Inspection·October 3, 2018

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. Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure quarterly care conferences were held. This affected one (Resident #38) of one resident reviewed for care planning. Additionally, the facility failed to ensure a plan of care was updated to reflect the residents current smoking status. This affected one (Resident #38) of two residents reviewed for smoking. The facility census was 52. Findings include: Review of Resident #38's medical record revealed an admission date of 02/22/18. Diagnoses included anxiety disorder, opioid abuse, alcohol dependence, major depressive disorder, Schizoaffective disorder, borderline personality disorder, cocaine dependence, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/01/18, identified the resident as being cognitively intact. 1. Review of Resident #38's medical record revealed there was a care conference held on 02/26/18. However, there was no evidence one was held after this date. Interview with Resident #38 on 09/30/18 at 11:28 A.M. voiced he has not had any care conferences. Interview with the Director of Nursing (DON) on 10/03/18 at 1:03 P.M. confirmed care conferences were to be completed quarterly. Interview with Social Service Designee (SSD) #103 on 10/03/18 at 2:49 P.M. confirmed Resident #38 had no care conferences held after 02/26/18. 2. Review of Resident #38's care plan revised 02/26/18 revealed the resident may smoke with supervision per smoking assessment. Interventions included to supervise the patient with smoking in accordance with assessed needs and to maintain the patients smoking materials at the nurses' station. Review of Resident #38's smoking evaluation, dated 08/05/18, identified the resident as being an independent smoker. Interview on 09/30/18 at 11:35 A.M. with Resident #38 revealed he can go outside to smoke whenever he wants to. Resident #38 voiced he was able to keep both his cigarettes and lighter with him. Observation on 09/30/18 at 11:35 A.M. revealed Resident #38 had both his cigarettes and lighter sitting on his bedside table in his room. Interview with Registered Nurse (RN) #105 on 10/02/18 at 10:30 A.M. revealed Resident #38 was an independent smoker and he was able to keep both his cigarettes and lighter both on him. Interview with the Director of Nursing (DON) on 10/02/18 at 3:28 P.M. confirmed Resident #38 used to be a supervised smoker. However, the DON confirmed Resident #38's care plan was not updated to reflect the residents current status as being an independent smoker. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gem City Healthcare and Rehabilitation Center 323 Forest Avenue Dayton, OH 45405 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview and policy review, the facility failed to ensure smoking materials were kept in a safe place. This affected two (#10 and #38) of two residents reviewed for smoking. The facility identified 20 residents (#3, #8, #10, #12, #17, #19, #21, #22, #27, #30, #32, #34, #37, #38, #41, #44, #45, #198, #200 and #202) who smoked. The facility census was 52. Findings include: 1. Review of Resident #38's medical record revealed an admission date of 02/22/18. Diagnoses included anxiety disorder, opioid abuse, alcohol dependence, Schizoaffective disorder, borderline personality disorder, cocaine dependence, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/01/18, identified the resident as being cognitively intact. Review of Resident #38's care plan, revised 02/26/18, revealed the resident may smoke with supervision per smoking assessment. Interventions included to supervise the patient with smoking in accordance with assessed needs and to maintain the patients smoking materials at the nurses' station. Interview on 09/30/18 at 11:28 A.M. with Resident #38 revealed he can go outside to smoke whenever he wants to. Resident #38 voiced he was able to keep both his cigarettes and lighter with him. Observation on 09/30/18 at 11:35 A.M. revealed Resident #38 had both his cigarettes and lighter sitting on his bedside table in his room. Interview with Registered Nurse (RN) #105 on 10/02/18 at 10:30 A.M. revealed Resident #38 was an independent smoker and he was able to keep both his cigarettes and lighter both on him. Interview with the Director of Nursing (DON) on 10/02/18 at 3:28 P.M. confirmed Resident #38 use to be a supervised smoker, however, confirmed Resident #38's care plan was not updated to reflect the residents current status as being an independent smoker. Review of the facility policy titled Smoking dated 06/15/17 revealed a patient's smoking status-independent, supervised, or not permitted to smoke will be documented in the care plan. I revealed the care plan will be updated as necessary. It revealed that if the patient is cognitively ad physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. It indicated that patients will not be allowed to maintain their own lighter, lighter fluid or matches. 2. Record review revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, myocardial infarction, Takotsubo syndrome, and nicotine dependence. Review of the MDS assessment, dated 06/28/18, revealed Resident #10 has moderate cognitive impairment. Review of the smoking assessment, dated 06/21/18, revealed Resident #10 was an independent smoker and safe to smoke unsupervised. Review of the care plan, dated 08/24/18, revealed Resident #10 may smoke independently per smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gem City Healthcare and Rehabilitation Center 323 Forest Avenue Dayton, OH 45405 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 0689 assessment. Intervention included to keep all smoking material at the nurse's station. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #10 on 09/30/18 at 10:46 A.M. voiced she goes outside to smoke when she wants to and was able to keep her cigarettes and lighter with her. Residents Affected - Few Observation on 09/30/18 at 11:00 A.M. revealed the Resident #10's cigarettes and lighter were observed to be lying in her room on her bedside table. Interview with the State Tested Nurse Aide (STNA) #152 on 10/01/18 at 4:29 P.M. confirmed Resident #10 keeps her smoking materials at the bedside. Interview with the Licensed Nursing Home Administrator (LNHA) on 10/03/18 at 2:20 P.M. revealed no residents were to keep their smoking materials with them, regardless if they were independent smoker or not. Review of the facility's list of residents who smoke revealed the facility identified 20 residents (#3, #8, #10, #12, #17, #19, #21, #22, #27, #30, #32, #34, #37, #38, #41, #44, #45, #198, #200 and #202) who smoked. Review of the facility policy titled, Smoking dated 06/15/17 revealed residents will not be allowed to maintain their own lighter, lighter fluid, or matches. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gem City Healthcare and Rehabilitation Center 323 Forest Avenue Dayton, OH 45405 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure a consent was obtained prior to the administration of an influenza vaccination. This affected one (#43) of five residents reviewed who received the influenza vaccination. The facility census was 52. Residents Affected - Few Findings include: Review of Resident #43's medical record revealed an admission date of 08/05/15 with diagnoses of muscle weakness, pure hypercholesterolemia, difficulty in walking, generalized anxiety disorder and cognitive communication deficit. Review of the annual Minimum Data Set (MDS) assessment, dated 08/27/18, identified the resident as having severe cognitive impairment. Review of the influenza immunization informed consent, dated 08/16/15, revealed Resident #43 declined the administration of the influenza vaccine annually. Further review of the medical record failed to indicate there was a signed consent for the influenza immunization to be administered. Review of Resident #43's medications administration record (MAR) revealed the influenza vaccine was administered on 10/14/18. Interview with the Director of Nursing (DON) on 10/03/18 at 1:02 P.M. confirmed Resident #43 was administered the influenza vaccine on 10/14/18 and confirmed there was no consent for the vaccine to be administered. Review of the facility policy titled Influenza Immunization Program dated 11/28/16 revealed a licensed nurse will provide the appropriate influenza immunizations to employees and patients with the patient/health care decision maker/employee consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 If continuation sheet Page 5 of 5