Inspection·March 21, 2022

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 medical record review, staff interview, and review of a facility policy, the facility failed to ensure advance directives were consistent throughout the medical record for one (#9) of 24 residents reviewed for advance directives. The census was 61. Findings include: Review of Resident #9's medical record revealed an initial admission date of [DATE] and a most recent admission date of [DATE]. Diagnoses included diabetes mellitus type II, chronic kidney disease, chronic obstructive pulmonary disease, muscle weakness, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #9 was assessed with moderately impaired cognition. Review of the most recently completed MDS assessment, dated [DATE], revealed Resident #9 had intact cognition. Review of Resident #9's physical chart revealed an advanced directives designation for Resident #9 to be Do Not Resuscitate Comfort Care (DNRCC)-Arrest, which meant providers would treat Resident #9 as any other resident with out 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. This document was signed by the physician and dated [DATE]. Review of a physician order in the electronic health record dated [DATE], revealed Resident #9's advance directives order was Full Code which meant resuscitative actions (including the use of powerful heart or blood pressure medications and/or cardiopulmonary resuscitation (CPR) to maintain life) were to be attempted if the resident went into cardio and/or pulmonary arrest. Interview on [DATE] at 2:53 P.M., Social Worker #400 stated resident advance directives are determined on admission and the nurses were responsible for translating the information to the electronic health record. Social Worker #400 verified Resident #9's advance directives were not consistent throughout the medical record. Social Worker #400 verified Resident #9 had a physician signed DNRCC-Arrest advance directives in the physical health record and a Full Code advance directives order in the electronic health record. Review of the facility policy titled NMH Advance Directives, last revised [DATE], revealed upon admission, each resident will be asked by nursing and social services if they have a current advance directives and will request a copy of such, if applicable. Code status documentation will be kept in limited locations to minimize conflicted guidance in the event of any emergency. Nurses will enter the code status order in the electronic health record upon receipt of a verbal or written order using the order template search so that it populates the communication drop down bar. Nurses will have the signed DNR papers kept in the chart under Advance Directives tab for interdisciplinary staff to access in the event of an emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 2 of 14 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 03/21/2022 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the Beneficiary Protection Notification Review, and staff interview, the facility failed to provide the Advance Beneficiary Notice of Non-Coverage when Medicare Part A services ended to one (#41) of three residents reviewed for Beneficiary Protection Notification. The facility census was 61. Residents Affected - Few Findings include: Review of the Beneficiary Protection Notification Review, completed 03/16/22, revealed Resident #41's last covered day of Medicare Part A Skilled Services was 03/06/22. The Notice of Medicare Non-Coverage was provided on 03/04/22. There was no evidence the Advance Beneficiary Notice (ABN) of Non-Coverage was provided to Resident #41 or his representative. Interview on 03/16/22 at 11:03 A.M., the Administrator revealed Resident #41 remained in the facility after Medicare Part A services ended. The Administrator verified the ABN should have been provided to Resident #41 and the resident's representative, but was not. The Administrator stated the ABN was explained to Resident #41, but the Social Worker forgot to provide the document to the resident or his representative. The Administrator stated the facility was still learning this process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 3 of 14 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 03/21/2022 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 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to assess the use of a pressure mat alarm used as a fall precaution to prevent a resident from changing positions without staff assistance. This affected one (#31) of one resident reviewed for pressure mat alarms. The facility identified 17 residents who utilized pressure mat alarms for fall precautions. The facility census was 61. Residents Affected - Few Findings include: Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included Parkinson's disease, Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, heart disease, and transient cerebral ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #31 was severely cognitively impaired, required extensive assistance with bed mobility and transfers, and had no falls since the previous assessment. Resident #31 used a bed alarm daily. Review of the plan of care, initiated 10/29/21, revealed Resident #31 was at risk for falls related to Parkinson's disease, Alzheimer's disease, generalized weakness, gait/balance problems, and psychoactive drug use. Interventions included pressure alarm to bed and chair. Review of current physician orders revealed Resident #31 was ordered pad alarm to bed and chair to alert staff to unassisted transfers. Review of a Fall Risk assessment dated [DATE] revealed Resident #31 was at high risk for falls. Review of a nursing progress note dated 01/01/22 revealed Resident #31 was found to be seated on the floor next to his bed. Resident #31 stated he slid out of the bed. Nursing intervention was to place a pad alarm into the resident's bed. Review of the medical record revealed no assessment had been completed to support the use of pressure mat alarms. Observation on 03/14/22 at 10:00 A.M. of Resident #31 revealed the resident seated in a wheelchair in the dining room. A pressure mat alarm was noted on the resident's wheelchair. Interview on 03/15/22 at 12:12 P.M., with Licensed Practical Nurse (LPN) #204 revealed Resident #31 had a few falls in the past. While LPN #204 stated Resident #31 would scoot in his chair, she had never observed the resident attempting to stand up unassisted and it had been a while since his last fall. LPN #204 stated Resident #31 had a pressure mat alarm to his chair and bed as a fall precaution. LPN #204 stated the facility utilized a device assessment, which included bed rails, but she was uncertain if it addressed the use of alarms. LPN #204 stated she was unaware of an assessment for the use of alarms. Interview on 03/16/22 at 7:15 A.M., with LPN #205 revealed Resident #31 had a chair and bed alarm due to a history of falls but she had never observed the resident attempting to get up unassisted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 4 of 14 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 03/21/2022 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPN #205 stated she was unaware of any assessment for alarm use and stated alarms were implemented based on physician order. Interview on 03/16/22 at 8:56 A.M., the Director of Nursing (DON) revealed the use of pressure mat alarms was a last resort for fall precautions. The DON stated the facility assessment process for the use of alarms included completion of the Physical Device Assessment prior to implementation and at least quarterly, with the use of alarms being reviewed at care conferences to determine if they were still necessary. While the device assessment did not specify alarms, staff were to check the other box and complete the assessment for the use of alarms. The DON stated nursing staff were aware the Physical Device Assessment was to be completed when alarms were utilized. Interview on 03/16/22 at 9:44 A.M., with LPN #204 verified Resident #31 had a Physical Device Assessment completed on 10/28/21 for bilateral half side rail use. LPN #204 verified Resident #31's medical record was silent for an assessment for pressure mat alarm use. Interview on 03/17/22 at 11:17 A.M., with MDS Coordinator (MDS) #410 revealed a device assessment was completed for alarm use prior to implementation and then prior to MDS assessments and care conferences. MDS #410 stated Resident #31 had a MDS assessment in February 2022 and was not due again until May 2022. MDS #410 verified Resident #31 was not assessed for the use of alarms prior to implementation and was not reassessed for continued use as part of his MDS assessment in February 2022. MDS #410 verified the use of alarms should have been reassessed as part of Resident #31's MDS assessment in February 2022. MDS #410 stated she looked yesterday for any evidence Resident #31 had been assessed for alarm use and she was unable to locate any evidence of such assessment. Review of facility policy titled Bed/Wheel Chair/Chair Alarm, revised May 2020, revealed residents are assessed according to assessment policies and procedures for the use of wheelchair/chair alarm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 5 of 14 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 03/21/2022 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, staff interview, and review of facility policy, the facility failed to provide written notice of transfer for hospitalizations. This affected two (#47 and #33) of two residents reviewed for transfer notification. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #47 was admitted on [DATE] and discharged on 03/04/22. Diagnoses included type II diabetes, hypertension, anxiety disorder, major depressive disorder, hemiplegia and hemiparesis, morbid obesity, and dysphagia following unspecified cerebrovascular disease. Review of the admission Minimum Data Set (MDS) assessment, dated 03/01/22, revealed Resident #47 was severely cognitively impaired. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was discharged and sent to the emergency department for stroke like symptoms. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was admitted to the hospital and would not be returning to the facility that evening. Additional review of Resident #47's medical record revealed no documentation of written transfer notification being provided to the resident, the resident's representative, or the Ombudsman. Interview on 03/16/22 at 2:34 P.M., the Administrator verified written transfer notification was not provided to Resident #47, the resident's representative, or the Ombudsman. The Administrator stated the resident had a stroke and did not return to the facility to be given the information. 2. Review of the medical record revealed Resident #33 was admitted on [DATE]. Diagnoses included pneumonitis, sepsis with septic shock, heart disease, hypertension, major depressive disorder, metabolic encephalopathy, rheumatoid arthritis, and seizures. Review of the admission MDS dated [DATE] revealed Resident #33 was severely cognitively impaired. Review of a nursing progress note dated 02/17/22 revealed Resident #33 was transferred to the emergency department due to complaints of headache and reddened sclera (outer coating of eye). Additional review of the medical record revealed no documentation of a written transfer notification being provided to Resident #33 or the resident's representative. Interview on 03/16/22 at 2:30 P.M., the Administrator verified written transfer notice was not provided to Resident #33, the resident's representative, or the Ombudsman. The Administrator stated the resident was sent out to the emergency department but was not admitted to the hospital. Review of facility policy titled NHM Adm, Trans, DC-Transfer or Discharge Notice, revealed written notice would be given as soon as it was practicable for an immediate transfer required by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 6 of 14 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 03/21/2022 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 resident's urgent medical needs. Additionally, in the event of immediate, urgent transfer out, staff would fill out the transfer form and try to obtain signatures from the resident and family member prior to transfer and, if unable to obtain signature, staff would document verbal notification on the form for the resident and representative and designated personnel would send out notices to the resident or representative. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 7 of 14 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 03/21/2022 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, staff interview, and review of facility policy, the facility failed to provide bed hold notification to residents transferred to the hospital. This affected two (#47 and #33) of two residents reviewed for bed hold notification. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #47 was admitted on [DATE] and discharged on 03/04/22. Diagnoses included type II diabetes, hypertension, anxiety disorder, major depressive disorder, hemiplegia and hemiparesis, morbid obesity, and dysphagia following unspecified cerebrovascular disease. Review of the admission Minimum Data Set (MDS) assessment, dated 03/01/22, revealed Resident #47 was severely cognitively impaired. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was discharged and sent to the emergency department for stroke like symptoms. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was admitted to the hospital and would not be returning to the facility that evening. Additional review of Resident #47's medical record revealed no evidence of the bed hold notification being provided to the resident or the resident's representative. Interview on 03/16/22 at 2:34 P.M., the Administrator verified bed hold notification was not provided to Resident #47 or the Resident's representative. The Administrator stated the resident had a stroke and did not return to the facility to be given the information. 2. Review of the medical record revealed Resident #33 was admitted on [DATE]. Diagnoses included pneumonitis, sepsis with septic shock, heart disease, hypertension, major depressive disorder, metabolic encephalopathy, rheumatoid arthritis, and seizures. Review of the admission MDS assessment, dated 02/08/22, revealed Resident #33 was severely cognitively impaired. Review of a nursing progress note dated 02/17/22 revealed Resident #33 was transferred to the emergency department due to complaints of headache and reddened sclera (outer coating of eye). Additional review of the medical record revealed no evidence of the bed hold notification being provided to Resident #33 or the resident's representative. Interview on 03/16/22 at 2:30 P.M., the Administrator verified bed hold notification was not provided to Resident #33 or the resident's representative. The Administrator stated the resident was sent out to the emergency department but was not admitted to the hospital. Review of facility policy titled NMH Adm, Trans, DC-Bed Hold Policy, revised May 2020, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 8 of 14 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 03/21/2022 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 facility would provide the resident and/or the resident's representative with a written copy of the bed hold policy prior to transfers. 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: 365668 If continuation sheet Page 9 of 14 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 03/21/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of medical record, family interview, and staff interview, the facility failed to ensure a resident and resident family were provided a written summary of the baseline care plan. This affected one (#154) of one resident reviewed for baseline care plans. The facility census was 61. Findings include Medical record review revealed Resident #154 had an admission date of 03/07/22. Diagnoses included pneumonia, type two diabetes mellitus, Parkinson's disease, chronic kidney disease, and dementia. Interview on 03/14/22 at 2:12 P.M., with Resident #154's family member revealed the resident had not had an initial care plan meeting. Resident #154's family member also revealed the resident had not been provided with a written summary of the baseline care plan. Interview on 03/16/22 at 10:39 A.M., Registered Nurse (RN) #306 was unaware if residents and their families received a copy of the baseline plan of care. RN #306 stated her orientation on paperwork was not in depth. Interview on 03/16/22 at 10:50 A.M. with RN #300 revealed residents or their families would sign the baseline care plan. RN #300 revealed she had not been told to provide a copy of the care plan to the resident or the resident's family. Interview on 03/17/22 at 10:25 A.M., Licensed Social Worker (LSW) #400 revealed she was not aware residents and resident families should be provided a copy of the baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 10 of 14 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 03/21/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, staff interview, and review of a facility policy, the facility failed to complete shiftily reconciliation counts for controlled medications stored in medication carts and refrigerators on the Transitional Care Unit (TCU). This deficient practice affected nine (#1, #2, #32, #53, #54, #55, #56, #57, and #153) residents with controlled substances kept in the medication cart or refrigerator in the TCU. The census was 61. Findings include: Observation of the medication cart and refrigerator in the TCU on 03/15/22 at 1:44 P.M. with Licensed Practical Nurse (LPN) #225 and Registered Nurse (RN) #306 revealed 13 total controlled medications were stored in the medication cart and refrigerator. Resident #1, Resident #2, Resident #53, Resident #54, Resident #55, Resident #56, Resident #57, and Resident #153's medications were in pill form and stored in the medication cart and Resident #32's medication was in liquid form and stored in the refrigerator. A controlled substance reconciliation was completed with LPN #225 and RN #306 and all counts verified as correct with all narcotic accounted for. Review of the facility shift to shift narcotic count record revealed no documentation that controlled substances in the TCU were reconciled during the change of shift on the morning of 03/15/22. Further review revealed on 03/14/22 the oncoming nurse signed the shift to shift narcotic count record, however, no count was documented and no off-going nurse signature was present. Interview on 03/15/22 at 1:44 P.M., LPN #225 stated she completed the shift to shift narcotic reconciliation with the off-going nurse on 03/15/22, but verified neither she nor the off-going nurse completed the shift to shift narcotic count record. LPN #225 signed the document at this time and was not able to state why the off-going nurse did not sign the shift to shift report at the time the count was completed. LPN #225 and RN #306 both confirmed there was no reconciliation documented on the morning of 03/14/22 between the oncoming and off-going nurse, and no signature of the off-going nurse was present. Review of a facility policy titled Controlled Substances, dated 06/21/17, revealed the facility shall maintain a record and signed scheduled medication count at each change of shift, by oncoming nurse or authorized individual with off-going nurse or authorized individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 11 of 14 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 03/21/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were stored securely in the medication cart during medication administration. This had the potential to affect 23 Residents (#3, #4, #6, #11, #15, #16, #17, #18, #20, #21, #23, #26, #27, #31, #32, #33, #34, #35, #40, #41, #44, #49 and #303) residing on the B Hall and left side of C Hall for whom the medications were administered by the facility. The facility census was 61. Findings include: Observation on 03/15/21 at 7:47 A.M. of medication administration was observed for Resident #4. Upon the gathering of this resident's medications, Licensed Practical Nurse (LPN) #204 walked away from the unlocked medication cart at 8:03 A.M. and entered Resident #4's bedroom. At 8:06 A.M. LPN #204 returned to medication cart to obtain a spoon for Resident #4, at which time LPN #204 locked the medication cart. At the time of the observation LPN #204 verified the unlocked medication cart was unattended and out of her sight for three minutes. Interview on 03/17/21 at 8:06 A.M., LPN #204 stated the medication cart contained medications for the residents of B Hall and the left side of the C Hall. Review of facility policy titled Medication Storage, dated 07/23/19, revealed medications are to be stored securely and medication supply is only accessible to licensed nursing personnel, pharmacy personnel or other staff members authorized to administer medications. The facility identified 23 Residents (#3, #4, #6, #11, #15, #16, #17, #18, #20, #21, #23, #26, #27, #31, #32, #33, #34, #35, #40, #41, #44, #49 and #303) residing on the B Hall and left side of C Hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 12 of 14 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 03/21/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure staff were wearing the appropriate personal protective equipment (PPE) when entering the room of a resident on quarantine for unknown COVID-19 status, changed PPE when exiting the quarantine room, and unvaccinated staff were wering a N95 when entering resident rooms. This had the potential to affect 13 residents (#2, #25, #45, #48, #53, #54, #55, #56, #58, #59, #153, #154, and #304) The facility census was 61. Residents Affected - Some Findings include: Medical record review revealed Resident #153 had an admission date of 03/08/22. Diagnoses included type two diabetes mellitus, hypertension, dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of physician orders dated 03/08/22 revealed Resident #153 was placed on droplet precautions until 03/22/22 due to not being vaccinated for COVID-19. Review of a nurse progress note dated 03/08/22 at 10:30 P.M. revealed droplet precautions maintained due to resident not being vaccinated for COVID-19. Observation on 03/14/22 at 8:14 A.M. revealed Resident #153 was sitting in a recliner in her room talking to Environmental Services Staff (ESS) #128. The door was left open. There was a sign outside the resident's room indicating the resident was on droplet precautions. The sign revealed staff should wear a mask and eye protection before entering the room. There was no sign stating to wear any additional personal protective equipment. There was a cart containing personal protective equipment (PPE) outside the room. Further observation revealed ESS #128 was wearing a face mask. ESS #128 was not wearing eye protection, a gown, or gloves. Inside the door to the resident's room was bin to dispose PPE before exiting the room. ESS #128 exited the resident's room wearing the same face mask. ESS #128 then continued to clean resident common areas. Interview on 03/14/22 at 8:19 A.M., ESS #128 revealed she should have donned an N95 mask and face shield while in the resident's room. ESS #128 revealed she had not previously noticed the droplet precaution sign posted outside of the resident's room. Further interview with ESS #128 revealed she had been vaccinated for COVID-19. Interview on 03/14/22 at 9:13 A.M., Licensed Practical Nurse (LPN) #203 revealed Resident #153 was on droplet precautions until 03/22/22. LPN #203 revealed staff entering Resident #153's room should wear a gown, mask, gloves and face shield. Observation on 03/14/21 at 11:41 A.M. revealed Dietary Staff (DS) #129 pushed a food cart down to Resident #153's room. DS #129 removed Resident #153's meal tray from the cart and entered the resident's room. DS #129 had on a face mask with no eye protection, gown, or gloves. DS #129 waited next to the resident while the resident repositioned in her chair. DS #129 then set up of the resident's meal tray on the bedside table in front of the resident. DS #129 then exited the room wearing the same face mask. DS #129 then completed hand hygiene. Interview on 03/14/21 at 11:44 A.M., DS #129 revealed she was not required to wear additional personal protective equipment while in the resident's room. Further interview on 03/17/22 at 1:24 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 13 of 14 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 03/21/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with DS #129 revealed she was not vaccinated for COVID-19 and was not aware she was required to wear an N95 when she entered the facility from the hospital kitchen. DS #129 was also not aware of what PPE was required when entering the room of a resident on transmission-based precautions. Further observation on 03/14/21 from 11:45 A.M. through 11:55 A.M. revealed DS #129 continued to deliver meal trays to nine additional residents (#2, #25, #45, #48, #53, #54, #55, #56, #58, #59, #154, and #304) in their rooms while wearing the same facemask worn in Resident #153's room. Interview on 03/15/22 at 1:52 P.M.,Infection Preventionist (IP) #223 revealed Resident #153 was a new admission and was unvaccinated for COVID-19 requiring droplet precautions to monitoring for 14 days for signs and symptoms of COVID-19. IP #223 revealed all staff entering the resident's room, including housekeeping staff and dietary staff, should wear a N95 mask, gown, eye protection and gloves. IP #223 revealed staff were instructed to ask if they were not sure what PPE was required for a resident placed on precautions. IP #223 stated the droplet precaution sign and PPE cart outside the resident's room should have alerted the staff. IP #223 stated DS #129 should have delivered Resident #153's meal tray last instead of first. Interview on 03/17/22 at 8:33 A.M., the Administrator revealed unvaccinated staff were required to wear a N95 respirator and complete testing two times per week. Interview on 03/17/22 at 9:30 A.M., the Director of Nursing (DON) revealed the facility followed CDC guidelines regarding new resident admissions. Review of the COVID-19 Staff Vaccination Matrix revealed DS #129 had not received a vaccination for COVID-19. Review of the facility policy titled Transmission-Based Precautions, revised 05/2020, revealed a droplet precaution sign indicated hand hygiene would be performed before entering and upon leaving. Eyes, nose and mouth are fully covered before room entry. Face protection would be removed before room exit. Review of the CDC guidance titled Infection Control for Nursing Homes, dated 02/02/22, revealed in general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Healthcare Practitioners caring for residents in quarantine should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365668 If continuation sheet Page 14 of 14