Inspection·July 14, 2022

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #502 stated Resident #19 was extremely hard of hearing. LPN #502 stated Resident #19's right hearing aid was missing. LPN #502 verified Resident #19 did not have any hearing aids in place. LPN #502 stated the family was aware of the missing hearing aid and the family was working on getting replacements. LPN #502 verified it was was very hard to communicate with Resident #19 without her hearing aids in place. Interview with Resident #19 on 07/14/22 at 9:30 A.M. revealed Resident #19 could not hear anything the Surveyor was saying. Resident #19 did not have any hearing aides in her ears. After giving Resident #19 gestures, Resident #19 removed small box from the cup holder in her recliner containing one hearing aid. Resident #19 stated she couldn't find the other hearing aid. Interview with LPN Unit Manager #515 on 07/14/22 at 9:45 A.M. stated she was new to the Unit Manger position and did not know Resident #19 had lost a hearing aid and was not wearing her left hearing aid. She stated Social Services took care of all lost items. Interview with the Administrator on 07/14/22 at 10:15 A.M. verified she was aware Resident #19 was missing her right hearing aid. The Administrator stated the daughter was notified and she was working an getting her a replacement. Interview with State Tested Nursing Assistant (STNA) #504 on 07/14/22 at 10:45 A.M. verified she was caring for Resident #19 that day (07/14/22). STNA #504 verified Resident #19 was missing her right hearing aid. STNA #504 stated she did not know why Resident #19 did not have her left hearing aid in today (07/14/22). STNA #504 verified Resident #19 had no hearing aids in place today. STNA #504 verified Resident #19 was extremely hard of hearing without her hearing aids in place and it was very difficult to communicate with Resident #19. Interview with STNA #10 on 07/14/22 at 10:50 A.M. stated she works with Resident #19 at times. STNA #10 verified Resident #19 was very hard of hearing without hearing aids in place. STNA #10 stated one of Resident #19's hearing aide was missing however just a few minutes ago they found the new hearing aids and put them in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 2 of 5 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 07/14/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, family and staff interviews, the facility failed to use a splint device as ordered by the physician. This affected one (Resident #17) of one resident reviewed for limited range of motion. The facility identified 13 residents with contractures. The facility census was 74. Finding include: Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral vascular accident with right hemiplegia (paralysis of one side of the body), aphasia ( inability to speak), dementia, and cardiomyopathy (weakness of the heart muscle). Review of the physician's monthly orders revealed an ordered initiated on 10/12/20 which stated Resident #17 was to wear a resting hand splint on his right hand when in bed during naps and at bedtime until waking hours. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had short and long term memory loss. Resident #17 has physical behaviors toward staff with care on one to three days of the assessment period. Resident #17 did not reject care. Resident #17 required extensive assistance with all mobility activities of daily living. Resident #17 was not ambulatory. Review of the plan of care dated 04/15/22 revealed Resident #17 was at risk for further alteration in muscle skeletal status, contracture of right hand and foot drop. The goal was for Resident #17 to remain free of injuries or complications related to the contracture of the right hand and foot through the review date. The interventions included applying ankle foot orthosis (AFO) brace to right leg daily when out of bed and monitoring, documenting, and physician notification of the physician for contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement), or pain after exercise or weight bearing. There wa no mention in the plan of care regarding right hand contracture or use of the resting hand splint. Review of the Occupational Therapy Discharge summary dated [DATE] for treatment dates 09/07/21 through 11/03/21 stated the goal was for Resident #17 to tolerate modalities to decrease overall spasticity in right hand and fingers and allow improved range of motion for hygiene and decreased pain. The discharge note on 11/03/21 stated Resident #17 tolerated therapy well. The fingers on the right hand were still having hypertonicty (excessive tone or tension) and remain flexed however can be easily opened without the resident complaining of pain. Review of Resident #17's treatment administration record (TAR) for June and July 2022 revealed the staff were signing the right resting hand splint were on during naps and at bedtime daily. There was no refusals marked. Review of the nursing progress notes from 09/01/21 through 07/13/22 revealed no mention of Resident #17 refusing the have the right resting hand splint placed. Observation of Resident #17 and an interview with a family member on 07/12/22 at 12:30 P.M. revealed Resident #17 was sitting in a chair in his room eating his lunch with his left hand. A family member was visiting. Interview with the family member at this time stated Resident #17 can't talk due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 3 of 5 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 07/14/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a stroke. The family member stated due to the stroke, Resident #17 was unaware he even has a right side. Resident #17 was able to feed himself independently with his left hand. The family member stated if she holds Resident #17's right arm up and allows his hand to dangle the fingers on his right hand will open up. This allows for her to do hand hygiene and trim his nails. She stated all other times when his right hand was resting it was clinched in a fist. The family member stated the facility used to place a rolled-up ace bandage in his hand to keep it open. The family member was not sure where the hand roll was now. The family member verified she has not seen a splint on his right hand or in his room. The family member verified she visits daily. Observation on 07/13/22 at 9:00 A.M. and 12:30 P.M. revealed Resident #17 was up in the chair. Resident #17's right hand fingers were flexed in a fist. There was no splint or device in his right hand. Observation on 07/13/22 at 3:00 P.M. revealed Resident #17 was in bed with his eyes closed. His right hand was lying on the bed with his finger flexed in a fist. There was not splint on his right hand. Interview with Licensed Practical Nurse (LPN) #505 on 07/13/22 at 3:10 P.M. verified Resident #17 did not have the resting hand splint on his right hand. LPN #505 stated Resident #17 has refused the splint in the past. LPN #505 was unable to locate the resting hand splint in Resident #17's room. Interview with the Director of Nursing (DON) on 07/13/22 at 3:30 P.M. verified there was no resting hand splint in Resident #17's room. The DON stated she called his spouse to see if she took it home and she denied seeing a resting hand splint. The DON stated they found the splint in the supply room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 4 of 5 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 07/14/2022 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure the facility floors were well maintained for 17 of 29 resident's rooms on the 100, 200, and 300 hallways. The facility census was 74. Finding includes: Environmental tour of the facility on 07/12/22 between 3:00 P.M. to 3:30 P.M. with Laundry and Housekeeping Lead #600 and the Administrator revealed the tile floor in the entrance to room [ROOM NUMBER] had a large chip out of the tile. There was also a large chip out of the tile in front of the recliner in room [ROOM NUMBER]. Resident's rooms #100, #101, #102, #103, #105, #106, #200, #201, #202, #203, #204, #205, #208, #209, #301, #302, #307, and #308 had a sticky dark wax build up throughout the rooms and the bathrooms. Interview with the resident residing in room [ROOM NUMBER] on 07/11/22 at 11:04 A.M. stated she felt the floor in her room looked dirty even though they sweep and mop the floor daily. She stated the floor in her needed stripped and waxed. Interview with the Administrator on 07/12/22 at 3:25 P.M. verified the floors in Rooms #100, #101, #102, #103, #105, #106, #200, #201, #202, #203, #204, #205, #208, #209, #301, #302, #307, and #308 had a sticky dark wax build up which was unsightly and appeared to be dirty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 5 of 5