Inspection·July 1, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many his room heated up around 12:00 P.M. Resident #108 stated that he was moved from another room because of the heat but his current room was still too hot. Interview with Resident #158 on 06/29/25 at 10:36 A.M. revealed it was hot in his room. Interview with the Director of Nursing (DON) on 06/29/25 at 11:03 A.M. revealed the facility had no discharges related to the excessively warm temperatures in the facility. Observation on 06/29/25, beginning at 1:06 P.M., with DPO #306 revealed the following ambient room temperatures on the second floor: the dining room was 89.2 degrees F, the 200 hallway was 88.5 degrees F, Resident #01 and Resident #03's room was 93.7 degrees F, Resident #02's room was 94.6 degrees F, Resident #04's room was 82.5 degrees F, Resident #05's room was 94.6 degrees F, Resident #06's room was 94.6 degrees F, Resident #07's room was 91.2 degrees F, Resident #108's room was 90.1 degrees F, Resident #109's room was 91.7 degrees F, and Resident #158's room was 92.8 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the Administrator on 06/29/25 at 1:19 P.M. revealed the facility identified the issue with the cooling tower on 06/04/25 when the facility turned on the air conditioning and it did not work. The Administrator stated the facility had previously received estimates on 03/31/25 and 04/14/25 to replace the cooling tower, but the facility was not aware that the cooling tower was not going to work until the cooling tower was turned on 06/04/25. A follow-up interview with the DON on 06/29/25 at 2:34 P.M. revealed the facility did not have any heating, ventilation, and air conditioning (HVAC) maintenance records from 06/29/23 through 06/29/25. A follow-up interview with the Administrator on 06/29/25 at 3:07 P.M. revealed the facility was in the process of looking for a temporary chiller but they were unable to find one that was the appropriate size for the facility. The Administrator stated the facility started to take daily temperatures and auditing residents for safety while the air temperatures were outside of a comfortable range. Observation on 06/29/25, beginning at 5:13 P.M. with DPO #306, revealed the following room temperatures on the second floor: the dining room was 90.6 degrees F, the 200 hallway was 88.1 degrees F, Resident #01 and Resident #03's room was 87.9 degrees F, Resident #02's room was 90.6 degrees F, Resident #04's room was 83.1 degrees F, Resident #05's room was 89.7 degrees F, Resident #06's room was 91.7 degrees F, Resident #07's room was 93.3 degrees F, Resident #108's room was 88.1 degrees F, Resident #109's room was 90.1 degrees F, and Resident #158's room was 90.5 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the Administrator and DON on 06/30/25 at 7:40 A.M. verified the facility did not enact the transfer agreement when the air temperatures went above 81 degrees F in the facility. Interview with the DON on 06/30/25 at 8:00 A.M. revealed the facility staff were educated about air temperatures being out of range on 06/03/25. The DON stated that the facility did not have temperatures out of range until 06/04/25 but the facility was able to predict that it was going to occur. Observation on 06/30/25, beginning at 8:09 A.M. with DPO #306, revealed the following room temperatures on the second floor: the dining room was 86.7 degrees F, the 200 hallway was 82.4 degrees F, Resident #01 and Resident #03's room was 79.3 degrees F, Resident #02's room was 82.7 degrees F, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Resident #04's room was 77.1 degrees F, Resident #05's room was 82.5 degrees F, Resident #06's room was 85.6 degrees F, Resident #07's room was 87.2 degrees F, Resident #108's room was 80.7 degrees F, Resident #109's room was 86.5 degrees F, and Resident #158's room was 82.2 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the DON on 06/30/25 at 10:14 A.M. verified the facility was provided the initial estimate from the heating and cooling company for a new cooling tower unit on 03/31/25 and the facility received an updated estimate for the cooling tower unit on 04/14/25. The DON confirmed the payment for the heating and cooling company to order the new cooling tower was not made until 05/08/25. The DON was not able to provide the reason for the delay in payment for the new cooling tower. Review of the facility's HVAC maintenance records from 06/29/23 to 06/29/25 revealed no evidence the facility had routine HVAC maintenance during this time. Review of a heating and air conditioning estimate, dated 03/31/25, revealed the facility received an estimate for a closed circuit cooling tower unit, with the total amount costing $69,000.00. Review of a heating and air conditioning estimate, dated 04/14/25, revealed the facility received an estimate for a new cooling tower unit, with the total amount costing $112,472.00. The estimate stated a 75 percent (%) deposit was required to order the new tower and to purchase the necessary materials. Review of a facility provided copy of a check revealed the facility did not make payment to replace the cooling tower unit until 05/08/25. Review of the facility's air temperature logs revealed on 06/26/25, resident room temperatures ranged ranged from 81 to 83 degrees F; on 06/27/25, resident room temperatures ranged from 80 to 89 degrees F; and on 06/28/25, resident room temperatures ranged from 78 to 82 degrees F. Review of the facility's cooling plan, dated 06/29/25, revealed the facility added seven additional industrial fans to circulate air from the portable air conditioners, black out covers to the windows to keep out additional heat, and insulation to cover the windows to vent out heat and prevent it from coming back in the windows. The facility also offered cold drinks and checked on the residents for comfort every 15 minutes. The facility also planned to continue to search for a temporary chiller to rent. Review of the facility policy titled, Safe and Homelike Environment, undated, revealed the facility would maintain comfortable and safe temperature levels. The facility would strive to keep temperatures in common resident areas between 71 and 81 degrees F. Review of the facility policy titled, HVAC System, undated, revealed the facility maintained an HVAC system in a manner that protected resident health and safety from fire and extreme temperatures. HVAC installation and maintenance shall be in accordance with the manufacturer's specifications and life safety code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure the medication error rate did not exceed five percent (%) when 13 medication errors were observed of 36 opportunities, resulting in an error rate of 36.11%. This affected three (Residents #108, #4, and #7) of three residents observed for medication administration. The facility census was 10. Residents Affected - Few Findings include: Review of medical record for Resident #108 revealed an admission date of 06/03/25, with diagnoses including diabetes mellitus Type II, hypertension, atherosclerotic heart disease, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and benign prostatic hyperplasia (BPH). Review of the current physician orders for Resident #108 revealed the resident had the following orders: albuterol-budesonide inhalation aerosol 90-80 micrograms per actuation (mcg/act) two puffs every morning, aspirin 81 milligrams (mg) every morning, bumetanide 0.5 mg every morning, carboxymethylcellulose 1 percent (% ) one drop in both eyes every morning, cholecalciferol 25 mcg every morning, finasteride five mg every morning, Steglatro five mg every morning, metoprolol tartrate 25 mg twice a day, guaifenesin 400 mg twice a day, Lyrica 50 mg every 12 hours, and albuterol sulfate nebulization solution 0.83% 2.5 mg/3 ml four times a day. Observation of medication administration on 06/30/25 at 8:45 A.M. for Resident #108 revealed Licensed Practical Nurse (LPN) #309 administered Lyrica, aspirin, finasteride, guaifenesin, and albuterol sulfate nebulization solution. Further observation revealed metoprolol tartrate, albuterol-budesonide inhalation aerosol, bumetadine, cholecalciferol, and Steglatro were not administered as ordered. Concurrent interview with LPN #309 verified the medications were not administered, adding the medications were unavailable for administration. 2. Review of the medical record for Resident #4 revealed an admission date of 10/05/25, with diagnoses including cerebral infarction (stroke) without residual deficits, diabetes mellitus type II, and COPD. Review of the current physician orders for Resident #4 revealed the resident had the following orders: lasix 20 mg every morning, losartan potassium 25 mg daily, magnesium 400 mg every morning, omeprazole 20 mg every morning, oxybutynin chloride extended release 15 mg daily, probiotic product acidophilus every morning, Thera M Plus every morning, Cystex Urinary Pain Relief 162-162.5 mg twice a day, Eliquis 2.5 mg twice a day, Lantus Subcutaneous Solution 100 unit/ml inject 56 units subcutaneously two times a day, meclizine 25 mg twice a day, metoprolol tartrate 25 mg twice a day, spironolaction 50 mg twice a day, Symbicort Aerosol 160-2.5 mg/act twice a day, Topamax 100 mg twice a day, and Humalog Injection Solution 100 unit/milliliter (u/ml) inject 15 units subcutaneously with meals. Observation of medication administration on 06/30/25 at 9:23 A.M. for Resident #4 revealed LPN #309 administered losartan, oxybutynin, topiramate (Topamax), lasix, Lantus Solostar, meclizine, metoprolol tartrate, omeprazole, acidophilus (probiotic), spironolactone, and Thera-M (vitamin supplement). Further observation revealed Cystex Urinary Pain Relief, Eliquis, magnesium, and Symbicort were not administered as ordered. Concurrent interview with LPN #309 verified the medications were not administered and stated they were not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the medical record for Resident #7 revealed an admission date of 05/16/25, with diagnoses including congestive heart failure, hypertension, diabetes mellitus type II, and major depressive disorder. Review of the current physician orders revealed Resident #7 was ordered the following: esomeprazole magnesium 20 mg every morning, Lantus Subcutaneous Solution 100 u/ml inject 20 units subcutaneously every morning and at bedtime, Novolog Subcutaneous Solution 100 u/ml inject 10 units subcutaneously with meals, sertraline 25 mg every morning, Cardizem Extended Release 240 mg every morning, Colace 100 mg every morning, ferrous sulfate 325 mg every morning, Flonase Allergy Relief Nasal Suspension 50 mcg/act two spray in both nostrils every morning, lasix 40 mg every morning, and buspirone 30 mg twice a day. Observation of medication administration on 06/30/25 at 9:46 A.M. for Resident #7 revealed LPN #309 administered buspirone, Colace, esomeprazole magnesium, ferrous sulfate, Flonase, Novolog Flex Pen, and sertraline 50 mg. Further observation revealed Cardizem and lasix were not administered as ordered. Concurrent interview with LPN # 309 verified Cardizem and lasix were not administered as ordered, adding the medications were unavailable. A follow-up interview on 06/30/25 at 09:56 A.M. with LPN #309 confirmed the physician order for sertraline was for 25 mg and further verified she administered sertraline 50 mg to Resident #7. Review of the facility policy titled, Medication Errors, undated, revealed the facility would ensure medications were administered according to physician's orders, per manufacturer's specifications regarding the preparation, and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of medication manufacturer instructions, the facility failed to ensure insulin pens were primed prior to administration. This affected two (#4 and #7) of three residents observed for medication administration. The facility census was 10. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 10/05/25, with diagnoses including cerebral infarction (stroke) without residual deficits, diabetes mellitus type II, and chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed an order dated 06/07/25 for Lantus SoloStar Subcutaneous Solution Pen-Injector (insulin) 100 units per milliliter u/ml, inject 56 units subcutaneously two times a day related to type II diabetes mellitus with other specified complications. Observation of Resident #4's medication administration on 06/30/25 at 9:23 A.M. revealed Licensed Practical Nurse (LPN) #309 prepared the resident's insulin for administration. LPN #309 attached a new needle to a Lantus Solostar insulin pen device and dialed to 56 units. LPN #309 did not prime the Lantus Solostar insulin pen device before administering the insulin Resident #4. Interview on 06/30/25 at 9:56 A.M. with LPN #309 verified she did not prime Resident #4's Lantus Solostar insulin pen prior to administration. Review of the manufacture instructions for the Lantus Solostar insulin pen device revealed to always perform the safety test (priming) before each injection to ensure accurate dosage by ensuring the pen and needle worked properly and removal of air bubble. To complete the safety check, the instructions indicated to select a dose of two units by turning the dosage selector clockwise, take off the outer needle cap and keep it to remove the used needle after injection, take off the inner needle cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, press the injection button all the way in, and check if insulin comes out of the needle tip. Further review revealed to perform safety tests before using the pen until insulin is seen coming out of the needle tip. If insulin is not seen before administering the dose, an underdose or no insulin at all could be administered, potentially causing high blood sugar. 2. Review of the medical record for Resident #7 revealed an admission date of 05/16/25, with diagnoses including congestive heart failure, hypertension, diabetes mellitus type II, and major depressive disorder. Review of the physician orders revealed an order dated 06/10/25 for NovoLog FlexPen Subcutaneous Solution Cartridge (insulin) 100 u/ml, inject 10 units subcutaneously with meals related to type II diabetes mellitus without complications. Observation of Resident #7's medication administration on 06/30/25 at 9:46 A.M. revealed LPN #309 prepared the resident's insulin for administration. LPN #309 attached a new needle to a NovoLog FlexPen insulin pen device and dialed to 10 units. LPN #309 did not prime the NovoLog FlexPen prior to administering the insulin to Resident #7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/30/25 at 9:56 A.M. with LPN #309 confirmed she did not prime the NovoLog FlexPen insulin pen device before administering the insulin to Resident #7. Review of the manufacturer instructions for the NovoLog FlexPen insulin pen device revealed to give an airshot (priming) before each injection. Before each injection, small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing, turn the dose selector to select two units, hold the insulin pen with the needle pointing up, tap the cartridge gently to make any air bubbles collect at the top of the cartridge, keep the needle pointing upwards, press the push-button all the way in until the dose selector returns to zero, a drop of insulin should appear at the needle tip, if not, change the needle and repeat the procedure no more than six times. If a drop of insulin is not seen after six times, do not use the insulin pen. Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, staff interview and review of the menu, the facility failed to ensure alternative food options were available. This affected all residents, except one (#5) resident identified by the facility as received no meals from the facility. The facility census was 10. Findings include: Observations on 06/29/25 and 06/30/25 revealed resident meals were delivered to the facility from an outside vendor, with nine meals delivered for each meal. Further observation revealed each of the meals were exactly the same and no alternate or extra foods were delivered. Interview with CNA #302 on 06/29/25 at 10:00 A.M. revealed resident meals were delivered to the facility by an outside vendor approximately 30 minutes prior to meal times. CNA #302 stated only nine meals were delivered for each meal and no alternatives or extras were provided. CNA #302 stated sometimes residents did not eat if they did not like what was delivered, adding she had nothing else to offered except for a peanut butter sandwich. Interview with Resident #109 on 06/29/25 at 10:14 A.M. revealed they had no choice for their meals and they could not get any extra food, if they wanted it. Interview with Resident #108 on 06/29/25 at 10:18 A.M. revealed they could not make any food choices and had to each what was served. Resident #108 stated he had to buy his own food. Interview with Resident #2 on 06/29/25 at 10:22 A.M. revealed there were no choices offered for meals. Interview with Food Vendor (FV) #350 on 06/29/25 at 12:00 P.M. confirmed the vendor only provided one meal for each resident at each meal. FV #350 verified residents could not request extra food or an alternative meal to what was provided, adding the residents had no choices. Review of the facility menu for June 2025 revealed three meals were offered per day. The menu listed one choice per meal, with no alternatives available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of the facility policy, the facility failed to ensure food was stored in a manner to prevent food born illness. This had the potential to affect all residents, except one (#5) who received no food from the kitchen. The facility census was 10. Findings include: Observations on 06/29/25 at 11:00 A.M. revealed the refrigerator located on the second-floor dining room contained the following items: a half gallon of chocolate milk with an expiration date of 06/23/25, a bag of opened Parmesan cheese with an expiration date of 05/20/25, and a bag of unopened lettuce that was brown and slimy. The pantry area also had an opened loaf of bread with an expiration date of 06/28/25. Interview with Certified Nursing Assistant (CNA) # 302 on 06/29/25 at 11:30 A.M. revealed no one was in charge of the dietary department at the present time because the facility had resident meals brought in due to kitchen construction. CNA # 302 stated she did not know who was responsible for removing expired foods. CNA #302 verified the expired food items in the refrigerator and pantry. Review of the undated facility policy for food storage revealed the facility would store food in accordance with professional standards for food service safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 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 365981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 ensure medications were handled in a sanitary manner. This affected three (#108, #4, and #7) of three residents reviewed for medication administration. The facility census was 10. Residents Affected - Few Findings include: 1. Observation on 06/30/25 at 8:45 A.M. revealed Licensed Practical Nurse (LPN) #309 prepared medications to administer to Resident #108. LPN #309 was observed removing medication from Resident #108's medication card and placing the medication into her ungloved hand before placing the medication into a medication cup. Interview on 06/30/25 at 9:56 A.M. with LPN #309 verified she placed Resident #108's medications into her bare, ungloved hand prior to administration. 2. Observation on 06/30/25 at 9:23 A.M. revealed LPN #309 prepared medications to administer to Resident #4. LPN #309 was observed removing medication from Resident #4's medication card and placing the medication into her ungloved hand before placing the medication into a medication cup. Interview on 06/30/25 at 9:56 A.M. with LPN #309 confirmed she placed Resident #4's medications into her bare, ungloved hand prior to administration. 3. Observation on 06/30/25 at 9:46 A.M. revealed LPN #309 prepared medication to administer to Resident #7. LPN #309 was observed removing medication from Resident #7's medication card and placing the medication into her ungloved hand before placing the medication into a medication cup. Interview on 06/30/25 at 9:56 A.M. with LPN #309 verified she placed Resident #7's medications into her bare, ungloved hand prior to administration. Review of facility policy titled, Medication Administration, undated, revealed to remove medication from source, taking care not to touch medications with bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365981 If continuation sheet Page 10 of 10