Inspection visit

InspectionJuly 23, 2019

GABLES CARE CENTER INCCMS #36605234 citations on this visit

34 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 34 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #73 and Resident #32 had periodic care conferences in which either the resident and/or their responsible party were included with a comprehensive interdisciplinary team to ensure the residents individual needs were being addressed. This affected two residents (#73 and #32) of two residents reviewed for care conferences. Findings include: 1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) required continuous oxygen and morbid obesity. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and was totally dependent on staff for activities of daily living (ADL) care. Review of the medical record revealed the only care conference notes for 2019 were dated 06/20/19 and there was no evidence the facility addressed all the family's concerns. Further review of the care conference revealed there were no direct care staff who participated in the meeting. The staff participating included the MDS Registered Nurse (RN) #315, social service, the activities director, the dietary manager and four family members. The family brought up many concerns. On 07/17/19 at 1:25 P.M., interview with the resident's family revealed the family visited frequently and attended the care conference meetings when they were held but felt the facility did not address all their concerns including concerns related to the resident's oxygen tank running out of oxygen and no one monitoring the tank and the resident not being changed timely when she was incontinent resulting in developing and not being able to heal pressure ulcers. The family member stated they asked about different pressure relieving devices for her wheelchair but no one would assess this to see about different options. The family had to inform the staff many times the resident's oxygen tank was empty while in use and requested staff to change the resident. The family felt because the resident was a mechanical lift it took to much staff and time to check and change her timely. On 07/17/19 at 2:57 P.M., interview with RN #315 revealed she ran the meetings and had the computer in the room in case the family had any questions. She verified she did not work the floor nor did she obtain any resident specific information from any direct care staff and verified they were not part of the care plan process. She verified the facility did not address all the family concerns from the 06/20/19 meeting. She verified there were no other care conferences in 2019. A care conference was scheduled on 01/24/19 but was needed to be canceled and then the resident was in the hospital so the first time available was 06/20/19. She was unable to find documentation to address the family's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 58 Event ID: 366052 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0553 concerns related to oxygen and incontinence care. Level of Harm - Minimal harm or potential for actual harm 2. Record review revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis which included Parkinson's disease. Residents Affected - Few Review of the quarterly MDS 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of one or more staff for ADL care. Review of the care conferences dated 01/03/19 and 05/16/19 revealed the resident did not attend and there was no evidence the resident was invited to attend. There was no evidence of any direct care staff attending or participating in the conference. The resident's wife attended and had many concerns. On 07/17/19 at 6:50 P.M., interview with the resident's wife revealed the facility did not always address her concerns. On 07/18/19 at 9:34 A.M., interview with RN #314 revealed she was the MDS nurse and did not work on the floor but was in charge of the care conferences. She verified there was no evidence the resident, who was alert and oriented, was invited to the care conferences and verified no direct care staff were interviewed or were approached to give input on the residents care needs. She was not aware this was a requirement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 2 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #32, who was on Medicaid, was not charged for personal care need items that should be covered under the State Medicaid program. This affected one resident (#32) of one resident reviewed related to paying for personal care items. Findings include: Record review revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis including Parkinson's disease. Review of the signed admission agreement revealed the resident was admitted on Medicaid services which continued throughout his stay. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of one or more staff for activities of daily living. On 07/17/19 at 6:50 P.M., interview with the resident's wife revealed the resident's non skid socks were old, lost their elasticity and the non skid part was worn down. She stated she asked Licensed Practical Nurse (LPN) #323 if she could get another pair for the resident and was told she would have to pay for them. The wife also revealed she purchased nutritional supplements, adult briefs and other personal care items and snacks for the resident as no one from the facility had informed her these items should be included in the resident's stay and provided by the facility. On 07/18/19 at 9:07 A.M., interview with LPN #323 revealed she did tell residents, including Resident #32 they would have to pay for any additional pairs of non-skid socks after the initial pair was given. On 07/18/19 at 10:05 A.M., interview with Admissions Director #355 revealed the Resident #32 was admitted on Medicaid services and continued on Medicaid services and should not be asked to pay for any personal care items because they were covered under Medicaid and should be supplied by the facility. On 07/18/19 at 10:15 A.M., LPN #323 was observed to tell the Director of Nursing (DON) she thought residents only got one free pair on non-skid socks and had to pay for any additional pairs requested. On 07/18/19 at 10:19 A.M., interview with the DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 3 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of physical abuse by staff towards Resident #182 was reported immediately as required. This affected one resident (Resident #182) of two residents reviewed for physical abuse. Findings include: Review of Resident #182's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which include dementia and anxiety. The resident passed away on 04/13/19. Review of the behavior care plan initiated 10/23/18 revealed the resident had behaviors including taking other resident's belongings, yelling at other male residents, thinking they were her husband and being physically abusive towards staff. Review of the attending physician note, dated 01/14/19 revealed the resident had become increasingly confused and was having more trouble with agitation at night and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable had delusions and the only behavior identified was wandering. Review of the nurse's notes from 02/10/19 through 02/11/19 revealed on 02/10/19 beginning at 9:27 P.M., the resident was at the nurse's station being verbally inappropriate with staff. Attempts to redirect back to bed were unsuccessful and all interventions ineffective. At 11:40 P.M., the resident continued to be verbally inappropriate with staff, yelling out profanity and entering other resident's rooms while they were sleeping. The resident was combative with staff, redirection, one on one and other interventions were ineffective. On 02/11/19 at 12:15 A.M., the physician was notified and ordered an intramuscular injection of Haldol, an antipsychotic medication used to make you feel less nervous, every six hours as needed for increased agitation. The medication was effective and the resident was sleeping in bed. Review of the a self reported incident (SRI) submitted to the State agency on 03/28/19 revealed a nurse claimed that another employee, a State Tested Nursing Assistant (STNA) had accused a staff member of mistreatment during medication administration. The SRI revealed the alleged incident occurred on 02/11/19 at 12:35 A.M.; however it was not reported to the facility until 03/28/19. Review of the Summary of the Incident form revealed an LPN (not named in the SRI) stated an STNA (not named in the SRI) said that a resident was mistreated during a medication administration. When interviewing others present at the facility who witnessed the administration no mistreatment was observed while stating that the staff intervened with the resident in a manner as to make sure the resident was cared for in a compassionate and safe manner. Further review of the investigation revealed there was no other documentation in the medical record related to the allegation. Review of an interview with Licensed Practical Nurse (LPN) #376 revealed former STNA #500 informed her awhile ago but she could not recall when that an STNA and nurse held down Resident #182 in a chair to give her multiple injections of a medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 4 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 07/23/19 at 10:15 A.M., interview with the Director of Nursing (DON) and Administrator verified LPN #376 did not immediately report an allegation of physical abuse according to the facility policy and State mandates. Review of the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, revised 11/28/16, revealed facility staff should immediately report all allegations of abuse, neglect, exploitation, mistreatment of a resident tor misappropriation of resident property including inquiries of unknown source to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. Event ID: Facility ID: 366052 If continuation sheet Page 5 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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** 2. Record review revealed Resident #77 was admitted to the facility on [DATE] with a diagnoses including mood disorder, schizophrenia, dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, anxiety, and depression. Residents Affected - Few Review of the Pre-admission Screening and Resident Review (PASRR) dated 08/03/13 (completed after a psychiatric stay) revealed it was determined the resident meet PASRR assessment requirements. The review revealed the resident had diagnoses of dementia with behavioral disturbance, schizophrenia, and psychotic disorder. Review of Resident #77's MDS 3.0 assessment, dated 04/17/19 and 06/17/19 revealed the resident was not considered by the State level II PASRR process to have a serious mental illness. Interview on 07/18/19 at 12:03 P.M., with Registered Nurse (RN) #315 verified the MDS 3.0 assessment, dated 04/17/19 and 06/17/19 were coded inaccurately related to PASRR/serious mental illness. She reported she would modify the MDS. Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment. 3. Record review revealed Resident #73 was admitted to the facility on [DATE] with a diagnoses which included chronic obstructive pulmonary disease. Review of the nursing evaluation dated 06/16/19 revealed the resident had one Stage I pressure ulcers and two Stage II pressure ulcers. Review of the annual MDS 3.0 assessment dated [DATE] revealed the resident had two Stage I pressure ulcers and one Stage II pressure ulcers. On 07/22/19 at 1:05 P.M., interview with RN #420 verified the the MDS was incorrect related to the resident's pressure ulcers. Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment. Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate. This affected three residents (#34, #73 and #77) of 30 residents reviewed for MDS 3.0 assessments. Findings include: 1. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a diagnosis including unspecified dementia without behavioral disturbance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 6 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #34 was occasionally incontinent of bladder. Review of the MDS assessment look-back period, dated 05/15/19 through 05/21/19 revealed Resident #34 was incontinent of urine on 10 occasions. On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 revealed occasionally incontinent was defined as having less than seven episodes of incontinence and frequently incontinent was defined as having seven or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period. MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate and should have been coded as being frequently incontinent of urine. Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment. Review of the policy titled Bowel and Bladder Continence Care Management dated March 2017 revealed occasionally incontinent was less than seven episodes of bladder incontinence during the seven day look back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 7 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to incorporate the recommendations from the Pre-admission Screening and Review (PASRR) level II determination and the PASRR evaluation report into Resident #77's care to ensure the resident received adequate mental health services. This affected one resident (#77) of two residents reviewed for PASRR. Findings include: Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including mood disorder, schizophrenia, dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, anxiety, and depression. The resident's two brothers were listed as the emergency contact. There was no evidence the resident had a legal guardian/conservator. There was no evidence the resident was receiving any type of mental health counseling or ongoing medication review by a psychiatrist. Review of PASRR documentation, dated 08/03/13 (completed after a psychiatric stay) revealed it was determined the resident meet PASRR assessment requirements and the following decisions had been made by the Ohio Mental Health and Addiction Services due to the residents diagnoses of dementia with behavioral disturbance, schizophrenia, and psychotic disorder: The nursing facility was to provide occupational therapy, mental health counseling, ongoing medication review by a psychiatrist, ongoing medications review by a physician, behavior management, and guardian/conservator. The rationale for the recommendation revealed the resident would benefit if a guardian/conservator was appointed for decision making regarding health and safety and family involvement. A behaviorally-based treatment plan was recommended to reduce negative behaviors, ongoing evaluation of the effectiveness of current psychotropic mediation on target symptoms and ongoing medication review by a physician. The resident would benefit from ongoing medication review by psychiatrist to insure his behavioral medication are managing his symptoms and by a physician to insure his medical medication are managing his medical symptoms. Review of Resident #77's current plan of care for PASRR revealed an intervention to refer to the PASRR. There were no resident specific interventions developed or identified. Review of Resident #77's Minimum Data Set (MDS) 3.0 assessments, dated 04/17/19 and 06/17/19 revealed the assessment inaccurately documented the resident was not considered by the State level II PASRR process to have a serious mental illness. Interview on 07/17/19 at 10:56 A.M., with the Director of Nursing (DON) confirmed the resident was not receiving mental health counseling, ongoing medications review by a psychiatrist, and he did not have a court appointed guardian/conservator per the PASRR recommendations dated 08/03/13. Interview on 07/17/19 at 11:21 A.M., with Registered Nurse (RN) #372 revealed the resident currently had verbally sexual behaviors. The RN stated in the past he had both verbal and physical sexual behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 8 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0644 Level of Harm - Minimal harm or potential for actual harm Interview on 07/18/19 at 12:03 P.M., with RN #315 verified the MDS 3.0 assessment, dated 04/17/19 and 06/17/19 were coded inaccurately to reflect PASRR/serious mental illness. She indicated the MDS would need modified and the resident's plan of care would need to be updated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 9 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure preadmission screening and resident review (PASRR) documentation was completed accurately to reflect Resident #53's serious mental illness. This affected one resident (#53) of two residents reviewed for PASRR. Residents Affected - Few Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis including psychosis not due to substance or known physiological condition and major depression. The resident had a previous short stay in 02/2018 that included the same diagnoses. Review of Resident #53's PASRR dated 12/31/18 revealed the resident had no mental disorders. Review of Resident #53's admission Minimum Data Set (MDS) 3.0 assessment, dated 01/12/19 revealed the resident was not currently considered by the State Level II PASRR (preadmission screening and resident review) process as had no serious mental illness identified. Review of Resident #53's physician's orders, dated 01/24/19 to present revealed the resident was ordered Risperdal 0.5 milligrams (mg) twice daily for psychosis and Lexapro 20 mg daily for depression. Review of Resident #53's plan of care revealed to follow PASRR recommendation. However, there were no evidence of resident specific interventions. Further review plan of care revealed the resident was at risk for drug related complications related to psychotropic medication use of antidepressant, antipsychotic for depression and psychosis. Review of verification of diagnoses letter from Resident #53's physician dated 07/16/19 revealed the resident had been on Risperdal for greater than eight years for bipolar two disorder and psychosis. The resident had been treated by mental health care in the past. Interview on 07/16/19 at 1:06 P.M., and 3:13 P.M., with the Director of Nursing (DON) verified the PASRR dated 12/31/18 was inaccurately completed and did not reflect the resident's mental disorders/diagnoses. The DON confirmed the resident had a history of psychosis that was noted from a previous stay in 2018. She called the physician's office on this date to clarify the psychosis diagnosis since it was not listed on the physician progress notes or in the hospital records. The physician's office reported the resident had a diagnosis of bipolar disorder in addition to psychosis and had received treatment from a mental health facility. The resident had been on medication for these disorders for over eight years. The DON verified the facility was not aware of the bipolar diagnosis until this date. The DON reported the hospital completed the PASRR, however it the PASRR documents were reviewed by the admission clerk and herself. She confirmed the facility should have verified the diagnosis and resubmitted a new PASRR to reflect the resident serious mental illnesses. Review of PASRR policy and procedures 12/06/18 revealed the facility would ensure all new admissions were appropriately screened prior to admission to determine if the individual required nursing facility level of care and to identify any specialized services that may be necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 10 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure comprehensive and individualized restorative programs, including programs for ambulation, toileting and/or range of motion were developed and implemented to meet the needs of Resident #32, #34 and #54. This affected three residents (#32, #34 and #54) of five residents reviewed for restorative services. Residents Affected - Few Actual Harm occurred when the facility failed to consistently implement restorative ambulation, range of motion and toileting programs for Resident #32 resulting in a significant decline in ambulation status. Between 01/28/19 and 03/08/19 the resident's ambulation ability declined from being ambulatory with a walker to non-ambulatory. The resident currently required extensive assistance from two staff for ambulation. Findings include: 1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, benign prosthetic hypertrophy and overactive bladder. Review of the residents falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself. Review of the current care plan revealed there was no evidence the resident was on a restorative toileting program or a range of motion program. The current care plan revealed the resident was on a restorative ambulation program which was to be provided four times a day seven days a week. Review of the Physical Therapy (PT) evaluation and treatment plan dated 01/12/19 revealed the resident was able to ambulate 200 feet with a walker. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate an unlimited distance with the walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level of performance and prevent decline. Review of the restorative program note dated 01/28/19 revealed the resident was on restorative ambulation with the walker daily for 15 minutes and restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention despite having no assessments to evaluate the programs. Review of the PT evaluation and treatment plan dated 03/08/19 revealed the resident was referred back to therapy because the resident was not able to ambulate at this time. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate 250 feet with walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level and prevent decline. Review of the restorative participation grids for May 2019 revealed the resident was encouraged to ambulate four times a day yet there was only one entry available for each day. The resident was ambulated only 11 days for the month and only one time each of the 11 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 11 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 Level of Harm - Actual harm Residents Affected - Few Review of the restorative toileting grid revealed to offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the State Tested Nurse Aid (STNA) documentation revealed the resident infrequently was able to walk in him room with assistance. Review of the restorative program note dated 05/02/19 revealed the resident continued on the ambulation program with unlimited distance with the walker daily and the toileting programs at scheduled times. This was not accurate and there were no assessments completed and there was no documentation the resident was able to walk an unlimited distance. Review of the Occupational Therapy (OT) evaluation and treatment plan on 05/16/19 revealed the resident needed maximum assistance for toileting. On 06/16/19 unable to test the resident's ability to transfer to the toilet due to safety concerns with his blood pressure dropping. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed he was cognitively intact but needed extensive assistance of one or more staff for activities of daily living (ADL). He needed extensive assistance of one person to walk in his room. He was frequently incontinent of bladder and continent of bowel. The assessment revealed he received restorative services for ambulation one day, dressing six days and eating seven days (did not indicate toileting of ROM). Review of the physician's order dated 05/23/19 revealed the resident was to be walked four times a day as tolerated. Review of the restorative participation grids for the month of June 2019 revealed the resident was encouraged to ambulate four times a day. Staff had the ability to enter two entries a day. The resident ambulated nine days and only once for each of the nine days for the month. Review of the restorative toileting grid revealed offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the STNA documentation revealed the resident infrequently was able to walk in him room with assistance. Review of the 06/10/19 restorative program note revealed the resident was tolerated the toileting program well with goals met and no decline. Continue to offer ambulation program daily but resident ambulates in his room and to and from the bathroom. Review of the OT progress note dated 06/21/19 revealed OT staff were not able to test the residents ability to transfer to the toilet due to safety concerns with his dropping blood pressure. Further review of the Discharge summary dated [DATE] reveled the resident demonstrated a medical decline and decreased safety awareness to self with attempting to get up on his own. The resident needed the assistance of two staff at all times for ADL's and mobility. Restorative ROM (which was not implemented) was recommended. Review of the restorative participation grids for July 2019 revealed the resident was encouraged to ambulate four times a day. Staff had the ability to document two entries a day. The resident was ambulated twice on 07/02/19 and once on 07/07/19 but no other times during the month. Review of the restorative toileting grid revealed offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 12 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 documentation revealed the resident infrequently was able to walk in him room with assistance. Level of Harm - Actual harm Review of the 07/16/19 restorative program note revealed the resident was tolerating the toileting program well with no changes. The resident met his 15 minute daily ambulation program and no decline in ambulation was noted. There was no acknowledgement of the previous therapy recommendations for ROM programs to be implemented. Residents Affected - Few On 07/15/19 at 11:00 A.M., interview with the resident revealed he used to be in a walking program but no one had offered to walk him in a while. The resident stated it had been months since he was consistently walked with staff and recently he kept falling when trying to ambulate himself to the toilet because he was not getting enough exercise. On 07/16/19 at 3:50 P.M., interview with State tested nursing assistant (STNA) #375 revealed there were not enough staff to walk all the residents who needed it. The floor staff were responsible for completing the restorative programs. She verified the resident was not walked and was usually not taken to the toilet but handed the urinal when he asked to use the restroom. She tried to check the resident three times on her shift but at no set times. She verified she did not complete any ROM with the resident. On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help. The resident had a urinal he used but needed assistance with using it. The STNA stated time did not always permit to get the restorative programs completed. He was not aware the resident was on a restorative ambulation, toileting or ROM programs. On 07/17/19 at 11:29 A.M., when walking past the resident's room he was observed moaning out and he requested assistance with activating the call light because it was not within his reach. The resident indicated he needed to use the restroom. At 11:31 A.M., STNA # 317 entered the resident's room and handed him the urinal and did not even ask if he wanted to go to the restroom. This was verified by STNA #317 at the time of the observation. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff would give him a urinal if he requested to urinate and required him to have bowel movements in his adult brief if he couldn't hold it. The STNA stated the resident was not on any toileting programs and staff just responded to him when he used his call light for assistance. The STNA stated the resident was on a restorative ambulation program which was supposed to be done once on each shift but they did not have time to do it. She was not aware the resident was to be on a restorative ROM program. On 07/17/19 at 11:40 A.M., interview with STNA #330 verified the resident was supposed to be walked for restorative programming on each shift but stated he had not been able to complete it due to time constraints. She was not sure if the resident was on any other restorative programs. On 07/17/19 at 1:56 P.M. interview with STNA #395 revealed she knew Resident #32 was on a restorative ambulation program but could not say the last time she walked the resident but it had been awhile because there was not enough time to complete the program and the resident needed two staff while walking. She was not aware of the resident being on any other restorative programs. She stated the resident used the urinal and they tried to take him to the toilet for a bowel movement but he wore an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 13 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 adult brief just in case. Level of Harm - Actual harm On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessments completed consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the STNA staff input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part of the fall team, they just told her what times to add to the plan. She verified this description was not what a restorative program was designed to be as it was supposed to assist the resident to restore as much function as possible. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift, which prevented her from getting an accurate reflection of the resident's continence status or progress or decline in the program. She verified there were no assessments competed in an attempt to ensure the residents' did not have a decline and the current programs remained appropriate. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above. Residents Affected - Few On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and he had not been walked in months nor had he been taken to the toilet regularly as he was supposed to be to keep his strength up. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and the STNA staff did not want to walk him in case he blacked out so they provided him with a urinal and he wore adult briefs for bowel movements (BM) accidents. She stated he also needed assistance with the urinal because of his shaking. On 07/18/19 at 2:20 P.M., interview with physical therapist assistant (PTA) #501 revealed Resident #32 had been on physical therapy (PT) for ambulation off and on to keep him as independent with his ambulation as possible. The resident had a lot of falls related to attempts to take himself to the toilet and they wanted him to stay strong enough to do this safely. She verified with the last two PT discharges reviewed the resident was referred to restorative for ambulation. She verified the resident had a decline in ambulation and when he was evaluated most recently he was not able to ambulate even though he had been ambulatory at the time of discharge (250 feet). She did not know if the resident was receiving the restorative ambulation program as recommended. 2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA) with left sided hemiplegia. Review of the current list of residents receiving restorative services did not indicate the resident was receiving restorative services for transfers but indicated she was getting services for ROM. Review of the therapy screen dated 12/20/18 revealed the resident presented with a decline in commode transfers according to the nursing staff. Further review of the OT evaluation and treatment plan dated 12/20/18 revealed the resident had a new onset of decrease in strength, functional mobility, transfers and increased need for assistance. The resident was totally dependent, with attempts to initiate, for toileting. Review of the Discharge summary dated [DATE] revealed to continue on restorative program for commode transfers with assist of two staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 14 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 Level of Harm - Actual harm Residents Affected - Few Review of the restorative program note dated 05/1/19 revealed the resident was on passive ROM for bilateral upper and lower extremities and transfers with two staff to encourage to stand for 30 seconds daily. The note indicated the resident had met her goals and no decline was noted despite no evidence of any restorative assessments being completed from 01/2019 through 05/2019. Further review of the May 2019 STNA documentation revealed the staff documented the resident was receiving ROM services daily but was not receiving the transfer program regularly. Review of the quarterly MDS 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for ADL care. The resident received restorative therapy for transfers five of the seven days reviewed and no ROM. Review of the 06/10/19 restorative program note revealed the restorative programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the June 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly. On 07/15/19 at 12:10 P.M., interview with the resident's husband, who visited daily for the majority of the day, revealed the resident was not receiving restorative ROM or transfer services to include standing for at least 30 seconds a day. He stated at times the resident was taken to the toilet and other times she was provided incontinence care in bed. On 07/15/19 at 12:11 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her room with her husband and without any staff. Review of the 07/16/19 restorative program note revealed the programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the July 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly. On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed she was not aware of the resident being on any restorative programs and the STNA floor staff were responsible for completing any planned restorative programs because the facility did not have separate restorative STNA's despite staff signing off on the restorative participation grids indicating services were completed. On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessments completed consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the STNA staff input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 15 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 Level of Harm - Actual harm Residents Affected - Few of the fall team, they just told her what times to add to the plan. She verified this description was not what a restorative program was designed to be as it was supposed to assist the resident to restore as much function as possible. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift, which prevented her from getting an accurate reflection of the resident's continence status or progress or decline in the program. She verified there were no assessments competed in an attempt to ensure the residents' did not have a decline and the current programs remained appropriate. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, anxiety and depression. Review of the Physical Therapy (PT) Discharge summary dated [DATE] revealed Resident #34's baseline on 02/12/19 and status at time of discharge on [DATE] from therapy was as follows: a. Sit-to-stand baseline was resident required moderate assist and at the time of PT discharge the resident required CGA (contact guard assist). b. Stand-Pivot Transfers to reduce falls baseline was resident was total dependent with attempts and at the time of PT discharge the resident required maximum assist. PT Discharge Recommendations included restorative nursing program (RNP) to facilitate patient maintaining current level of performance and to prevent decline. Development of and instructions in active range of motion (AROM) and transfer RNP's were completed with the Interdisciplinary Team. Prognosis to maintain the current level of functioning was excellent with consistent staff support. Review of the restorative progress note dated 03/13/19 revealed physical therapy was discontinued, encourage ROM added to ADL (activities of daily living) program and encourage resident to maintain gait and weight bear as tolerated during toilet transfers. Review of the PT evaluation dated 04/30/19 to 06/12/19 recommend RNP including transfers and AROM. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely impaired for daily decision-making, required extensive assist with dressing, personal hygiene, and toileting and had received no restorative nursing during the seven day assessment period. Review of the medical record revealed no evidence of a restorative assessment, methodology, care plan or comprehensive monitoring of the resident's restorative program. On 07/17/19 at 12:35 P.M., interview with the Director of Nursing (DON) verified there were no restorative evaluations, assessments or data to review for Resident #34. On 07/17/19 at 1:20 P.M., interview with the DON verified restorative programs were not comprehensive and programs should be provided if needed to restore or maintain the health and well-being of residents. On 07/17/19 at 3:50 P.M., interview with MDS Supervisor #383 revealed she does not complete a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 16 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0676 Level of Harm - Actual harm Residents Affected - Few nursing restorative assessment but just uses the therapy discharge recommendations. MDS Supervisor #383 verified the progress notes for restorative programs were not comprehensive, there was no methodology and she only puts a resident on a maximum of two restorative programs because staff would not be able to spend an hour a day completing restorative programs. MDS Supervisor #383 stated she normally won't write a ROM range of motion program because that is done when completing ADL's, she may write a transfer program but mainly ADL and ambulation were the programs she wrote. She stated she does not have evidence the restorative toileting program was evaluated to meet the needs of the resident or to identify patterns of incontinence. She stated Resident #34 had been on the every two hour (q2hr) while awake toileting program and this was mainly to help keep her from falling. The MDS Supervisor verified this was not a program initiated to restore bladder function. She stated there was no pattern to her incontinence and staff do not document every time the resident's toileting program was implemented. Review of the policy titled Establishment of an Individual Restorative Program, dated October 2016 revealed the facility was to provide restorative nursing programming services to residents based on initial evaluation, referrals and other clinical indicators to maintain and /or improve the residents functional abilities. Residents recommended for restorative programming would be referred to he nurse in charge of restorative programming using the electronic documentation restorative program evaluation and/or progress note. This would be utilized to determine the baseline function to identify the resident's individual restorative needs and determine the appropriateness for a restorative nursing program. Review of the policy titled Therapy Screens, revised October 2016 revealed residents were routinely screened by the therapy department on a quarterly basis and as needed. Residents were to be monitored by nursing staff for improvement or decline in physical and cognitive functioning. When a decline or improvement was observed this shall be communicated to the therapy department and based on the results of the screen the therapy department shall evaluate, monitor for improvement/decline, recommend restorative programming or recommend functional maintenance programming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 17 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #64, who was dependent on staff for eating received adequate and timely assistance and monitoring with meals and failed to ensure Resident #73 received adequate and timely incontinence care. This affected two residents (#64 and #73) of two dependent residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances and unspecified psychosis. Review of the care plan titled Restorative Dining Program, dated 03/09/15 revealed the resident was unable to focus on and complete meals without staff assistance due to cognitive deficits. Interventions included to provide verbal cueing, provide instructions in simple one to two step commands, monitor for coughing or symptoms of aspiration after meals, and monitor for difficulty swallowing, chewing, or pocketing of food during meals. Review of the Restorative Dining Description, revised 11/03/15 revealed set up for meals, provide cueing, hands on assist and spoon feeding as needed to consume meal. The goal was for the resident to assist with self-feeding and to stay on task. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 was severely impaired for daily decision-making, required extensive assist with eating and participated in seven days of restorative eating and/or swallowing. On 07/15/19 between 12:15 P.M. and 12:28 P.M., observation of the lunch meal revealed Resident #64 was served a hamburger, ice cream and a glass of juice. Resident #64 was observed taking a bite of the hamburger, chewing, then taking two additional bites of the hamburger prior to swallowing. State Tested Nursing Assistant (STNA) #395 sat next to Resident #64 and began to feed Resident #66. Resident #64 continued to chew and took an additional bite of the hamburger. STNA #395 cued the resident to take a drink, as he was still chewing, held his glass of juice up to his mouth and after the resident took a drink he coughed. The resident took another bite of the hamburger and then continued to intermittently cough approximately eight times. STNA #395 asked the resident if he was okay and continued to assist Resident #66. Resident #64 would open his mouth, lean up and back in the wheelchair and then would cough. At that time, Licensed Practical Nurse (LPN) #354 came into dining room, began assisting residents and Resident #64 continued to cough intermittently. Review of the record revealed no documented evidence of an assessment or monitoring for aspiration/choking between 07/15/19 and 07/22/19. On 07/22/19 at 12:43 P.M., interview with the Director of Nursing verified Resident #64 did not have any changes to the restorative dining program from 11/03/15 until today. The DON verified the resident required assistance with meals otherwise he would not eat, the family had declined speech therapy and due to the resident's cognition he would not have the capability to restore independent eating. The DON also verified there was no evidence LPN #354 had assessed the resident for possible aspiration per care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 18 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/22/19 at 12:51 P.M., interview LPN #383 verified the resident would not be able to be independent with a dining program due to his cognition however staff had continued the same restorative program without any changes to meet the resident's total care needs. 2. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. There was no evidence an admission bowel and bladder tracker was completed in an attempt to determine continence capability nor was this assessment completed from admission through current date. Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds. Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel. The resident was a fair candidate for a restorative bowel and bladder program but under the comments it stated the resident was not appropriate and the program was not initiated. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift. The resident was not trialed on a toileting program since admission and was always incontinent of bladder and frequently incontinent of bowel. On 07/17/19 at 1:25 P.M., interview with the resident's family revealed they visited frequently and had brought up the concern the resident was frequently saturated in urine. The family stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member indicated family had ben told the staff were supposed to check and change her every two to three hours but this was not happening. The family stated they were worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers. On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during this time period. On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since. She verified the resident was not on any type of toileting program and was changed before and after getting in and out of bed. On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the resident's buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 19 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program. On 07/17/19 at 6:45 P.M., interview with STNA #332 revealed this STNA said she had changed the resident at 3:00 P.M. but could not remember if she had any visitors at the time she provided care or who assisted her. On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation and the fact that STNA #322 indicated the resident was changed at 3:00 P.M. but verified with continuous observation the resident was not observed being changed. On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed the resident was a mechanical lift for transfers and was changed during transfers in and out of bed and was not able to say how often the resident was changed daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 20 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #54's anti-embolitic compression stockings (AECS) were in place as ordered and failed to ensure a leg positioning device was ordered, assessed and properly care planned prior to use. The facility failed to ensure comprehensive and individualized bowel protocols were developed and implemented for Resident #5, #23 and #44 when the residents were without consistent bowel movements (BM) as planned. This affected three residents (#5, #23 and #44) of five residents reviewed for elimination and one resident (#54) of two residents reviewed for assistive devices. Residents Affected - Some Findings include: 1. Record review revealed Resident #54 was admitted to the facility on [DATE] with a diagnosis which included cerebrovascular accident (CVA) with left sided hemiplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for dressing. On 07/15/19 at 12:09 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair on the left rest. Review of the physician's orders, assessments, progress notes, care plan and resident appliance checklist revealed there was no indication in the medical record for the use of a left leg strap (a one inch wide piece of Velcro strap which wrapped around the pole of the wheelchair and the resident's left leg to keep the residents leg secure on the leg rest). On 07/15/19 at 12:10 P.M., interview with the resident's husband revealed he kept asking the facility to do something because the resident's left leg kept falling off the leg rest and he did not want her to get hurt but no one did anything so he brought in a Velcro strap that secured the resident's leg in place and on the leg rest. He verified staff would apply the Velcro strap which had been in place for a while and no one questioned him about it. On 07/15/19 at 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest. On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest. On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest. On 07/17/19 at 11:35 A.M., interview with State Tested Nursing Assistant (STNA) #406 revealed the resident had the leg strap for awhile and she placed it on the resident this morning. On 07/17/19 at 12:05 P.M., interview with the Director of Nursing (DON) revealed the resident was not supposed to be wearing any kind of left leg strap and she was not aware the resident had one in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 21 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her wheelchair without the left leg strap in place and her leg was dangling below the leg rest. On 07/18/19 at 9:10 A.M., interview with Licensed Practical Nurse (LPN) #323 revealed she was aware the resident had the left leg strap in place for awhile because her leg would not stay on the leg rest. She stated the resident's husband was worried about her leg dangling and not being able to stay on the leg rest and staff or the husband would apply the strap daily. In addition, review of the physician's order dated 06/02/17 revealed the resident was to wear bilateral AECS when out of bed. Review of the resident appliance checklist, updated 07/15/19, revealed the resident was to wear AECS when out of bed. Review of the July 2019 treatment administrator record revealed the AECS were applied daily from 07/01/19 through 07/22/19. Further review of the STNA task revealed there was no indication the resident was to wear AECS. On 07/15/19 at 12:09 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her wheelchair with no AECS on. On 07/16/19 at 9:40 A.M., the resident was observed in her wheelchair with no AECS on. On 07/16/19 at 9:41 A.M., interview with STNA #366 revealed she had cared for the resident for awhile and was not aware the resident was to wear AECS and verified she did not have any on at this time. On 07/16/19 at 3:00 P.M. and 3:49 P.M., the resident was observed in her wheelchair with no AECS on. On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her wheelchair with no AECS on. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed the resident was not able to put on or remove any clothing including socks and verified she did not put on the resident's AECS today. On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her wheelchair without her AECS on. On 07/18/19 at 9:07 A.M., the resident was observed in her wheelchair without her AECS on. On 07/18/19 at 9:10 A.M., interview with LPN #323 verified the resident did not have on AECS as ordered. On 07/18/19 at 1:50 P.M., the resident was observed in her wheelchair without her AECS on. On 07/22/19 at 7:45 A.M., the DON was informed of the above findings. No additional information was provided as to why the resident did not have the AECS on as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 22 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0684 Level of Harm - Minimal harm or potential for actual harm On 07/22/19 at 12:06 P.M., the resident was observed in her wheelchair without her AECS on which was verified by her husband. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included dementia and constipation. Residents Affected - Some Review of the current bowel elimination care plan revealed the resident was at risk for constipation because the resident had a history of constipation. The only goal was to keep her clean, dry and odor free with interventions which included toilet as needed and check and change on routine rounds. There were no interventions related to attempting to prevent constipation. Record review revealed the resident had standing orders for a bowel protocol that was signed by the physician on 03/27/18 which indicated if the resident went without a BM in three days bowel sounds was be assessed and check for abdominal distention. If hypoactive bowel sounds or absence of bowel sounds and abdominal distention do not implement the bowel protocol and notify the physician immediately. If no BM in three days give Dulcolax, a stimulant laxative, 10 milligrams (mg) orally or rectal suppository every day as needed or give fleets enema, a fast acting laxative, rectally every day as needed for constipation. If no BM after fleets enema given call the physician. Review of the annual MDS 3.0 assessment, dated 04/08/19 revealed the resident was not interviewable and needed assistance from staff for ADL care including toileting. Review of the BM record for May 2019 revealed the resident went without a BM from 05/16/19 until 05/22/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Further review revealed the resident went without a BM from 05/24/19 until 05/30/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Review of the BM record for June 2019 revealed the resident went without a BM from 06/10/19 until 06/13/19 (four days), from 06/14/19 until 06/18/19 (five days) and from 06/21/19 until 06/24/19 (four days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Review of the BM record for July 2019 revealed the resident went without a BM from 07/03/19 until 07/10/19 (eight days) and from 07/11/19 until 07/15/19 (five days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. On 07/22/19 at 7:45 A.M., the above findings were reviewed with the DON and she verified the facility had no additional information, the bowel protocol was not implemented as planned, no assessments of bowel sounds were completed, the care plan was not individualized and the physician was not notified. 3. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included dementia and constipation. Review of the current care plan for requiring assistance with toileting revealed the resident had a history of constipation. The only goal was to keep her clean, dry and odor free with interventions which included monitor for constipation and ensure a medium to large formed BM every three days. Provide as needed laxatives per protocol. Encourage increased physical activity and adequate hydration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 23 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident had standing orders for a bowel protocol that was signed by the physician on 02/21/16 which indicated if the resident went without a BM in three days bowel sounds was be assessed and check for abdominal distention. If hypoactive bowel sounds or absence of bowel sounds and abdominal distention do not implement the bowel protocol and notify the physician immediately. If no BM in three days give Dulcolax, a stimulant laxative, 10 milligrams (mg) orally or rectal suppository every day as needed or give fleets enema, a fast acting laxative, rectally every day as needed for constipation. If no BM after fleets enema given call the physician. Review of the quarterly MDS 3.0 assessment, dated 06/28/19 revealed the resident was not interviewable and needed assistance from staff for ADL care including toileting. Review of the BM record for April 2019 revealed the resident went without a BM from 04/17/19 until 04/24/19 (eight days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Review of the BM record for June 2019 revealed the resident went without a BM from 06/22/19 until 06/26/19 (five days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Review of the BM record for July 2019 revealed the resident went without a BM from 07/06/19 until 07/12/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. On 07/22/19 at 7:45 A.M., the above findings were reviewed with the DON and she verified the facility had no additional information, the bowel protocol was not implemented as planned, no assessments of bowel sounds were completed and the physician was not notified. 4. Medical record review revealed Resident #23 was admitted on [DATE] with diagnoses including constipation. Review of the BM (bowel movement) report dated April 2019 and May 2019 revealed Resident #23 had no BM between 04/15/19 and 04/22/19, no BM between 05/04/19 and 05/07/19, no BM between 05/09/19 and 05/13/19 and no BM between 05/19/19 and 05/24/19. Review of the Medication Administration Record dated April and May 2019 revealed no as needed (PRN) medications were administered per the resident's standing physician orders related to elimination. Review of the care plan titled At Risk for Constipation related to decreased mobility, a history of constipation and medication use dated 06/09/19 revealed interventions included to encourage the resident to drink fluids, observe bowel movement status, frequency, amount, and consistency, observed for signs of constipation and update the physician as needed. Review of the undated physician Standing Orders revealed if a resident had no BM in three days, the nurse must assess for bowel sounds and check for abdominal distention, give Dulcolax 10 milligrams (mg) orally or by rectal suppository daily as needed or may give a fleets enema rectally daily as needed for constipation. If there was no BM after the fleets enema had been given, the nurse was to call the physician. On 07/18/19 at 12:12 P.M., interview with the DON revealed each resident had a copy of the standing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 24 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0684 Level of Harm - Minimal harm or potential for actual harm orders in the chart and the nurses were to use these, if needed, including no BM within three days. The DON stated sometimes the resident would use the bathroom independently without telling staff and verified this was not documented on the care plan or in the record. The DON verified the facility did not identify or implement orders as written for a resident without a BM for greater than three days. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 25 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 - Some 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 observation, record review and interview the facility failed to ensure Resident #73 was transferred safely with the mechanical lift to prevent an accident/injury and failed to ensure fall interventions were in place as planned for Resident #11, #34 and #59 to decrease the residents risk for falls. This affected four residents (#73, #34, #11 and #59) of six residents revealed for accident hazards. Findings include: 1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. Review of the current mobility care plan revealed the resident was to be transferred using a mechanical lift. The intervention included two staff to assist the resident for transfers. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and was totally dependent on staff for transfers utilizing a mechanical lift. Review of the nurse aid skill and competency review revealed State Tested Nurse Aide (STNA) #332 passed for mechanical lift transfers on 06/26/19 and STNA #334 passed on 06/27/19. On 07/17/19 at 6:27 P.M., STNA #334 was observed bringing the Invacare Reliance 600 mechanical lift into the resident's room. STNA #334 and #332 were then observed hooking up the resident's lift pad to the lift to begin transferring the resident from the wheelchair into bed. The wheelchair was at the left side at the foot of the bed facing the window, the lift was long ways with the left side of the bed with the right lift leg between the front and back wheels of the wheelchair. The lift left leg was in front of the wheelchair and the lift legs were in the closed position. STNA #334 operated the lift, lifted the resident out of the wheelchair and the resident continued to face the window and not STNA #334 which was a 90 degree turn away from facing STNA #334. As the resident was lifted STNA #334 pulled the lift back from the wheelchair about six feet and the turned the lift 90 degrees and pushed the lift legs under the resident's bed. The legs of the lift continued in the closed position as the resident was lowered into the bed. On 07/17/19 at 6:46 P.M., interview with STNA #334 verified the lift legs were closed during the entire transfer and the resident did not face the lift operator during the transfer. STNA #334 verified the lift legs were only opened when necessary because it was safer to keep the legs closed. If approaching the wheelchair from the front the legs would need to be opened but would be closed when able to move the wheelchair. At 6:48 P.M., interview with STNA #332 verified she operated the lift the same way as STNA #334. On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), the Administrator and Registered Nurse (RN) #420 were informed of the above observation. On 07/18/19 at 11:25 P.M., interview with the DON, with RN #420 present, revealed according to the Invacare lift manual, STNA #332 and #334 did not transfer the resident properly. She verified the facility policy indicated staff needed to be trained and observed for competency and they were trained on hire and observed for competency on their yearly reviews but no in-services were completed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 26 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 - Some the staff. No documentation was available besides the manufacturer's recommendations for how to transfer a resident using the mechanical lift. Review of the facility safe lifting and movement of resident's policy, revised July 2017, revealed to ensure direct care staff were trained in the use of the mechanical lifting devices and only staff with documented training would be able to use the mechanical lifts. Review of the facility hoyer lift policy, dated 10/15/97, revealed the facility would follow the manufacturer's recommendations for transfers. Review of the Invacare reliant 600 manufacturer's user manual, dated 2018, revealed the legs of the lift must be in the maximum opened position before lifting the resident and the shifter handle locked into place for optimum stability and safety. The resident's arms should be inside the straps and when raising the resident turn the resident so he/she faces the assistant who was operating the lift. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including history of falls, unsteadiness on feet, muscle weakness, cognitive communication deficit involving cognitive function and awareness, Alzheimer's disease, dizziness, and dementia. The resident sustained 19 falls from 10/15/18 to 07/02/19. Review of Resident #11's falls plan of care revealed the resident was at risk for falls and fall related injuries related to cognitive impairment, vision impairment, medication use, required assist with ambulation, required assist with transfers and had an unsteady gait. The resident's intervention included to assist the resident with wearing appropriate footwear and gripper socks always on. Observation on 07/17/19 at 3:05 P.M., with STNA #394 revealed the resident had regular white ankle socks on. Confirmed findings with STNA #394 during observation. The STNA verified the resident was to always wear gripper socks. Review of fall policy dated 05/06/19 revealed staff would identify interventions related to resident specific risk and causes to try to prevent the resident from falling and try to minimize complication from falling. If interventions have been successful in preventing falls, staff would continue the interventions. 3. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, osteoporosis with pathological fracture of right femur, unsteady on feet, hearing loss, muscle wasting and atrophy, difficulty walking, and intellectual disabilities. The resident had two noted in falls from 12/16/18 to 04/05/19. Review of Resident #59's fall plan of care revealed a sign would be hung in the resident's room to remind the resident to lock her wheelchair brakes before getting up. Observation of Resident #59's room on 07/17/19 at 2:00 P.M. and 2:13 P.M. with STNA #317 and the Director of Nursing (DON) revealed no evidence a sign was hung in the resident's room to remind her to lock wheelchair brakes before getting up. The DON reported the sign should have been a picture of her wheelchair brakes to show the resident how to lock her brakes. Review of fall policy dated 05/06/19 revealed staff would identify interventions related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 27 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 resident specific risk and causes to try to prevent the resident from falling and try to minimize complication from falling. If interventions have been successful in preventing falls, staff would continue the interventions. 4. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance. Residents Affected - Some Review of the care plan titled At Risk for falls and fall related injury dated 09/06/18 revealed the resident had cognitive impairment, a history of falls, impaired vision, poor safety awareness, an unsteady gait, and required assistance with ambulation and transfers. Interventions included to assist with toileting needs, toileting program, incontinence care on routine rounds and as needed, and to provide restorative nursing or rehabilitation programs as indicated. Review of the quarterly Minimum Data Set 3.0 (MDS) 3.0 assessment dated [DATE] revealed the resident had two or more falls with no injuries and the quarterly MDS assessment dated [DATE] revealed Resident #34 had one fall with no injury. Review of the policy titled Falls and Fall Risk, Managing revised 05/06/19 revealed the staff were to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the quarterly Fall Risk assessment dated [DATE] revealed Resident #34 was at high risk for falls. Review of the Accident/Incident Reports, the Fall Investigation Forms and the Post Fall Head to Toe assessments revealed the following: On 12/05/18 at 3:03 A.M., Resident #34 was found on her knees at the bedside. The resident was assisted off the floor, toileted, dressed, and put in her chair for the day. The new intervention was for speech therapy to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring. On 01/29/19 at 6:10 A.M., Resident #34 stood up and lost her balance when she leaned on the bedside table. The new intervention was for occupational therapy (OT) to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring. On 02/09/19 at 5:00 P.M., Resident #34 attempted to rise unassisted and fell. The new intervention was for physical therapy to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring. On 06/30/19 at 9:06 P.M., an alarm was sounding and staff found Resident #34 lying on her right side on the floor. The resident stated she was reaching for the floor. Staff toileted the resident, assisted her to the chair and brought her to a common area. An OT referral was ordered. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring. Review of the Task List: Restorative-Toileting revealed to offer toileting every two hours while awake for fall prevention at 12:00 A.M., 3:30 A.M., 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 5:00 P.M., 7:00 P.M. and 9:00 P.M Review of the record revealed no documented evidence an individualized restorative toileting program was developed and no evidence the routine check and change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 28 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 for incontinence program was implemented as written for Resident #34. Level of Harm - Minimal harm or potential for actual harm On 07/17/19 at 2:09 P.M., interview with the DON verified there were no immediate interventions implemented on 12/05/18, 01/29/19, 02/09/19 and 06/30/19 to keep the resident from falling again. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 29 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to comprehensively assess for the type of incontinence demonstrated by residents and failed to develop and implement comprehensive and individualized bladder programs to restore normal bladder function for Resident #29, #32, #34 and #73 to assist each resident to remain as continent as possible. This affected four residents (#29, #32, #34 and #73) of five residents reviewed for incontinence. Findings include: 1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. There was no evidence an admission bowel and bladder tracker was completed in an attempt to determine continence capability. Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds. Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel. The resident was a fair candidate for a restorative bowel and bladder program but under the comments it stated the resident was not appropriate and the program was not initiated. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift. The resident was not trialed on a toileting program since admission and was always incontinent of bladder and frequently incontinent of bowel. On 07/17/19 at 1:25 P.M., interview with the resident's family indicated they visited frequently and they had brought up the concern the resident was frequently saturated in urine. The family member stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member stated family was told the staff were supposed to check and change her every two to three hours but this was not happening. The family was worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers. On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during that time period. On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since. She verified the resident was not on any type of toileting program and was changed before and after getting in and out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 30 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the residents buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program. On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation. On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed a bowel and bladder tracker had not been completed on the resident since admission and verified she was not able to provide any type of assessment that was completed in an attempt to keep the resident as continent as possible. She stated the resident was a mechanical lift for transfers and was changed during transfers in and out of bed and was not able to say how often the resident was changed daily. Review of the bowel and bladder continence care management policy, dated March 2017 revealed it was to facility goal for improvement in bowel and bladder function in those who could improve and to prevent deterioration in function. The program included to evaluate for incontinence, promote continence, appropriate toileting routines and the evaluation of each resident's care plan to ensure the continence program was being managed effectively. The plan was to develop individualized toileting needs. Programs included rehabilitation/bladder retraining which required the resident to resist or inhibit the sensation of urgency and to urinate according to a timetable rather than to the urge. Prompted voiding which included regular monitoring with encouragement to report continence status using a schedule. Habit training/scheduled voiding which was a behavioral technique with scheduled toileting at regular intervals. Check and change which was to check on the resident at regular intervals using incontinence products. The type of urinary incontinence should be determined such as urge, overflow, mixed or functional. The resident should be evaluated on admission, quarterly and after any change in condition for patterns and potential to restore function. This included to initiate a voiding and bowel movement monitoring record that included incontinence and continent episodes. Complete for three to seven days to establish an individual voiding and bowel movement pattern and observe for trends. An individualized care plan should then be developed and document the effectiveness of the interventions developed. 2. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and multi-system degeneration of the autonomic nervous system. Review of the resident's current care plans for toileting/elimination of bowel and bladder indicated to provide assistance with toileting and incontinence care on routine rounds and as needed. Review of the resident's falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself. Review of the restorative program note dated 01/28/19 revealed the resident was on restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M. and 3:30 A.M. Further review of the medical record revealed there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 31 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 evidence the program was implemented. Level of Harm - Minimal harm or potential for actual harm Review of the bowel and bladder evaluation dated 02/02/19 revealed the resident needed extensive assistance of staff for mobility was frequently incontinent of urine at least daily and was occasional incontinent of stool less than daily. The resident was a fair candidate for restorative bowel and bladder programs and the resident was willing to participate in the programs. Residents Affected - Some Review of the May 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had seven bowel incontinence episodes for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented. Review of the bowel and bladder evaluation dated 05/02/19 revealed the resident needed extensive assistance of staff for mobility was frequently incontinent or urine at least daily and was always continent of stool. The resident was a fair candidate for restorative bowel and bladder programs and the resident was willing to participate in the programs. Review of the quarterly MDS 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of two or more staff for transfers and toileting. He was frequently incontinent of bladder and continent of bowel. Review of the June 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had 11 bowel incontinent episodes for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented. Review of the July 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had seven bowel incontinent episodes thus far for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented. On 07/15/19 at 11:00 A.M., interview with the resident revealed he was supposed to be taken to the restroom for toileting but the staff gave him a urinal and at times had to defecate in his adult brief because staff did not want to take him to the restroom even when he asked. The resident stated he fell many times attempting to toilet himself. On 07/16/19 at 3:50 P.M., interview with STNA #375 revealed the resident needed the assistance of two staff for toileting and they just gave him the urinal and he used his adult brief when he had to have a bowel movement unless staff could get to him in time. The STNA indicated the resident was not on any toileting program but she tried to check the resident three times on her shift for his toileting needs. On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help assistance from staff. The resident had a urinal he used but needed assistance with using it and used his adult brief for bowel movements if staff could not get to him. The STNA indicated the resident was not on any toileting program and would call for help when needed to urinal or defecate. On 07/17/19 at 11:29 A.M., when walking past the resident's room he was observed moaning out and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 32 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some requested assistance with activating the call light because it was not within his reach. The resident indicated he needed to use the restroom. At 11:31 A.M., STNA # 317 entered the residents room and handed him the urinal and did not even ask if he wanted to go to the restroom. This was verified by STNA #317 at the time of the observation. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff gave him a urinal and would try to take him to the toilet for bowel movements but wears an adult brief just in case. The STNA indicated the resident was not on any toileting programs and staff just assisted him when he used his call light for assistance. On 07/17/19 at 11:40 A.M., interview with STNA #330 revealed she was not aware the resident was on a toileting program On 07/17/19 at 1:56 P.M., interview with STNA #395 revealed she was not aware the resident was on a toileting program. On 07/17/19 at 3:15 P.M., interview with LPN #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessment consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the aids input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part of the fall team, they just told her what times to add to the care plan. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift and this resulted in the inability to get an accurate reflection of the resident's continence status. She verified there were no assessments competed in an attempt to ensure the resident did not have a decline. She verified the only way a resident was on a toileting program was to put them on a restorative program. She verified all residents were either independent or checked and changed every two to three hours as able. When asked the difference between Resident #32's restorative program which indicated to toilet him every two hours and a check and change she indicated a check and change was when the staff could get to a resident but if specific times were entered the resident needed toileted at those times usually because they had a fall at that time while attempting to toilet themselves. She verified the resident had many falls attempting to toilet himself and stated this was because he had an overactive bladder. On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and staff did not routinely take the resident to the bathroom. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and she thought maybe they were afraid to walk him so they provided him with a urinal and he wore adult briefs for bowel movements (BM). 3. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was continent of bowel and occasionally incontinent of urine. Review of the Bowel/Bladder Evaluation V.1 - V 4 dated 05/14/19 revealed the resident was severely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 33 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impaired for daily decision-making and was frequently incontinent of urine and of bowel at least daily. The resident was a fair candidate for restorative bowel and bladder program and the resident was willing to participate. A program was to be initiated; however, a program was already in place for fall prevention. Review of the record revealed no comprehensive restorative toileting assessment or care plan for Resident #34. Review of the MDS assessment look-back dated 05/15/19 through 05/21/19 revealed Resident #34 was incontinent of urine on 10 occasions. The quarterly MDS assessment dated [DATE] revealed Resident #34 was occasionally incontinent of bladder. Review of the Task List: Restorative-Toileting revealed Resident #34 was to be offered toileting every two hours while awake and as needed. There was no evidence of an individualized program for Resident #34 and no bowel program to restore function. On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 stated occasionally incontinent was defined as having less than seven episodes of incontinence and frequently incontinent was defined as having seven or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period. MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate and should have been coded as being frequently incontinent of urine. Review of the quarterly MDS assessment dated [DATE] revealed the resident was occasionally incontinent of bladder and bowel. Review of the look back indicated the resident had 10 urine incontinent episodes and one incontinent bowel episodes. Review of the care plan titled Alteration in Bowel Elimination revised 07/15/19 revealed goals including to maintain current status. Interventions included to assist with toileting needs and incontinence care on routine rounds and as needed (PRN). Review of the care plan titled Requires Assist with Toileting revised 07/15/19 revealed the resident required a restorative toileting program due to falls. Goals included to maintain current status and interventions included to assist with toileting needs and incontinence care on routine rounds and PRN. Provide and/or offer toileting every two hours as directed while awake to assist in the prevention of falls. Change or add scheduled times as needed. Complete a bladder assessment per facility policy and monitor voiding, awareness of need and pattern to provide toileting as appropriate to meet the resident's need and ability. On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate, the resident had declined in urinary continence without implementing new interventions to restore bowel/bladder function. Review of the policy titled Bowel and Bladder Continence Care Management dated March 2017 revealed the purpose was to maintain an interdisciplinary team approach to bowel and bladder continence management, to facilitate improvement in bowel and bladder function in those who can improve and to prevent deterioration of bowel/bladder function. Appropriate strategies and interventions were to be initiated and resident outcomes and product effectiveness was to be evaluated and monitored. 4. Medical record review revealed Resident #29 was admitted on [DATE] with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 34 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 Parkinson's disease and urinary urgency. Level of Harm - Minimal harm or potential for actual harm Review of the care plan titled Requires Assist with Toileting and Risk for UTI, dated 11/03/17 revealed to assist with toileting needs and incontinence care on routine rounds and PRN, when soiled or upon request. Check and change on routine rounds and monitor voiding, awareness of need and pattern to provide toileting as appropriate to meet the resident's need and ability. Residents Affected - Some Review of the annual MDS 3.0 assessment dated [DATE] and the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was not on a toileting program and was continent of bladder. Review of the Care Area Assessment: Urinary Incontinence dated 11/09/18 revealed the resident required assistance with toileting with modifiable factors contributing to transitory urinary incontinence including psychological or psychiatric problems, urinary urgency and the need for assistance in toileting. The urinary incontinence care plan objective was to slow or minimize decline, avoid complications and maintain current level of functioning. A referral to another discipline was warranted; however, none was identified. Review of Resident #29's quarterly MDS 3.0 assessment dated [DATE] revealed the resident was continent of urine with no toileting program and the quarterly MDS assessment dated [DATE] revealed the resident had declined to occasionally incontinent of urine with no toileting program. Review of the quarterly Bowel/Bladder Evaluation dated 05/12/19 revealed the resident required extensive assistance with mobility, was occasionally incontinent of urine due to functional incontinence, was a good candidate for restorative program and resident was willing to participate, States program was already in place and was tolerating well. Review of the Task List: Bladder Elimination dated 06/17/19 through 07/16/19 revealed Resident #29 was incontinent of urine on 06/23/19, 07/05/19 and 07/07/19 at 7:20 A.M., 10:24 A.M., and 10:29 A.M Review of the record revealed no evidence of a comprehensive and individualized toileting program to restore bladder continence was implemented. Review of Resident #29's medical record revealed no evidence of a urinary incontinence care plan. On 07/16/19 at 1:11 P.M., interview with the Director of Nursing (DON) verified Resident #29 was not on a restorative toileting program and the resident had declined from being continent of urine as of 02/09/19 to occasionally incontinent of urine 05/12/19 with no intervention to restore bladder function. On 07/16/19 at 2:20 P.M., interview with MDS Supervisor #383 revealed Resident #29 only had one episode of incontinence during the assessment period, did not feel that warranted a toileting program and considered that to be isolated even if the resident was previously continent of urine. MDS Supervisor #383 also verified the bowel/bladder assessment indicated the resident was on a toileting program; however, she was only on a routine check and change program while awake, she did not implement an incontinence care plan or identify the type of urinary incontinence because she did not think of that. On 07/16/19 at 2:26 P.M. and 3:17 P.M., interview with the DON stated the resident had never been started on a restorative toileting program, was picked up by therapy due to falls and there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 35 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0690 documented evidence in the therapy notes that therapy was working on toileting. Level of Harm - Minimal harm or potential for actual harm On 07/16/19 12:56 P.M., the surveyor knocked on Resident #29's door and announced self. The resident peaked around the door, wearing only an incontinence brief and stated she had to get changed because she was wet. The resident was holding another incontinence brief in her hand. No staff was observed in the room with the resident. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 36 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #73's oxygen was monitored and on as ordered. This affected one resident (#73) of one resident reviewed for oxygen use. Residents Affected - Few Findings include: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) required continuous oxygen and morbid obesity. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable and was totally dependent on staff for activities of daily living (ADL) care. Review of the physician's order, dated 06/18/19 revealed the resident had continuous oxygen at two liters per minute. Review of the 06/20/19 care conference notes revealed the family had a concern with the resident's oxygen not being on as ordered due to the E tanks not being maintained with oxygen. Review of the July 2019 Medication Administration Record (MAR) and Treatment Administrator Record (TAR) revealed there was no evidence of monitoring the resident's use of oxygen including ensuring the E tanks had an adequate supply of oxygen. On 07/17/19 at 1:25 P.M., interview with the resident's family revealed family visited frequently and attended care conference meetings where they had discussed their concerns with the E tanks being empty while the resident was supposed to be using the oxygen continuously. She stated the resident could not always tell when the oxygen was not functioning properly. On 07/17/19 at 1:35 P.M., the resident was observed in the hall outside the main dining room waiting to attend bingo. The resident had an E tank which read empty and the resident was to be receiving the oxygen via the nasal cannula which the tubing was in her nose. The resident was asked if her oxygen was working and she said yes but then she put the nasal cannula in her mouth and started to panic and said no nothing is coming out. The resident did not appear to be struggling for breath. At 1:38 P.M., State Tested Nursing Assistant (STNA) #405 was walking down the hall and verified the E tank was empty and the resident was not receiving any oxygen at that time. On 07/17/19 at 1:38 P.M., interview with STNA #405 revealed Licensed Practical Nurse (LPN) #396 had to put a new E tank on at 11:45 A.M. because the other tank was empty so it should not be empty. STNA #405 verified only the nurses had the key to change or adjust the oxygen. On 07/17/19 at 1:40 P.M., interview with Registered Nurse (RN) #372 verified the E tank was empty and brought a new tank for the resident. She had difficulty adjusting it to ensure it was functioning properly but was able to adjust it to ensure the oxygen was flowing at two liters per minute at 1:45 P.M. At 1:48 P.M., the resident's pulse oxygen was taken and read 92 percent and RN #372 verified they wanted it to read between 92 and 100 percent. On 07/17/19 at 2:57 P.M., interview with RN #315 verified the family had concerns with the E tank running out of oxygen. She was not able to show any evidence the facility addressed the concern. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 37 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 07/22/19 at 7:45 A.M., the Director of Nursing was informed of the above concerns and verified there was no documentation to show the oxygen was periodically monitored to ensure proper flow. Review of the oxygen administrator policy, revised October 2010, revealed to observe the resident periodically to ensure the oxygen was being tolerated. Documentation should include the date and time the oxygen was administered, name and title of individual administering, rate of flow and route, frequency and duration and how the resident tolerated the oxygen. Event ID: Facility ID: 366052 If continuation sheet Page 38 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure personal care services including restorative nursing services for toileting were provided to meet the total care needs of all residents. This affected three residents (Resident #32, #54 and #73) and had the potential to affect all 79 residents residing in the facility. Findings include: 1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, benign prosthetic hypertrophy and overactive bladder. Review of the residents falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself. Review of the restorative program note dated 01/28/19 revealed the resident was on restorative ambulation with the walker daily for 15 minutes and restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention despite having no assessments to evaluate the programs. Review of the PT evaluation and treatment plan dated 03/08/19 revealed the resident was referred back to therapy because the resident was not able to ambulate at this time. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate 250 feet with walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level and prevent decline. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed he was cognitively intact but needed extensive assistance of one or more staff for activities of daily living (ADL). He needed extensive assistance of one person to walk in his room. He was frequently incontinent of bladder and continent of bowel. The assessment revealed he received restorative services for ambulation one day, dressing six days and eating seven days (did not indicate toileting of ROM). Review of the physician's order dated 05/23/19 revealed the resident was to be walked four times a day as tolerated. On 07/15/19 at 11:00 A.M., interview with the resident revealed he used to be in a walking program but no one had offered to walk him in a while. The resident stated it had been months since he was consistently walked with staff and recently he kept falling when trying to ambulate himself to the toilet because he was not getting enough exercise. On 07/16/19 at 3:50 P.M., interview with State tested nursing assistant (STNA) #375 revealed there were not enough staff to walk all the residents who needed it. The floor staff were responsible for completing the restorative programs. She verified the resident was not walked and was usually not taken to the toilet but handed the urinal when he asked to use the restroom. She tried to check the resident three times on her shift but at no set times. She verified she did not complete any ROM with the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 39 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help. The resident had a urinal he used but needed assistance with using it. The STNA stated time did not always permit to get the restorative programs completed. He was not aware the resident was on a restorative ambulation, toileting or ROM programs. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff would give him a urinal if he requested to urinate and required him to have bowel movements in his adult brief if he couldn't hold it. The STNA stated the resident was not on any toileting programs and staff just responded to him when he used his call light for assistance. The STNA stated the resident was on a restorative ambulation program which was supposed to be done once on each shift but they did not have time to do it. On 07/17/19 at 11:40 A.M., interview with STNA #330 verified the resident was supposed to be walked for restorative programming on each shift but stated he had not been able to complete it due to time constraints. On 07/17/19 at 1:56 P.M. interview with STNA #395 revealed she knew Resident #32 was on a restorative ambulation program but could not say the last time she walked the resident but it had been awhile because there was not enough time to complete the program and the resident needed two staff while walking. She was not aware of the resident being on any other restorative programs. She stated the resident used the urinal and they tried to take him to the toilet for a bowel movement but he wore an adult brief just in case. On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and he had not been walked in months nor had he been taken to the toilet regularly as he was supposed to be to keep his strength up. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and the STNA staff did not want to walk him in case he blacked out so they provided him with a urinal and he wore adult briefs for bowel movements (BM) accidents. She stated he also needed assistance with the urinal because of his shaking. 2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA) with left sided hemiplegia. Review of the current list of residents receiving restorative services did not indicate the resident was receiving restorative services for transfers but indicated she was getting services for ROM. Review of the therapy screen dated 12/20/18 revealed the resident presented with a decline in commode transfers according to the nursing staff. Further review of the OT evaluation and treatment plan dated 12/20/18 revealed the resident had a new onset of decrease in strength, functional mobility, transfers and increased need for assistance. The resident was totally dependent, with attempts to initiate, for toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 40 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Discharge summary dated [DATE] revealed to continue on restorative program for commode transfers with assist of two staff. Review of the restorative program note dated 05/1/19 revealed the resident was on passive ROM for bilateral upper and lower extremities and transfers with two staff to encourage to stand for 30 seconds daily. The note indicated the resident had met her goals and no decline was noted despite no evidence of any restorative assessments being completed from 01/2019 through 05/2019. Further review of the May 2019 STNA documentation revealed the staff documented the resident was receiving ROM services daily but was not receiving the transfer program regularly. Review of the quarterly MDS 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for ADL care. The resident received restorative therapy for transfers five of the seven days reviewed and no ROM. Review of the 06/10/19 restorative program note revealed the restorative programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the June 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly. On 07/15/19 at 12:10 P.M., interview with the resident's husband, who visited daily for the majority of the day, revealed the resident was not receiving restorative ROM or transfer services to include standing for at least 30 seconds a day. He stated at times the resident was taken to the toilet and other times she was provided incontinence care in bed. On 07/15/19 at 12:11 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her room with her husband and without any staff. Review of the 07/16/19 restorative program note revealed the programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the July 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly. On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed she was not aware of the resident being on any restorative programs and the STNA floor staff were responsible for completing any planned restorative programs because the facility did not have separate restorative STNA's despite staff signing off on the restorative participation grids indicating services were completed. On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her room with her husband and without any staff. On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 41 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0725 Level of Harm - Minimal harm or potential for actual harm to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above. 3. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. Residents Affected - Many Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds. Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift. On 07/17/19 at 1:25 P.M., interview with the resident's family indicated they visited frequently and they had brought up the concern the resident was frequently saturated in urine. The family member stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member stated family was told the staff were supposed to check and change her every two to three hours but this was not happening. The family was worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers. On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during that time period. On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since. On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the residents buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program. On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 42 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide the necessary behavioral health care and services to Resident #44 to allow the resident to attain or maintain her highest practicable physical, mental, and psychosocial well-being and to attempt to reduce observed behaviors. This affected one resident (#44) of two residents reviewed for behaviors. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors and psychosis. Review of the current plan of care revealed there was no plan that addressed behaviors despite the resident being on antipsychotic medication and having a plan to monitor for the side effects of the medications. Further review of the nursing notes from May 2019 through July 2019 revealed there were no documented behaviors for the resident. Review of the psychiatric progress notes dated 02/15/19, 03/21/19, 04/25/19 and 05/17/19 revealed the resident was not exhibiting any behaviors. The resident does make repetitive grunting sounds in her throat and was unable to hold any goal directed conversation. The notes revealed to continue on the current regimen of antipsychotic medications. However, review of the May 2019 medication administrator record (MAR) revealed the resident was fearful, restless and/or irritable from 05/23/19 through 05/29/19 on both shifts. Review of the June 2019 MAR revealed there were no behaviors noted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/28/19 revealed the resident was not interviewable but had physical symptoms towards others one to three days in the seven day look back period. Review of the 06/29/19 social service note revealed the resident's affect remained flat and pleasant. During periods of restlessness and/or anxiety the resident would become tearful. Review of the July MAR revealed the resident was fearful, restless and/or irritable from 07/13/19 through 07/17/19 on both shifts. On 07/16/19 at 3:35 P.M., while standing at the nurse's station the surveyor heard yelling off and on down the resident's hall, it was Resident #44 yelling non-sensically off and on while in bed. On 07/16/19 at 3:40 P.M., Licensed Practical Nurse (LPN) #404 entered the resident's room and asked the resident what she needed, the resident was mumbling but the nurse was not able to understand and informed the resident they would get her up soon for dinner and the resident stated okay. On 07/16/19 at 3:42 P.M., interview with LPN #404 revealed this was a normal off and on behavior for the resident. She stated the State tested nursing assistant (STNA) was in the resident's room a little bit ago but was not able to calm her down. She got better for a while when the doctor changed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 43 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her medications but had begun the behavior again a couple weeks ago. She stated at times the resident can understand and be understood. At 3:53 P.M., the resident was brought out to the common area near the nurse's station but continued yelling out. She was placed in front of the television but not given anything to do. At 4:03 P.M., the resident continued yelling off and on but then was heard saying clearly I have to go to the bathroom. LPN #404 also heard this and asked STNA #405 if she had changed her lately and she stated yes. STNA #405 approached the resident and tried to distract her by talking with her which was not very effective and then STNA #405 walked away as the resident continued yelling out non-sensically . LPN #404 verified small lolly pops work in calming her down but since she had been on a pureed diet for awhile we don't give her any. The LPN was not sure what else would be effective and stated staff had not tried anything else. On 07/17/19 at 11:25 A.M., the resident was observed being wheeled out of her room by STNA #337 and was crying out as she was placed in the common area near the nurse's station in front of the television. STNA #337 left the resident in the area as she continued to cry out. On 07/17/19 at 11:26 A.M., interview with STNA #337 revealed this was an on going behavior the resident had but she did not even think the resident knew she was doing it and thought it was a habit. The STNA stated when the resident gets louder staff ask her if she wants to lay down, wants a drink or if she is in pain. The STNA revealed the one thing that was effective were the small lolly pops but she stated she hadn't given them to her in a while and didn't know if the facility had any. On 07/17/19 at 4:46 P.M., the resident was observed being wheeled out of her room by STNA #414. The resident was crying out as she was placed in the common area near the nurse's station in front of the television and left by staff as she continued to cry out. On 07/22/19 at 9:40 A.M., interview with the Director of Nursing (DON) revealed she was aware of the resident's crying and yelling out. When informed there were no interventions attempted besides putting the resident in front of the television which was not effective, the DON stated small lolly pops were affective but since the resident was changed to a pureed diet she had not been given them. When asked if speech therapy was involved to see if the lolly pops would be okay or if there was another similar candy that would be okay and she stated no. She verified there was no behavior care plan in place and no evidence of any effective interventions in an attempt to satisfy or calm the resident. On 07/22/19 at 3:30 P.M., phone interview with the resident's daughter revealed this behavior started when the hospital gave the resident a medication she should not have had which had since been discontinued. She stated she visited her in the evening and she seemed to be better and staff tell her she is not yelling out or crying anymore but now she saw that she had been. She stated on occasion when she does it she would give her a small lolly pop and that was effective and the behavior would stop but they won't give her any now because she is on a pureed diet but they won't try anything else either. She stated she had talked to staff about trying something else but they don't listen to anything she says. The resident's daughter believed the resident moaned and yelled out when she gets scared and staff put her in front of the television and when they put other residents near her it seemed to scare her. The daughter thought this might be because she couldn't move at all by herself and she felt stuck there. The resident' daughter indicated the only intervention she saw staff do were to put the resident in front of the television. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 44 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #182 and #23, who had dementia, were provided adequate dementia care to ensure optimal psychosocial well being. This affected two residents (#182 and #23) of five residents reviewed for dementia care. Residents Affected - Few Findings include: 1. Review of Resident #182's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which include dementia and anxiety. The resident passed away on 04/13/19. Review of the behavior care plan initiated 10/23/18 revealed a plan of care related to the resident taking other resident's belongings, yelling at other male residents, thinking they were her husband and being physically abusive towards staff. There were no individualized interventions for the resident. Further review of the care plan revealed there was no plan of care related to the resident's diagnosis of dementia. Review of the attending physician note dated 01/14/19 revealed the resident had become increasingly confused and was having more trouble with agitation at night and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/23/19 revealed the resident was not interviewable, had delusions but the only behavior identified was wandering. Review of the social service note dated 01/26/2019 revealed the resident continued to exhibit severe cognitive decline relative to her diagnosis of dementia. Most recently she had exhibited an increase in restlessness and anxiety which caused crying that did not resolve when consoled, expression of painful past memories related to her husband and poor appetite. She becomes anxious with excessive stimulation. The psychiatrist was consulted and an order was obtained for Buspar, an anti-anxiety medication. Review of the nurse's note, dated 01/30/19 revealed the resident was having hallucinations, mood swings, tearfulness, going in other residents rooms looking in their drawers and closets and arguing with staff and other residents. She refused to stay in bed because she thought someone was going to kill her. She was given a shower and put to bed at midnight. Review of the neurologist note dated 02/01/19 revealed the resident was being combative with staff and not sleeping sell with increased agitation which worsened at night. The medication Depakote (an anti-convulsant medication that can be used during manic phases of bipolar) was started at night. Review of the February 2019 medication administrator record (MAR) for behavior monitoring documentation revealed the only behaviors were on 02/01/19 and 02/02/19. Review of the nurse's note, dated 02/02/19 revealed the resident continued to have increased agitation with other residents accusing them of stealing her shoes, radio and clothes. The resident was attempting to go into other residents rooms to get her shoes or find her husband. No interventions were effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 45 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0744 Level of Harm - Minimal harm or potential for actual harm Review of the nurse's note, dated 02/05/19 revealed the resident was wandering throughout the hallway attempting to go into other resident's rooms. Attempts to redirect the resident back to bed were unsuccessful. The resident was taking to the lounge to watch television. Further review of the February 2019 MAR reveled there were no behaviors noted on 02/10/19 or 02/11/19. Residents Affected - Few Review of the nurse's notes from 02/10/19 through 02/11/19 revealed on 02/10/19 beginning at 9:27 P.M., the resident was at the nurse's station being verbally inappropriate with staff, attempts to redirect back to bed were unsuccessful and all interventions ineffective. At 11:40 P.M., the resident continued to be verbally inappropriate with staff, yelling out profanity and entering other resident's rooms while they were sleeping. The resident was combative with staff, redirection, one on one and other interventions were ineffective. On 02/11/19 at 12:15 A.M., the physician was notified and ordered an intramuscular injection of Haldol, an antipsychotic medication used to make you feel less nervous, every six hours as needed for increased agitation. The medication was effective and the resident was sleeping in bed. On 07/18/19 at 10:15 A.M., interview with the Director of Nursing (DON) revealed the facility has been working towards educating the physicians and nurses to contact the resident's psychiatrist, if applicable, when a change in behavior was noted because currently the attending physician was also ordering psychotropic medications if notified of a possible change in behavior and that is what happened in this case. On 07/18/19 at 11:12 A.M., interview with the DON revealed the facility was unable to print off the education provided to staff regarding dementia care, managing challenging behaviors or delirium. On 07/22/19 at 9:40 A.M., interview with the DON verified the documentation did not warrant the use of an intramuscular injection antipsychotic. There was no evidence of the resident attempting to do anything different that prior notes which did not warrant medications contained. The DON verified there was no care plan related to dementia just related to behavior problems which were not individualized to the resident. The DON verified the facility did not address the resident's change in not being able to sleep at night which had been on going and should not have lead to the need for Haldol on 02/11/19. The DON verified the resident saw the psychiatrist for the first time on 01/25/19 but they were not able to find the note. On 07/22/19 at 7:00 P.M., phone interview with State Tested Nurse Aide (STNA) #387 revealed she did not recall having any dementia training since being employed at the facility since 01/08/19. On 07/23/19 at 5:50 A.M., phone interview with STNA #314 revealed she did not recall having any dementia training since being employed at the facility since 08/09/18. 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia with behavior disorder, delusions and schizophrenia. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #23 was severely impaired for daily decision-making and received daily antipsychotic medications. Review of the Psychiatric Progress Notes revealed on 04/25/19 the resident's behavior was in control and the resident's antipsychotic medication, Seroquel was decreased from 25 milligrams (mg) to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 46 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0744 12.5 mg. On 05/17/19, the psychiatric progress note indicated to continue Seroquel 12.5 mg at bedtime. Level of Harm - Minimal harm or potential for actual harm Review of the Physician's Orders dated May 2019 revealed Resident #23 received Seroquel 12.5 milligrams (mg) at bedtime related to psychosis. On 05/23/19, the attending physician ordered as needed (PRN) Haldol, an antipsychotic 1 mg intramuscularly (IM) for increased agitation and on 05/29/19 ordered Risperdal, an antipsychotic 0.25 mg daily for agitation. Residents Affected - Few Review of Resident #23's Progress Notes revealed the following: On 05/23/19 at 8:46 P.M., the resident was angry, yelling and screaming due to her roommate's daughter visiting. The resident had increased agitation, anxiety and was combative with staff. The attending physician was notified and new orders were received. On 05/28/19, Resident #23 was very agitated and had aggressive behavior towards staff and her room mates daughter. The attending physician was notified and new orders were received. On 06/04/19, the physician was notified of Resident #23's increased confusion along with foul-smelling, cloudy urine and a urinalysis/culture sensitivity was ordered. On 06/05/19 at 4:22 P.M., the NP ordered Ceftin (antibiotic) 500 mg after being notified of the urinalysis results. On 06/06/19 at 4:32 P.M., Resident #23's psychiatrist was updated on the resident's psychotic episode and that the attending physician had started the resident on Risperdal and has since started treatment for a urinary tract infection. The psychiatrist discontinued the Risperdal. Review of the Medication Administration Record (MAR) dated May 2019 revealed Resident #23 received one dose of Haldol 1 mg IM for increased agitation on 05/23/19 at 9:00 P.M. in the left arm. The attending physician also ordered the resident to receive Risperdal 0.25 mg daily starting on 05/30/19 and Haldol 1 mg IM for increased agitation as needed (PRN). Review of the MAR dated June 2019 revealed Risperdal 0.25 mg was administered daily between 06/01/19 and 06/06/19. The PRN Haldol was discontinued on 06/04/19. Further review of the MAR's revealed the resident had no documented behaviors until 05/23/19 (night shift) through 05/29/19 and on 06/02/19 through 06/05/19. No other atypical behaviors were documented and there was no documented evidence of what targeted behaviors were exhibited other than what was documented in the progress notes. Review of the record revealed no documented evidence Resident #23's psychiatrist was notified of the resident's behavior between 05/23/19 and 06/04/19 and no evidence the facility investigated the reason why Resident #23 became agitated when the roommates daughter visited. Review of the record revealed no documented evidence non-pharmacological approaches were attempted prior to the notification of the attending physician or the administration of PRN Haldol. Review of the current care plan titled At Risk for Drug Related Complications due to the use of psychotropic medication (last revised 06/07/18) revealed to observe for drug related side effects including increased confusion. Interventions included to attempt non-pharmacological interventions prior to medicating with PRN psychotropic medications i.e., redirection, calm environment, and 1:1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 47 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interaction, observe results and share effective interventions with other staff members. Review of the record revealed the facility had not identified or documented individualized interventions that were effective for the resident. On 07/18/19 at 10:15 A.M., interview with the Director of Nursing (DON) revealed the facility has been working towards educating the physicians and nurses to contact the resident's psychiatrist, if applicable, when a change in behavior was noted because currently the attending physician was also ordering psychotropic medications if notified of a possible change in behavior and that was what happened in this case. Later a urinalysis was ordered and it was realized that the increased behavior was possibly due to an infection, the behaviors were related to this and the antipsychotics administered were not necessary. The DON stated when the psychiatrist was notified he discontinued the Risperdal. On 07/18/19 at 11:12 A.M., interview with the DON revealed the facility was unable to print off the education provided to staff regarding dementia care, managing challenging behaviors or delirium. On 07/18/19 at 11:17 A.M., further interview with the DON revealed she looked at new orders everyday and communicated with nursing staff to provide individualized care but it was a shift in thinking. The DON verified the facility did not identify or address possible issues that caused the agitation and the resident received unnecessary antipsychotic medication when actually the behavior was more than likely from the infection. Review of the policy titled Psychotropic Medication Use (Antipsychotic's, Anxiolytics, Antidepressants, Hypnotics), dated November 2017 revealed psychotropic medications may be considered for residents with dementia, depression, anxiety and/or other mental disorders, but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents were only to receive psychotropic medications when necessary to treat specific conditions for which they were indicated and effective. The attending physician and facility staff were to identify acute psychiatric episodes and differentiate them from enduring psychiatric conditions. Diagnoses alone did not warrant the use of antipsychotic medication. In addition, antipsychotic medications would generally only be considered if the following conditions were also met: the behavioral symptoms present a danger to the resident or others and the symptoms are identified as being due to mania or psychosis (such as auditory, visual or other hallucinations; delusions, paranoia or grandiosity) or behavioral interventions have been attempted and included in the plan of care except in an emergency (which was an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 48 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #53 and #42's pharmacy recommendations contained physician responses with adequate rational for the continued use of medications including psychotropic medications. This affected two residents (#53 and #42) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis including psychosis not due to substance or known physiological condition and major depression. Further review of physician's notes and hospital records revealed no documented evidence of a diagnosis of psychosis. Review of Resident #53's physician's orders dated 01/24/19 to present revealed the resident was ordered the antipsychotic medication, Risperdal 0.5 milligrams (mg) twice daily for psychosis and the antidepressant medication, Lexapro 20 mg daily for depression. The resident's behaviors were identified to be restlessness, irritability and fearfulness. There was no evidence of targeted behaviors for the psychosis diagnosis. Review of Resident #53's pharmacy recommendation dated 03/12/19 and 06/27/19 revealed the recommendation for a gradual dose reduction (GDR) of the Lexapro and Risperdal. On 03/12/19 the physician checked the behaviors were improved/maintained on current doses and no apparent side effects at this time. There was no evidence of individual rational for declining the GDR. On 06/27/19 the physician checked a box on the form that indicated a GDR would cause more risk than benefit. There was no evidence of individual rational for declining the GDR or how the GDR would cause more risk than benefit. Review of Resident #53's behavior monitoring dated 01/05/19 to 07/16/19 revealed no evidence the resident had atypical behaviors including being restless, irritable or fearful. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment, dated 01/05/19 to 06/19/19 revealed the resident had no behaviors. Interview on 07/16/19 at 3:48 P.M., with the Director of Nursing (DON) confirmed the pharmacy recommendation did not include an individual rational for declining the GDR requests. She confirmed the resident did not have any noted behaviors except two refusals of care since admission on [DATE]. She verified neither the physician progress notes nor the hospital records confirmed the diagnosis of psychosis. 2. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors, congestive heart failure with insertion of a pacemaker, dementia, atrial fibrillation and ischemic cardiomyopathy. Review of the resident's current physician orders included an order for Eliquis, an anticoagulant (blood thinner), Aspirin, a blood thinner, Plavix an antiplatelet medication, Zoloft, an antidepressant and Risperdal, an antipsychotic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 49 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's 05/27/19 quarterly MDS 3.0 assessment revealed the resident was not interviewable and did not exhibit any behaviors. Review of the pharmacy recommendation dated 12/17/18 revealed the resident was receiving Aspirin and Plavix together which was not advised for greater than 90 days. Review of the physician's response, dated 01/07/19 revealed to continue the current medications as ordered by the cardiologist. Review of the pharmacy recommendation dated 02/15/19 revealed a recommendation for a GDR for Risperdal 1.0 milligrams (mg) and Zoloft 50 mg. The physician's response on 02/15/19 revealed the medications were controlling and improving the targeted symptoms and to continue the medications at the current doses. Review of the cardiologist note dated 02/25/19 revealed the resident was ordered Aspirin and Eliquis and the Plavix was to be discontinued. Review of the April, May, June and July 2019 medication administrator records (MAR) revealed the resident's targeted behaviors for the Risperdal were fearfulness, restlessness, irritability, verbal and sexual inappropriateness and paranoia. The targeted behaviors for the Zoloft were fearfulness, restlessness and irritability. The resident was not identified to have any of the above behaviors for the past four months. On 07/15/19 at 9:52 A.M., 3:05 P.M. and 4:20 P.M., the resident was observed sitting in his recliner in his room. On 07/15/19 at 5:52 P.M., the resident was observed in the dining room attempting to feed himself but kept falling asleep. On 07/15/19 at 8:59 A.M., the resident was observed in his bed sleeping. On 07/16/19 at 12:33 P.M., the resident was observed reclined in his chair watching television (TV). On 07/16/19 at 2:27 P.M. and 3:51 P.M., the resident was observed laying in his bed sleeping. On 07/17/19 at 9:10 A.M., 10:45 A.M., the resident was observed laying in his bed sleeping. On 07/18/19 at 3:00 P.M., interview with the DON verified the resident was still on the Aspirin, Eliquis and Plavix and they did not discontinue the Plavix as recommended by the pharmacist or ordered by the cardiologist. The DON verified the facility did not attempt any GDR's despite not having any documented behaviors. On 07/22/19 at 8:45 A.M., the resident was observed laying in his bed sleeping. Review of the consulting pharmacist monthly drug review policy, dated November 2016 revealed the pharmacist should report any identified medication irregularities, unnecessary drugs and review psychotropic medications for excessive doses, duration, monitoring, adverse consequences monthly and documented on a separate written report. The physician must document in the medical record the irregularities had been reviewed and what if any action had been taken. If no change in the recommendation the physician must document on the next visit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 50 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure psychotropic medication use was justified and only used to treat appropriate behaviors, failed to ensure behavioral symptoms were monitored and/or failed to ensure gradual dose reductions were attempted as required to meet the needs of Resident #5, #44 and #53. This affected three residents (#5, #44 and #53) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including psychosis not due to substance or known physiological condition and major depression. Review of Resident #53's discharge hospital records dated 12/26/18 revealed no evidence of a bipolar or psychosis diagnoses. Review of Resident #53's physician's orders, dated 01/24/19 to present revealed the resident was ordered the antipsychotic medication, Risperdal 0.5 milligrams (mg) twice daily for psychosis and the antidepressant medication, Lexapro 20 mg daily for depression. The resident's identified behaviors were noted to be restlessness, irritability and fearfulness. There was no evidence of targeted behaviors for the psychosis diagnosis. Review of Resident #53's physician's office notes, dated 03/12/19, 03/21/19 and 05/16/19 revealed the resident was on Risperdal 0.25 mg daily at bedtime. There was no evidence of a bipolar or psychosis diagnosis. Review of Resident #53's behavior monitoring dated 01/05/19 to 07/16/19 revealed no evidence the resident had atypical behaviors including restlessness, irritability or fearfulness. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessments, dated 01/05/19 to 06/19/19 revealed the resident had no behaviors, including psychosis behaviors. Review of a verification of diagnoses letter from Resident #53's physician dated 07/16/19 revealed the resident had been on Risperdal for greater than eight years for bipolar two disorder and psychosis. The resident had been treated by mental health care in the past. The letter indicated the resident's current Risperdal order was 0.25 mg daily at bedtime, however the treatment indicated to continue Risperdal 0.5 mg daily. The resident's orders indicated the resident was ordered Risperdal 0.5 mg twice daily since 01/15/19. Interview on 07/16/19 at 1:06 P.M. and 3:13 P.M. and 07/17/19 at 10:32 A.M. with the Director of Nursing (DON) verified the resident's psychosis diagnosis was initially documented from a previous stay in the facility in 2018. She called the physician's office to clarify the psychosis diagnosis since it was not listed on the physician progress notes or in the hospital records. The physician's office reported the resident had a diagnosis of bipolar disorder in addition to the psychosis and had received treatment in the past from a mental health facility. The resident had been on medication for these disorders for over eight years. The DON verified the facility was not aware of the bipolar diagnosis until today. She reported targeted behaviors were determined by interviewing the resident and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 51 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication review. The DON verified there were no noted targeted behavior (delusion, hallucination) for the psychosis diagnosis. She verified the physician notes were inaccurate to reflect the resident current dose of Risperdal. Interview with the mental health facility on 07/17/19 at 10:14 A.M. revealed the resident had not been seen since 09/2018 and was only seen for medication management. She was not seen for counseling. The mental health facility offered services for primary care, therapy, case mangers (arrange transportation and appointments), and they have a nurse practitioner that does medication management for behaviors medication such as depression, anxiety, psychosis, etc. Interview on 07/17/19 at 9:39 A.M., interview with Resident #53 revealed she had never been diagnosed with bipolar disorder or psychosis. She stated she had some issues with depression and anxiety related to losing a son four years ago and had been on medication for that. She stated she had not been hospitalized or received counseling services for mental health. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with a diagnosis which included dementia with behaviors. Review of the current psychotropic medication care plan revealed to address pharmacist recommendations. There was no actual behavior care plan developed for the resident to identify behaviors and/or the use of psychotropic medications. Review of the resident's initial physician orders, dated 04/17/18 until current revealed the resident was on Ativan, an antianxiety medication, 0.25 mg at night. The resident was on the antipsychotic medication, Seroquel 50 mg twice a day and 150 mg at night. Review of the pharmacy recommendations, dated 10/13/18 recommended a GDR for the Ativan. The physician's response, dated 11/19/18 revealed the dose, duration and indications were clinically appropriate but did not indicate why attempted reductions were contraindicated. At the time of the survey, the facility was not able to locate the December 2018 recommendations. Review of the pharmacy recommendations dated 01/11/19 continued to recommend a GDR for the resident's Ativan. The physician's response, dated 01/31/19 revealed no changes-check with the psychiatrist. Further review revealed there was no documented evidence the psychiatrist was contacted. Review of the pharmacy recommendations dated 02/15/19, 04/04/19 and 05/09/19 continued to recommend a GDR for Ativan and stated the resident was on a high dose of Seroquel, an antipsychotic, at night and maybe the Ativan might no longer be needed. Further review revealed the physician did not make any changes nor give any rationale as to why no changes should be made. Review of the annual MDS 3.0 assessment, dated 04/08/19 revealed the resident was not interviewable and had behaviors of rejecting care one to three days during the assessment reference period. Review of the medication administrator record (MAR) for May, June and July 2019 revealed the resident continued on the Ativan 0.25 mg at night and Seroquel 150 mg at night as well as 50 mg twice a day. Further review of the MAR revealed the resident was being monitored for behaviors including fearfulness, irritability, being combative with care and verbal aggression but there was no evidence the resident displayed any of these behaviors in the past three months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 52 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0758 Level of Harm - Minimal harm or potential for actual harm On 07/15/19 at 12:50 P.M., the resident was observed being fed lunch. On 07/15/19 at 3:00 P.M. and 4:17 P.M., the resident was observed sleeping in bed. On 07/16/19 at 8:59 A.M. and 3:35 P.M., the resident was observed sleeping in bed. On 07/17/19 at 9:05 A.M. and 10:41 A.M., the resident was observed in sleeping in bed. On 07/17/19 at 3:44 P.M., the resident was observed in her wheelchair in the common area looking around. On 07/22/19 at 8:40 A.M., the resident was observed sleeping in bed. Residents Affected - Few On 07/22/19 at 9:40 A.M., interview with the DON verified there was no documented evidence to support the continued use of the Ativan without attempted a GDR and verified the physician had not addressed the GDR since 10/13/18. 3. Record review revealed Resident #44 was admitted to the facility on [DATE] with a diagnosis which included dementia with behaviors and psychosis. Review of the 01/28/19 pharmacy recommendation revealed the resident had been on Zoloft 50 mg at night, an antidepressant, since 03/02/17 without a GDR. On 01/28/19 the physician agreed to reduce the medication. Further review of the nurse note on 01/28/19 revealed the daughter was notified and did not want the dose reduced therefore the dose was not reduced. Review of the pharmacy recommendations dated 02/26/19, 04/29/19 and 05/20/19 revealed recurrent recommendations to reduce the Zoloft because it continued at 50 mg. With each recommendation the physician declined the reduction without giving justification. Review of the MAR's for targeted behaviors revealed the medication was used for repetitive sounds, crying, fidgeting and restlessness. Further review of the MAR revealed the resident had few behaviors documented for May and July 2019 and none for June 2019. On 07/22/19 at 9:50 A.M., interview with DON verified originally the physician agreed to try a GDR on 01/28/19 but when the daughter was notified she refused and the physician continued at the original dose of 50 mg. No additional attempts to reduce the medication had been attempted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 53 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure beneficiary notices and elopement assessments were legible and accurate. This affected one resident (#34) of two residents reviewed for elopement and one resident (#9) of three residents reviewed for beneficiary notices. Findings include: 1. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance. Review of the care plan titled At Risk for Elopement revised 06/11/18 revealed a wander guard/code alert (electronic device that sounds when the device goes through a door leading outside the facility) was to be worn daily, check function weekly and placement every shift. Review of the quarterly Wander Risk Evaluation dated 11/15/18, 02/13/19 and 05/18/19 revealed Resident #34 was not at risk for elopement. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #34 used a wander elopement alarm daily. Review of the Physician Orders dated July 2019 revealed staff was to check placement and function of Resident #34's code alert every shift. On 07/16/19 at 9:42 A.M., Resident #34 was observed self-propelling in a wheelchair wearing a code alert. On 07/17/19 at 11:50 A.M., interview with the Director of Nursing verified the elopement assessment and the care plan: At Risk for Elopement were inaccurate. 2. Record review revealed Resident #9 was admitted on [DATE] with diagnoses including chronic respiratory failure. Review of Resident #9's Beneficiary Protection Notification revealed a Medicare Non-Coverage note dated 02/09/19 for skilled services to in February 2019. The day the skilled services was to end and the date written by the resident's signature was not legible. On 07/16/19 at 11:11 A.M. interview with Director #378 verified the original date typed on the notice had been written over and not legible stating it had been changed because the wrong date was entered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 54 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the infection control log, policy review and interview the facility failed to ensure infection control practices were maintained during meal services to prevent the spread of infection. The facility also failed to ensure the infection control log was comprehensive to include all infections. This had the potential to affect all 79 residents residing in the facility. Residents Affected - Many Findings include: 1. Observation of lunch meal on 07/15/19 at 12:04 P.M. revealed Staff member #391 applied a gown and gloves and entered room [ROOM NUMBER], a contact isolation. The staff member was observed to touch the resident's bedside table and set up the resident's meal tray. The staff member removed her gloves and gown and left the room without providing hand hygiene. An interview with Staff member #391 immediately following the observation verified the staff member did not complete any type of hand hygiene after removing gloves and exiting room [ROOM NUMBER] for a resident who was in contact isolation. Review of the isolation policy dated 01/2012 revealed for contact isolation to remove gloves before leaving the room and perform hand hygiene. 2. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including urinary tract infections (UTI), overactive bladder and benign prostatic hyperplasia. Review of Resident #26's physician's orders and medication administration records (MAR) dated 06/28/19 to 07/03/19 revealed Resident #26 received Bactrim DS twice daily for UTI. Review of Resident #26's progress notes dated 05/28/19 to 07/04/19 revealed no evidence the resident had urinary symptoms. On 05/28/19 there was a note indicating to recheck urinalysis in one month. On 06/28/19 there was a note for new orders for the Bactrim, however no evidence of urinary symptoms. Review of Resident #26's urine culture results dated 06/25/19 revealed the urine was positive for providencia stuartii and was sensitive to Bactrim. Review of the infection control log dated 06/19 to 07/19 revealed no evidence Resident #26 was noted on the log. Interview on 07/18/19 at 12:43 P.M., with Registered Nurse (RN) #359 confirmed the resident received Bactrim DS twice daily for a UTI from 06/28/19 to 07/03/19, however he was not included on the infection control log. Review of infection policy and procedure, dated 07/2019 revealed resident infection would be monitored and reported on the line listing of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 55 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of antibiotic stewardship log, review of McGeer criteria and interview the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent the unnecessary/inappropriate use of antibiotics. This affected two residents (#26 and #47) and had the potential to affect all 79 residents residing in the facility. Residents Affected - Many Findings include: 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including urinary tract infections (UTI), overactive bladder, and benign prostatic hyperplasia. Review of Resident #26's physician's orders and medication administration records (MAR) dated 06/28/19 to 07/03/19 revealed Resident #26 received Bactrim DS twice daily for UTI. Review of Resident #26's progress notes dated 05/28/19 to 07/04/19 revealed no evidence the resident had urinary symptoms. On 05/28/19 there was a note indicating to recheck urinalysis in one month. On 06/28/19 there was a note for new orders for the Bactrim, however no evidence the resident had urinary symptoms. Review of Resident #26's urine culture results dated 06/25/19 revealed the urine grew less than 100,000 colony-forming units per milliliter (CFU/ml) providencia stuartii and was sensitive to Bactrim. Review of the antibiotic stewardship log dated 06/19 to 07/19 revealed no evidence Resident #26 was noted on the log or met criteria for treatment. Review of McGeer criteria for UTI revealed the resident without an indwelling catheter must meet both criteria one and two. Criteria one included the resident must meet one of the following sign or symptoms: A. acute dysuria or acute pain, swelling, tenderness of the testes, epididymis, or prostate. B. Fever or leukocytosis and one of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase incontinence, urgency, or frequency. C. In the absence of fever or leukocytosis, then two of more of the following localizing urinary tract sub criteria must be meet: suprapubic pain, gross hematuria, new or marked increase incontinence, urgency, or frequency. The second criteria in which one of the following must be met: A. at least 10 5 cfu/ml or more than two species of microorganisms in a voided urine sample or B. at least 10 2 cfu/ml of any number of organisms in a specimen collected in-and-out catheter. Interview on 07/18/19 at 12:43 P.M., with Registered Nurse (RN) #359 confirmed the resident received Bactrim DS twice daily for a UTI from 06/28/19 to 07/03/19, however he was not included on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 56 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0881 Level of Harm - Minimal harm or potential for actual harm antibiotic stewardship log nor was there a McGeer form completed to ensure resident met criteria. The urine culture was only obtained as it was ordered on 05/28/19 to be rechecked in one month. 2. Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including dementia, cataract, and Methicillin-resistant Staphylococcus aureus (MRSA) of the left eye. Residents Affected - Many Review of Resident #47's progress notes, culture results, Medication Administration records (MAR), and orders dated 07/03/19 to 07/06/19 revealed on 07/03/19 the resident's left eye looked swollen, red, tender/painful to touch. The physician was updated, and new orders were received for Tobrex eye drops two drops four times day and culture left eye. If no improvement after 48 hours notify the physician. On 07/06/19 the culture results returned and was positive for MRSA and sensitive to Gentamicin and resistant to Erythromycin. The lab suggested recollecting the specimen as the specimen was missing the resident's date of birth on the specimen. On 07/06/19 new orders were received for Gentamicin 0.3% ointment three times daily until clear and warm compresses three times daily until healed. The Gentamicin was noted to be on back order and new orders were received for Erythromycin ointment 5% three times a day for seven days, which the culture indicated was resistant to the organism. The MAR indicated the resident received two doses of the Erythromycin on 07/06/19. Another physician was notified of the culture results later that day on 07/06/19 and new orders were given for Polytrim drops two drops to left eye three times daily, Keflex 250 milligrams (mg) three times daily for seven days, Probiotic twice a day for seven days, and to place the resident on contract isolation. Review of physician's progress notes revealed no evidence the physician assessed the resident 72 hours after prescribing antibiotics over the phone. The last time the physician saw the resident was on 06/27/19. Review of the McGeer Criteria infection Surveillance checklist dated 07/09/19 revealed for conjunctivitis the resident must meet at least one of the criteria: Pus from one or both eyes greater than 24 hours, new or increased conjunctival erythema and new or increased conjunctival pain for greater than 24 hours. The resident form indicated she met the criteria because she had pain for greater than 24 hours only. There was no evidence the resident had received the Erythromycin; however, the form included the Tobrex, Polytrim, and Keflex. Review of the antibiotic stewardship log and infection control log dated 07/2019 revealed no evidence the resident received Erythromycin. Review of antibiotic stewardship policy and procedure, dated 11/2017 revealed antibiotics would be prescribed and administered to residents under the guidance of the facility Antibiotic Stewardship Program. To ensure the facility would use a format to track and trend antibiotic usage. When antibiotics were prescribed over the phone the primary care practitioner would assess the resident within 72 hours of the telephone order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 57 of 58 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 366052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gables Care Center Inc 351 Lahm Drive Hopedale, OH 43976 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 0881 Level of Harm - Minimal harm or potential for actual harm Interview on 07/18/19 at 10:49 A.M., with RN #359 verified the resident had not been seen by the physician within 72 hours after receiving the telephone order for antibiotic treatment per policy, the culture was resistant to Erythromycin and the resident received two doses. She verified she was on vacation the end of June 2019 and the first of July 2019 and the McGeer criteria and logs for the resident were not completed until she returned to work the following week. Residents Affected - Many 3. Review of the infection/antibiotic trending surveillance dated 04/2019 to 07/2019 revealed there were five to seven residents who were noted not to have met the McGeer criteria and received antibiotic treatments. Interview on 07/18/19 at 10:49 A.M., with RN #359 verified these findings and reported she had just started transitioning into the program in April 2019. RN #359 revealed she was going to meet with the physician to try to decrease antibiotic use. She was also scheduled to attend training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366052 If continuation sheet Page 58 of 58

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Citations

34 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
0912GeneralS&S Fpotential for harm
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0926GeneralS&S Epotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0725GeneralS&S Fpotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0740GeneralS&S Dpotential for harm
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Fpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0553GeneralS&S Dpotential for harm
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
0571GeneralS&S Dpotential for harm
F571 - The facility must not impose a charge against the personal funds of a
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0676SeriousS&S Gactual harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0744GeneralS&S Dpotential for harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

FAQ · About this visit

Common questions about this visit

What happened during the July 23, 2019 survey of GABLES CARE CENTER INC?

This was a inspection survey of GABLES CARE CENTER INC on July 23, 2019. The surveyor cited 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GABLES CARE CENTER INC on July 23, 2019?

Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install emergency lighting that can last at least 1 1/2 hours."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·July 23, 2019