Inspection·July 11, 2019

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 and staff interviews, the facility failed to ensure residents and their representatives were provided written notification for the reason for a hospital transfer. Additionally, the facility also failed to provide notification to the Ombudsman of the hospital transfers. This affected three (#30, #40 and #103) out of three residents reviewed for hospitalization. The facility census was 107. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 01/26/19. Resident #40 was identified as paying privately for services at the facility. The record identified upon admission Resident #40 was provided the bed hold policy and on 01/30/19, elected to decline paying for a bed hold in the event she required hospitalization. Resident #40 did require hospitalization starting on 05/28/19 with re-admission to the facility occurring on 05/31/19. Further review of Resident #40's medical record revealed no evidence the resident and the residents representative were notified of the transfer in writing. Additionally, there was no evidence the Ombudsman was notified of the transfer. Interview with Social Services Designee (SSD) #95 on 07/10/19 at 11:11 A.M. SSD #95 identified he was not aware of the requirement for written notification for all transfers to the resident/representative and the ombudsman. 2. Review of Resident #30's medical record revealed an admission date of 02/06/15 with diagnoses of multiple sclerosis, anxiety disorder, major depressive disorder, urinary tract infection, type two diabetes mellitus and mild cognitive impairment. Review of Resident #30's nurses notes dated 05/28/19 at 10:35 P.M. revealed the resident was transported to the emergency room and admitted to the hospital. Review of the medical record revealed no evidence the resident/resident representative was notified in writing of the reasoning for the transfer to the hospital. Interview with SSD #95 on 07/10/19 at 7:53 A.M. confirmed he did not issue a written notice to the resident/resident's representative regarding the transfer of Resident #30 to the hospital on [DATE]. 3. Review of the medical record for Resident #103 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, atrial fibrillation, repeated falls, dysphagia, cardiac pacemaker, and somnolence. Review of the five day minimum data set assessment dated [DATE] revealed Resident #103 was dependent on staff for all activities of daily living. Review of the progress notes revealed Resident #103 was often confused. Review of a nurse's note dated 05/06/19 revealed Resident #103 was transferred and admitted to the hospital. Review of Resident #103's closed record lacked evidence a written notice was given to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 2 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 Resident #103 or his representative with reasoning for the transfer to the hospital. Level of Harm - Minimal harm or potential for actual harm Interview on 07/10/19 at 9:49 A.M. with SSD #95, confirmed a written notice of transfer had not been given to Resident #103 or the representative. SSD #95 did not know written transfer notices needed to be given to residents who transfer to the hospital. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 3 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 policy review, the facility failed to ensure residents were provided bed hold notification at the time of transfer to the hospital. This affected three (#30, #40 and #103) out of three residents reviewed for hospitalization. The facility census was 107. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 01/26/19. Resident #40 was identified as paying privately for services at the facility. The record identified upon admission Resident #40 was provided the bed hold policy and on 01/30/19, elected to decline paying for a bed hold in the event she required hospitalization. Resident #40 did require hospitalization starting on 05/28/19 with re-admission to the facility occurring on 05/31/19. Review of Resident #40's [NAME] records identified Room and Board Charges were conducted for 4 days (May 28-31, 2019) at half cost off 115 dollars a day for total of $460.00. Further review of Resident #40's medical record revealed no evidence the resident was provided with the bed hold policy when the resident was transferred/admitted to the hospital on [DATE]. Interview with Social Services Designee (SSD) #95 on 07/10/19 at 11:11 A.M. The interview identified the facility charges half the per diem rate for private pay residents for bed holds. The interview further confirmed the facility incorrectly charged Resident #40 a total of $460.00 for bed hold. The interview confirmed the facility did not provide the bed hold policy for Resident #40 at the time of her discharge to the hospital on [DATE]. 2. Review of Resident #30's medical record revealed an admission date of 02/06/15 with diagnoses of multiple sclerosis, anxiety disorder, major depressive disorder, urinary tract infection, type two diabetes mellitus and mild cognitive impairment. Review of Resident #30's nurses notes dated 05/28/19 at 10:35 P.M. revealed the resident was transported to the emergency room. Review of the medical record revealed no evidence the resident/resident representative was notified in writing of the bed hold policy or bed hold days. Interview with SSD #95 on 07/10/19 at 7:53 A.M. confirmed he did not issue a written notice to the resident/resident's representative regarding the bed hold policy when Resident #30 was transported to the hospital on [DATE]. 3. Review of the medical record for Resident #103 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, atrial fibrillation, repeated falls, dysphagia, cardiac pacemaker, and somnolence. Review of the five day minimum data set assessment dated [DATE] revealed Resident #103 was dependent on staff for all activities of daily living. Review of the progress notes revealed Resident #103 was often confused. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 4 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 Review of a nurse's note dated 05/06/19 revealed Resident #103 was sent to the hospital and admitted . Review of Resident #103's closed medical record revealed no evidence the resident or the representative received the bed-hold policy upon his transfer to the hospital. Interview on 07/10/19 at 10:23 A.M. with SSD #95 confirmed the bed-hold policy was not given to Resident #103 or his representative upon his transfer to the hospital. Review of the facilities bed Hold Policy dated 05/2019 identified upon admission as well as prior to transfers and therapeutic leaves, residents and or representatives will be informed in writing of the bed hold and return policy. Prior to transfer, written information will be given to the residents and the resident representative that explains in detail; rights and limitations of the resident regarding bed hold. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents) and the details of the transfer (per the Notice of Transfer). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 5 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to ensure the resident's minimum data set (MDS) assessments were accurate. This affected five (#33, #46, #100, #36 and #103) of 22 resident records reviewed for accuracy of the assessment. The census was 107. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, asthma, heart failure, diabetes mellitus type two, hypokalemia, hypothyroidism, major depressive disorder, anxiety disorder, mood disorder, hearing loss, and tremors. Review of the medication administration record (MAR) dated 04/19, revealed Resident #33 was administered tramadol (opioid medication) 50 mg on 04/17/19 and 04/18/19. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 received opioids on one day during the seven day reference period. Interview on 07/09/19 at 2:56 P.M. with MDS nurse #159 verified Resident #33 was administered two opioids during the seven day reference period. MDS nurse #159 verified the quarterly MDS assessment dated [DATE] completed for Resident #33 was not accurate. 2. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, dementia, vascular dementia, atrial fibrillation, hydro-nephrosis, diabetes mellitus type two, neuromuscular dysfunction of the bladder, urinary tract infection, muscle weakness, repeated falls, hypertension, bacteremia, altered mental status, bacteremia, insomnia, benign prostatic hyperplasia, and urine retention. Review of the MAR dated 04/19, revealed the Resident #46 was administered Amoxicillin-pot clavulanate tablet (antibiotic medication) 875-125 milligram (mg); give one tablet by mouth two times a day for urinary tract infection for six days. Documentation revealed the resident received the medication on 04/19/19, 04/20/19, 04/21/19, 04/22/19, 04/23/19, and 04/24/19. Review of a significant change MDS assessment dated [DATE], revealed Resident #46 received antibiotics on seven days during the seven day reference period. Interview on 07/10/19 at 11:53 A.M. with MDS nurse #40 verified Resident #46 received antibiotics on six days during the seven day reference period. The nurse verified the MDS was not accurate. 3. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hypotension, tachycardia, atrial fibrillation, congestive heart failure, cardiomyopathy, hyperkalemia, hyponatremia, hyperlipidemia, weakness, amnesia, major depressive disorder, diabetes mellitus type two, obesity, chronic pain, hypertension, unspecified osteoarthritis, fibromyalgia, and malaise. Review of the medication administration record dated 06/19, revealed no documentation of an order for routine or as needed antipsychotic medication for Resident #100. Further review of the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 6 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0641 record revealed no evidence Resident #100 received antipsychotic medication from 06/13/19 to 06/19/19. Level of Harm - Minimal harm or potential for actual harm Review of Resident #100 admission MDS dated [DATE] revealed the resident was documented as receiving an antipsychotic on two out of the seven day period of the assessment. Residents Affected - Some Interview on 07/09/19 at 3:02 P.M. with MDS nurse #159 verified the revealed Resident #100 was not administered antipsychotic medication during the seven day verified the admission MDS assessment was inaccurate. The resident was not administered antipsychotic medication during the seven day reference period. 4. Review of the medical record for Resident #36 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, dysphagia, type 2 diabetes, hypertension, depressive episode and gastro-esophageal reflux disease. Review of Resident #36's physician orders revealed her Risperdal (anti-psychotic medication) had been changed from 0.5 milligram two times a day to one milligram once a day on 03/29/19. Review of Resident #23's medical record revealed the physician had contraindicated a gradual dose reduction on 04/05/19 related to Resident #23's aggressive verbal and physical behaviors. Review of Resident #36's Significant Change MDS assessment dated [DATE], revealed a gradual dose reduction had been completed on 04/05/19. The MDS also revealed the physician contraindicated a gradual dose reduction on 04/05/19. Interview on 07/10/19 at 11:29 A.M. with MDS Coordinator #40 revealed Resident #36's had an MDS entry error and that she/he had not had a gradual dose reduction on 04/05/19 and verified Resident #23's Risperdal orders had changed from 0.5 milligrams twice a day to one milligram once a day on 03/29/19. The MDS coordinator verified the medication change was not a dose reduction. MDS Coordinator #40 verified the physician did contraindicate a dose reduction on 04/05/19. 5. Review of the medical record for Resident #103 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, atrial fibrillation, repeated falls, dysphagia, cardiac pacemaker, and somnolence. Review of the residents skilled nursing notes dated 04/26/19 to 05/05/19 revealed Resident #103 was dependent on staff for all activities of daily living. Continued review of the nurse progress notes revealed Resident #103 was often confused. Review of Resident #103's five day Minimum Data Set (MDS) dated [DATE], revealed Resident 103's cognition interview (section C), mood interview (section D), behavior evaluation (section E), and pain interview (Section J) were marked as not assessed. Interview with MDS Coordinator #159 on 07/10/19 at 9:45 A.M. revealed Social Service Designee (SSD) #95 was responsible for sections C, D, and E. MDS Coordinator #159 verified he/she missed completing the areas. Interview on 07/10/19 at 9:49 A.M., SSD #95 verified he did not complete sections C, D, and E of Resident #103's MDS and that Resident 103 was in the building during the reference period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 7 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview and policy review, the facility failed to ensure Resident #38's comprehensive care plan included interventions to address his/her behavior of banging on walls/doors. This affected one (#38) of 24 residents reviewed for comprehensive care plans. The census was 107. Findings include: Review of the medical record for Resident #38 revealed an admission date of 05/19/16 with diagnoses including dementia with behavioral disturbances, anxiety, and chronic obstructive pulmonary disease. Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment and exhibited physical and verbal behaviors towards others one through three days out of the assessment period. Review of the nurse's notes dated 06/19/19, 06/28/19, 07/07/19, and 07/08/19 revealed Resident #38 exhibited a behavior of banging on the walls/doors. Review of Resident #38's comprehensive care plan revealed no interventions targeted towards the treatment of the residents behavior of banging/hitting the walls and doors. Observation on 07/08/19 at 10:12 A.M. revealed Resident #38 was hitting the door with his hands and sliding his walker back and forth making loud noises. Observation on 07/08/19 at 11:40 A.M. revealed Resident #38 was hitting the table by the Special Care Unit dining room. Observation on 07/10/19 at 9:16 A.M. revealed Resident #38 was hitting the walls and doors in his/her room making loud noises. Interview with Licensed Practical Nurse (LPN) #56 on 07/10/19 at 9:13 A.M. verified Resident #38 had a behavior of banging/hitting the walls and doors. LPN #56 stated Resident #38's behavior of banging on the walls and doors started roughly one month ago. Interview with LPN #40 on 07/10/19 at 9:47 A.M. verified Resident #38's behavior of banging on the walls and doors was not addressed on the comprehensive care plan. Review of the policy titled Comprehensive Person-Centered Care Plans last revised August 2017 revealed the comprehensive person-centered care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the policy further revealed the comprehensive person-centered care plan will incorporate identified problem areas and risk factors associated with identified problems as well as reflect treatment goals, timetables, and objectives in measurable outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 8 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews and policy review, the facility failed to complete a care planning meeting for one (#93) of 22 residents reviewed for care planning. The census was 107. Findings include: Review of Resident #93's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including dementia, hypotension, diverticulitis, atherosclerotic heart disease, atrioventricular block, atrial fibrillation, hyperlipidemia, anxiety, legal blindness, major depressive disorder, hypertension, esophagitis and hearing loss. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Mental Status (BIMS) score of 13, indicating intact cognition. Resident #93 requires supervision or limited assistance with his activities of daily living. Further review of the medical record revealed there was no evidence of a care planning conference for Resident #93. During an interview on 07/08/19 at 9:43 A.M., Resident #93 revealed he had never had a care plan meeting conference with facility staff since his admission on [DATE]. Interview on 07/10/19 at 1:04 P.M. with MDS Nurse #159 revealed he/she is responsible for setting up care conferences for Resident #93's unit and confirmed that Resident #93 had never had a care planning meeting during the entirety of his admission. Review of a facility policy titled Interdisciplinary Care Conference/[NAME] Meeting Reviews, dated August 2018, revealed all residents, family, or legal representative will have the opportunity to participate and fully be informed of the on-going care and total health status of the resident. All residents will have an initial care plan meeting within the first 21 days after admission and at least quarterly thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 9 of 10 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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. Based on observations and staff interviews, the facility failed to ensure facility was maintained in good repair. This affected four (#62, #85, #49 and #37) out of 25 residents sampled during the survey. The census was 107. Findings include: Observation on 07/08/19 at 9:30 A.M. of Resident #62's room, revealed chipped and peeling paint behind a bed and a six inch crack in the windowsill. Observation on 07/08/19 at 3:31 P.M. of Resident #85's room, revealed several areas of chipped paint behind the bed. Observation on 07/08/19 at 4:16 P.M. of Resident #49 and #37's shared room, revealed several large chunks of wall and chips of paint, all of various sizes, out of the wall and laying on the floor behind a recliner by the closet. Observation on 07/11/19 at 8:40 A.M. revealed two chairs located outside the special care unit, in the courtyard, with three ripped and dirty cushions. Continued observation at 8:42 A.M. revealed a leather chair in the special care unit with various sized tears. Interview on 07/09/19 at 3:47 P.M. with the Assistant of Resident Care Services verified the large chunks of wall missing from the wall and laying on the floor and chipped paint were present. Continued interview on 07/09/19 at 3:48 P.M. with Assistant of Resident Care Services verified the chipped paint behind the bed in Resident #62 and #85's room. Further interview on 07/09/19 at 3:49 P.M. with the Assistant of Resident Care Services verified the presence of the chipped and peeling paint as well as the crack in the windowsill in Resident #49 and #37's room. Interview on 07/11/19 at 8:40 A.M. with Social Service Designee (SSD) verified the two chairs outside the special care unit in the courtyard were ripped and dirty cushions. The SSD further verified the presence of the rips in the leather chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 10 of 10