagnoses included type two diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Observation on 04/22/24 at 9:39 A.M., revealed a dried spilled area on the floor next to the bed. Further observation revealed the resident's window shade was broken. Interview on 04/22/24 at 9:39 A.M., with Resident #53 revealed it bothered her the staff had not cleaned up the milk she had spilled on the floor two days ago and her broken window shade. Resident #53 revealed she had reported the spilled milk to a nursing assistant. Observation on 04/23/24 at 3:17 P.M., revealed the dried spilled area on floor next to the resident's bed was now covered with two wash cloths and the window shade was still broken. Interview on 04/23/24 at 3:17 P.M., with LHS #127 verified the dried spill on the floor and the resident's broken window shade. LHS #127 revealed floors in resident rooms should be cleaned daily. 3. Review of the medical record for Resident #38 revealed an admission date of 07/26/23. Diagnoses included osteoarthritis and essential tremor. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 15 of 16 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 04/25/2024 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 04/23/24 at 11:34 A.M., Resident #38 and Resident #38's family member revealed the resident's window shade had been broken since the resident admitted to the facility. Interview on 04/23/24 at 3:21 P.M., LHS #127 verified the broken window shade in Resident #38's room. 4. Review of the medical record revealed Resident #21 had an admission date of 11/04/21. Diagnoses included epilepsy, glaucoma, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Observation on 04/23/24 at 3:21 P.M., revealed the window shade in Resident #21's room was broken. Interview on 04/23/24 at 3:21 P.M., with LHS #127 verified the broken window shade in Resident #21's room. Interview on 04/23/24 at 4:21 P.M., with Resident #21 revealed her window shade had been broken a long time and she told maintenance about it but in never got fixed. Review of the undated policy titled, Cleaning and Disinfecting Residents Room, revealed housekeeping surfaces (floors and tabletops) would be cleaned on a regular basis, when spills occur, and when these surfaces were visibly soiled. Review of the policy titled, Maintenance Service, dated December 2009, revealed functions of maintenance personnel included maintaining the building in good repair and free from hazards and providing routinely scheduled maintenance service to all areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365430 If continuation sheet Page 16 of 16