Inspection·December 5, 2019

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. Based on medical record review, observations, and staff interview, the facility failed to maintain a safe environment for one Resident with a diagnoses of seizures by leaving the resident's bed in a high position. This affected one resident (#57) of three reveiwed for accidents. The facility census was 57. Findings include: Review of Resident #57 medical record revealed an admission date of 10/18/18, with diagnoses including seizure disorder, stroke and hemiplegia (paralysis on one side). The most recent Minimum Date Set (MDS) assessment dated on 10/25/19 revealed Resident #57 was severely cognitively impaired and required extensive assist of one with bed mobility. The most recent plan of care updated on 10/25/19 revealed the resident's bed was to be in low position when the resident was in bed. Observation of Resident #57 on 12/02/19 at 9:30 A.M., 10:30 A.M., and 1:30 P.M revealed the resident's bed was in a high position. Interview on 12/02/19 at 1:40 P.M. State Tested Nursing Assistant (STNA) #15 on 12/03/19 at 1:05 P.M. confirmed Resident #56's bed was in a high position and should not have been. 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 12/05/2019 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 provide ordered monitoring for medication use for one Resident (#49) of five reviewed for unnecessary medications. The facility census was 57. Residents Affected - Few Findings include: Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), pulmonary hypertension, and heart failure. Review of Resident #49's physician orders dated 10/08/18, revealed an order for Metoprolol Tartrate (for high blood pressure) 12.5 milligrams (mgs) two times a day. Hold Metoprolol if blood pressure is less than 100 systolic or heart rate is less than 60. Review of Resident #49's care plan modified on 11/11/19 revealed the resident was at risk for alteration in cardiac status related to hypertension. Interventions included to monitor blood pressure and pulse as indicated, and notify physician of changes. Review of Resident #49's documented vital signs revealed from 11/29/19 through 12/03/19 the resident's pulse was not checked prior to the administration of the scheduled 9:00 P.M. dose of Metoprolol Tartrate. Interview with the Director of Nursing (DON) on 12/05/19 at 2:08 P.M. confirmed Resident #49's physician orders were to hold the Metoprolol Tartrate if the resident's heart rate was less than 60. The DON confirmed Resident #49's pulse was not checked from 11/29/19 through 12/03/19 prior to the 9:00 P.M. dose of Metoprolol Tartrate being administered. 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 12/05/2019 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to serve food in a form to meet the individual needs for one Resident (#46) of three reveiwed for nutrition. The facility census was 57. Findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including dementia, high blood pressure and schizophrenia. The most recent Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired, and required extensive assistance of one with meals. Review of Resident #46's current physicians orders revealed the resident was to have a regular diet with hand held foods. Observations Resident #46 on 12/03/19 at 12:30 P.M. during the lunch meal revealed the resident had peaches, mashed potatoes, and a chicken patty. The resident was trying to eat her mashed potatoes with her fingers. State Tested Nursing Assistant (STNA) #25 would hand the resident her spoon and assist her at times, and tried to cue her. Then the resident would go right back to eating the mashed potatoes with her fingers. Interview with STNA #25 at the time of the observation revealed the resident did so much better with food she could pick up and she rarely received hand held foods. Observation on 12/05/19 at 12:35 P.M. revealed the resident had mashed potatoes, rice with gravy, and pork roast. The resident again was trying to eat the mashed potatoes, and rice with gravy with her fingers. Interview on 12/04/19 at 1:20 P.M. with the Dietician revealed she did not realize Resident #46 could not eat with a spoon. The dietician noted the resident had lost weight. Interview on 12/05/19 at 12:45 P.M. with Dietary Manager #49 revealed the resident received the wrong diet on 12/03/19 and 12/05/19. 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 12/05/2019 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 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, and review of facility policy, the facility failed to handle soiled incontinence products in a manner to prevent the potential of the spread of infection. This affected one Resident (#46) of one observed for incontinence care. The facility census was 57. Residents Affected - Few Findings include: Observation of Resident #46's room on 12/04/19 at 5:10 P.M., revealed a pile of soiled incontinence products were noted on the floor beside the resident's bed. State Tested Nursing Assistant (STNA) #50 was providing incontinence care for the resident . The resident was incontinent of bowel and bladder. Interview with STNA #50 on 12/04/19 at 5:20 P.M. revealed she was hurrying and knew the linen should be bagged and not thrown on the floor. Interview with Licensed Practical Nurse (LPN) #44 on 12/04/19 at 5:30 P.M. revealed it was the policy of the facility to place soiled linens in a bag and not thrown on the floor. Review of the facility policy titled, Infection Control revealed all dirty linen should be placed in a bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 If continuation sheet Page 5 of 5