Inspection·May 30, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the resident was cognitively impaired. Review of Resident #46's physician orders revealed an order dated [DATE] for Do Not Resuscitate Comfort Care Arrest (DNR-CCA) which permitted the use of life-saving measures (such as powerful heart or blood pressure medications) before a person's heart or breathing stopped. At a time where the heart stopped beating or breathing stopped, no cardiopulmonary resuscitation (CPR) was to be performed. Review of the resident's paper chart revealed the resident's advanced directive wishes were the same. Review of Resident #46's computer chart revealed there were no advanced directive wishes indicated for Resident #46. Interview on [DATE] at 4:08 P.M. the Director of Nursing (DON) revealed resident's advance directive wishes were to be consistent throughout the medical record (including the resident's paper and computer chart) to ensure the resident's wishes would be honored. The DON verified Resident #46's advanced directive wishes were not consisted throughout her medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 2 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to follow their policy to timely report an injury of unknown origin to the Administrator and the State Agency for one (#3) of one resident reviewed for an injury of unknown origin. This had the potential to affect all 69 residents of the facility. Residents Affected - Few Findings include: Review of the medical record revealed Resident #3 was admitted to the facility 01/24/13. Diagnoses included anxiety, depression, stroke, hemiplegia, dementia and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 05/01/19, for Resident #3 revealed the resident was assessed with moderate cognitive impairment. The resident required total dependence and two-person physical assist for transfers. Review of the care plan updated 04/19/19 for Resident #3 revealed the resident was planned as non-ambulatory with total dependence for transfers with the use of a mechanical lift. Review of the nursing note dated 05/04/19 at 3:15 A.M. for Resident #3 revealed the nurse was made aware of a purplish/yellow bruise to Resident #3 left lower leg. Review of the nursing notes for Resident #3 did not reveal an observed source of the injury. The injury of unknown origin was not reported to facility administration. Review of the facility SRI report and investigation dated 05/07/19 revealed on 05/06/19, Licensed Practical Nurse (LPN) #103 was made aware of the bruise to Resident #3's leg and reported the bruise to the Certified Nurse Practitioner (CNP). The CNP assessed Resident #3, ordered an x-ray and reported the injury to the Director of Nursing (DON). Result of the x-ray for Resident #3 revealed the resident with a left tibia/fibula fracture. The physician was notified with an order for a leg immobilizer. Review of the facility SRI investigation conclusion for Resident #3 revealed the facility was unable to determine the cause of the fracture for Resident #3. The report stated the information from staff interviews did suggest the Resident #3 may have acquired the injury on 05/01/19 during a mechanical lift, although there was no traumatic event associated with the lift. The CNP and the physician classified the fractures as pathological in nature. The facility unsubstantiated the investigation of abuse. Interview on 05/30/19 at 9:30 A.M., the DON stated the facility completed a full investigation of the injury for Resident #3 and could find no evidence of abuse or injury during the mechanical transfer of Resident #3. The DON confirmed the bruising to Resident #3 was originally noted on 05/04/19. The cause was not observed and at that time should have been considered an injury of unknown origin and reported. The DON confirmed the injury was not reported in the time frame per requirement and facility procedure. Review of the facility policy titled Abuse/Neglect, Injuries of Unknown Source and/or Misappropriation of Property, updated 05/2019, revealed an injury of unknown origin was classified as an injury without an observed cause and one that is suspicious because of the location or extent of the injury. Licensed health professionals and state tested nurse aides should report any incident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 3 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 0607 Level of Harm - Minimal harm or potential for actual harm director of nursing, house supervisor, and administrator. The incident should be reported to the Ohio Department of Health no later than 24 hours after the incident and a thorough investigation should be completed no later than five business days after the incident. This deficiency substantiates Complaint Number OH00104355. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 4 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to timely report an injury of unknown origin to the Administrator and the State Agency for one (#3) of one resident reviewed for an injury of unknown origin. This had the potential to affect all 69 residents of the facility. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility 01/24/13. Diagnoses included anxiety, depression, stroke, hemiplegia, dementia and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 05/01/19, for Resident #3 revealed the resident was assessed with moderate cognitive impairment. The resident required total dependence and two-person physical assist for transfers. Review of the care plan updated 04/19/19 for Resident #3 revealed the resident was planned as non-ambulatory with total dependence for transfers with the use of a mechanical lift. Review of the nursing note dated 05/04/19 at 3:15 A.M. for Resident #3 revealed the nurse was made aware of a purplish/yellow bruise to Resident #3 left lower leg. Review of the nursing notes for Resident #3 did not reveal an observed source of the injury. The injury of unknown origin was not reported to facility administration. Review of the facility SRI report and investigation dated 05/07/19 revealed on 05/06/19, Licensed Practical Nurse (LPN) #103 was made aware of the bruise to Resident #3 leg and reported the bruise to the Certified Nurse Practitioner (CNP). The CNP assessed Resident #3, ordered an x-ray and reported the injury to the Director of Nursing (DON). Result of the x-ray for Resident #3 revealed the resident with a left tibia/fibula fracture. The physician was notified with an order for a leg immobilizer. Review of the facility SRI investigation conclusion for Resident #3 revealed the facility was unable to determine the cause of the fracture for Resident #3. The report stated the information from staff interviews did suggest the Resident #3 may have acquired the injury on 05/01/19 during a mechanical lift, although there was no traumatic event associated with the lift. The CNP and the physician classified the fractures as pathological in nature. The facility unsubstantiated the investigation of abuse. Interview on 05/30/19 at 9:30 A.M., the DON stated the facility completed a full investigation of the injury for Resident #3 and could find no evidence of abuse or injury during the mechanical transfer of Resident #3. The DON confirmed the bruising to Resident #3 was originally noted on 05/04/19. The cause was not observed and at that time should have been considered an injury of unknown origin and reported. The DON confirmed the injury was not reported in the time frame per requirement and facility procedure. Review of the facility policy titled Abuse/Neglect, Injuries of Unknown Source and/or Misappropriation of Property, updated 05/2019, revealed an injury of unknown origin was classified as an injury without an observed cause and one that is suspicious because of the location or extent of the injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 5 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 0609 Level of Harm - Minimal harm or potential for actual harm Licensed health professionals and state tested nurse aides should report any incident to the director of nursing, house supervisor, and administrator. The incident should be reported to the Ohio Department of Health no later than 24 hours after the incident and a thorough investigation should be completed no later than five business days after the incident. Residents Affected - Few This deficiency substantiates Complaint Number OH00104355. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 6 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to provide written notification of a transfer to the hospital for one (#67) of two residents reviewed for hospitalization. The facility census was 69. Findings include: Medical record review revealed Resident #67 admitted to the facility on [DATE]. Diagnoses included a left hip fracture, Diabetes mellitus, and hypertension. Further review revealed the resident was transferred to an acute care hospital on [DATE]. There was no documentation the facility provided the resident and the residents representative written notification of the reason for the transfers. Interview on 05/30/19 at 8:47 A.M., the Director of Nursing (DON) revealed the resident's nurse was responsible for filling out a transfer form indicating the reason for the resident's need for a transfer to an acute care hospital. The nurse was supposed to give a copy of the form to the resident and the resident's family, if they were present. If the resident's family was not present, they were to be given a copy of the form when they came to the facility or the facility would email a copy to them. The DON was unable to provide evidence Resident #67 and/or the resident's family was provided written notification for the reason for the resident's transfer to an acute care hospital on [DATE]. Review of a facility policy titled Transfer or Discharge Notice, revision date 04/2018, revealed the facility was supposed to provide written notification to residents and the resident representatives when immediate transfer and/or discharge was required by the resident's urgent medical needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 7 of 8 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 365668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwalk Memorial Home 272 Benedict 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review and staff interview, the facility failed to have a policy regarding resident bed holds upon transfer from the facility and failed to provide notification of the facility bed hold policy upon discharge to an acute care hospital for two (#67 and #65) of two residents reviewed reviewed for hospitalization. The facility identified 12 residents identified by the facility who discharged to the hospital. The facility census was 69. Findings include: 1. Medical record review revealed Resident #67 admitted to the facility on [DATE]. Diagnoses included a left hip fracture, Diabetes mellitus, and hypertension. The resident was transferred and admitted to an acute care hospital on [DATE]. No documentation the facility notified the resident of the facility's bed hold policy was found in the resident's medical record. 2. Medical record review revealed Resident #65 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, and major depressive disorder. Further review revealed the resident was transferred and admitted to an acute care hospital on [DATE]. No documentation the facility notified the resident of the facility's bed hold policy was found in the resident's medical record. Interview on 05/30/19 at 8:52 A.M., Licensed Social Worker (LSW) #108 revealed she was responsible for determining if a resident wished to place a hold on their bed when discharged to the hospital. LSW #108 revealed in the four and a half years she worked at the facility, she never provided residents with the facility's bed hold policy when they discharged to an acute care hospital. LSW #108 further revealed she did not have a policy to provide to them. The facility was unable to provide a policy for bed holds when a resident was admitted to an acute care hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 8 of 8