Health inspection·June 13, 2019

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was alert and oriented with intact cognition and was totally dependent on two or more staff for transfers. On 06/12/19 at 4:50 P.M., the surveyor heard Resident #140 yelling out repeatedly which continued until 4:55 P.M. when the survey entered the room. Resident #140 was observed in his wheelchair and the call button was clipped to the resident's pillow on his bed and was out of his sight and out of his reach. On 06/12/19 at 4:56 P.M., interview Resident #140 revealed he wanted assistance and was not able to find or reach the call button. This was verified by Licensed Practical Nurse (LPN) #202 who was present during the interview with the resident who was very upset and agitated because he could not ring for assistance. Based on observation, interview and record review, the facility failed to ensure call lights were within reach for six residents, Residents #4, #5, #50, #77, #85, and #140. This affected six of 42 residents reviewed for call lights. Findings include : 1. Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease, spondylosis cervical region, and generalized anxiety. The Minimum Data Set (MDS) 3.0 assessment of 03/15/19 revealed the resident was severely cognitively impaired, required the extensive assistance of two staff for transfers and toileting, and was frequently incontinent of bladder and bowels. The care plan dated 06/07/19 revealed care areas identified for Resident #5 being at risk for falls and activities of daily living (ADL) self-care performance deficit. Interventions included staff to ensure the call light was within reach and encourage Resident #5 to use it when assistance was needed. Observation on 06/10/19 at 2:45 P.M. revealed Resident #5 was laying in bed. The call light was observed laying on the floor against the the wall and out reach. Interview on 06/10/19 at 2:47 P.M. with State Tested Nursing Assistant (STNA) # 110 verified the resident's call light was not in reach and said it should always be in reach. 2. Resident #50 was admitted on [DATE] with diagnoses including dementia, hearing loss, and epilepsy. The MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, was totally dependent on two staff for transfers and toileting and required extensive assistance of one staff for eating. She was always incontinent of bladder and bowels. The care plan dated 04/26/19 revealed care areas identifying her to be at risk for falls and ADL self-care performance deficit. Interventions included staff to ensure her call light was within reach and encourage her to use it as needed for assistance. Observation on 06/10/19 at 10:46 A.M. revealed Resident #50 sitting in her wheelchair with both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 2 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0558 hands clenched and the call light hanging behind the resident on the tube feed pole, out of her reach. Level of Harm - Minimal harm or potential for actual harm Interview on 06/10/19 at 10:48 A.M. with STNA #103 verified the call light was out of her reach and said the resident could unclench her fists and would sometimes write on a white board to communicate. Residents Affected - Some Observation on 06/11/19 at 11:45 A.M. revealed Resident #50 asleep in bed with the call light hanging on the tube feed pole behind her head and out of reach. Interview and observation on 06/11/19 at 11:46 A.M. with STNA #105 verified the call light was out of reach and should be pinned right next to the resident's hand. Interview on 06/13/19 7:46 A.M. with Registered Nurse (RN) #211 revealed Resident #50 used the call light at times. 3. Resident #77 was admitted on [DATE] with a cervical spinal cord injury and generalized anxiety. The MDS dated [DATE] revealed she was alert, oriented and cognitively intact. She was totally dependent on two staff for most ADLs. Review of the care plan dated 05/17/19 revealed care areas for risk of falls and ADL self-performance deficit with interventions including staff to ensure her call light was within reach and encourage use as needed for assistance. Observation on 06/10/19 at 9:57 A.M. revealed Resident #77 was seated in her wheelchair with her call pad laying on her abdomen, not pinned to her clothing, and out of her reach. Resident #77 verified she had very limited arm movement and demonstrated how she could only move her forearm and hand a few inches and had no finger dexterity. She indicated the call pad had to be very close to her hand in order for her to activate it to get staff assistance. Interview 06/10/19 at 9:57 A.M. with STNA #114 verified the call pad should always be within reach and the STNA adjusted the call pad closer to her hand. 4. Resident #85 was admitted on [DATE] with diagnoses including to diabetes with neuropathy, dementia, anxiety disorder and major depressive disorder. The MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, required extensive assist of two staff for transfers and extensive assist of one staff for toileting. The care plan dated 02/27/19 included care areas for risk of falls and ADL self-care performance deficit. Interventions included staff to ensure the call light was within reach and encourage use for assistance as needed. Observation on 06/11/19 at 11:31 A.M. of Resident #85 revealed the resident seated in her recliner with her dentures clutched in her left hand hand and she was calling out for help. The resident's call light was draped over the dresser to the right and behind her recliner. The call button was in the far side of the top drawer, out of Resident #85's reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 3 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0558 Interview on 06/11/19 11:33 A.M. with STNA #102 verified the resident's call light was not in reach. Level of Harm - Minimal harm or potential for actual harm Interview on 06/13/19 at 12:39 P.M. with Licensed Practical Nurse (LPN) #101 revealed the resident used the call light when she needed assistance. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 4 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 record review and interview the facility failed to administer laxative medications as ordered by the physician to prevent constipation for Resident #45. This affected on of five residents reviewed for unnecessary medications. The facility census was 97. Residents Affected - Few Findings include: Resident #45 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbances, alcohol dependence, major depressive disorder, psychosis and nutritional deficiency. Resident #45 had physician's orders dated 01/24/19 for Milk of Magnesia suspension (laxative medication) 400 milligrams (mg) per 5 milliliters (ml) orally every 24 hours as needed for no bowel movement (BM) for two days, a Dulcolax rectal suppository (laxative medication) every 24 hours as needed for decreased bowel motility and a Fleet enema (saline enema for constipation) 17-19 Grams per 118 ml rectally every 24 hours as needed for decreased bowel motility. Review of the BM records for Resident #45 for May 2019 and June 2019 indicated Resident #45 had no BMs on 05/01/19, 05/02/19, 05/03/19, 05/04/19 and 05/05/19, on 05/16/19, 05/17/19 and 05/18/19, on 05/20/19, 05/21/19 ,05/22/19, 05/23/19, 05/24/19, 05/25/19 and 05/26/19, on 05/28/19, 05/29/19 and 05/30/19 and on 06/06/19, 06/07/19 and 06/08/19. The time frames the resident did not have a BM ranged from three days to seven days. There was no evidence the resident was administered the Milk of Magnesia, Dulcolax rectal suppository or Fleet enema when she did not have a BM for two days. This concern was reviewed and verified with the Director of Nursing on 06/12/19 at 4:00 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 5 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to apply hand splints and a bone growth stimulator as ordered for Resident #77 and failed to ensure Resident #14, who had limited mobility, received appropriate services, equipment and assistance to maintain or improve her mobility with maximum practicable independence. This affected two (Residents #77 and #14) of five residents reviewed for position and mobility. Findings include: 1. Resident #77 was admitted on [DATE] with a cervical spinal cord injury with spinal stenosis and partial paralysis. Review of the physician orders of 05/17/18 and 05/18/19 revealed the resident was ordered to wear a bone growth stimulator (tens unit) and hand splints to both hands and were to be applied at 9:00 A.M. and removed at 1:00 P.M. daily. The comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #77 was alert and oriented with intact cognition and was totally dependent on two staff for most activities of daily living (ADLs). Review of care plan of 05/17/19 revealed Resident #77 had impaired joint mobility with an intervention to have splints to both arms and the bone growth stimulator to the neck. Observation and interview on 06/12/19 at 11:47 A.M. with Resident #77 revealed her in her wheelchair in her room. She was not wearing either hand splint or the bone growth stimulator. The resident reported staff did not apply the splints and bone stimulator as ordered by the physician. Interview on 06/12/19 at 12: 25 P.M. with the Director of Nursing verified the splints and bone growth stimulator were not being worn by Resident #77. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (stroke) and dementia. Review of the 10/05/18 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely cognitively impaired and not interviewable. The assessment indicated she was able to stand with the assistance of staff but her balance with transitions was unsteady. She was transferred with a sit to stand lift (a device the resident needed to be able to bear weight and assist in elevating for transfers). Review of the undated mobility device evaluation for a custom manual tilt in space wheelchair revealed the resident needed her feet in contact with the floor to decrease agitation and extensor thrust but needed her feet up for dependent wheelchair propulsion throughout the facility. The evaluation said she got anxious when her feet were consistently restrained by positional devices. The custom wheelchair was delivered to the facility on [DATE]. Review of the physician order dated 12/21/18 revealed staff were to apply a pummel cushion (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 6 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm cushion with an elevated section in the middle front of the cushion which is positioned between the legs at the groin area to prevent sliding down in the chair) to the wheelchair, remove the foot rests when the resident becomes agitated and add a lap buddy to the wheelchair. There were no parameters for the degree staff were to tilt the wheelchair backwards or when to tilt the wheelchair. The resident was to be transferred using a sit to stand lift. Residents Affected - Few A physician order dated 02/15/19 directed staff to add an alarm to the lap buddy (this was an intervention after a fall sustained on 02/15/19). Review of physician progress note dated 03/24/19 revealed no mention of the resident utilizing an alarming lap buddy, pummel cushion or tilt wheelchair. Review of physician progress note dated 04/10/19 revealed no mention of the resident utilizing an alarming lap buddy, pummel cushion or tilt wheelchair. Review of the care conference progress note dated 06/04/19 revealed it listed the devices including alarming lap buddy, pummel cushion, remove foot petals when agitated, non-skid material to seat of her wheelchair and her ability to use the sit to stand lift. There was no discussion about the need for or the effectiveness of any of these devices. Review of the current plan of care revealed multiple interventions to reduce falls due to her impaired cognition which included the pommel cushion and seat belt and lap buddy. The current interventions included alarming lap buddy, pummel cushion (not observed in place), front and rear anti tippers (not observed in place), instruct staff on safe use of the devices, observe for problems with positioning to avoid potential problems and re-evaluate her every three months and as needed for continued appropriateness. Review of the current [NAME], a guide for State Tested Nurse Aides (STNA) to follow to enable them to provide individual care to a resident, revealed there was no plan for when to tilt her backwards in her wheelchair or the degree to tilt the wheelchair, no direction regarding the application and removal of the alarming lap buddy, when to use the foot rests and had no information about a pummel cushion being used. Review of June 2019 STNA documentation revealed the pummel cushion was applied to the Resident #14's wheelchair daily (despite the resident not having a pummel cushion). On 06/11/19 at 11:38 A.M., Resident #14 was observed sitting in the wheelchair in the common area near the nurses station with her husband, who was also an uninterviewable resident. Her legs were dangling four inches off the floor because the custom wheelchair was tilted back. She was slouched down in the seat with her buttocks in the middle of the seat and she was not properly positioned. The resident was observed with an alarming lap buddy that clipped onto the wheelchair on the right side and was attached to the right side with magnetic releases that were around the bar of the wheelchair. The resident was sitting on a dycem, a non-skid device in the seat of the wheelchair. There was no pummel cushion observed in the seat of the wheelchair. Attempts to interview the resident revealed she was not interviewable. On 06/11/19 at 11:40 A.M., observation Resident #14's devices and positioning with Registered Nurse (RN) #118, with another surveyor present, revealed her custom chair was tilted back so the resident could not lean forward in the chair. Her feet were not able to touch the floor. She had on an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 7 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alarming lap buddy. RN #118 verified this observation and verified Resident #14 did not have a pummel cushion in her wheelchair. On 06/11/19 at 3:06 P.M., Resident #14 was observed in the common area near her husband with her wheelchair reclined and her legs dangling four inches from the floor. She was slouched down with her buttock in the middle of the seat, her head was not near the head rest, the dycem was in place, but there was no pummel cushion in place. Resident #14 was pushing at the lap buddy to move it away from her and the alarm sounded a few times but then stopped each time. At 3:08 P.M., State Tested Nursing Aide (STNA) #205 approached the resident, tilted her wheelchair into the upright position so the resident's feet could touch the ground and pushed her to the restroom. On 06/11/19 at 3:40 P.M., interview with STNA #205 said Resident #14's wheelchair was usually kept reclined and her feet could not touch the floor. On 06/11/19 at 5:18 P.M., the resident was observed in the dining room with her husband and son with the lap buddy attached to the wheelchair, the wheelchair was upright and her feet were on the floor. On 06/11/19 at 5:55 P.M., interview with RN #119 verified the lap buddy was not released during the meal and did not know if it was supposed to be or not. On 06/11/19 at 5:58 P.M., interview with resident's son revealed the resident had a stroke prior to admission about three years ago, she had confusion from the stroke and for the first three months of admission she kept falling and banging her head against the wall and the facility said they could not restrain her they wanted the lap buddy on to prevent her from getting out of the wheelchair. He verified the lap buddy was not removed during meals because the staff would just have to put it back on after she ate. On 06/12/19 at 10:00 A.M., Resident #14 was observed reclined in the wheelchair with her feet three inches off the floor in the common area with the lap buddy on. On 06/12/19 continuous observation from 11:20 A.M. until 11:40 A.M., revealed Resident #14 was in the common area reclined in the wheelchair with her feet a couple inches from the floor, pushing her buttocks forward in her chair (thrusting) while holding the cord to the alarm and trying to put it inside the lap buddy. The lap buddy was loose and sideways and did not assist with positioning. The resident asked if the surveyor was going to watch her bake. On 06/12/19 at 12:35 P.M., interview with the Director of Nursing (DON) verified Resident #14 had not been assessed for staff to tilt her backwards in the wheelchair. The DON verified there was no instruction on when or how far back to tilt the wheelchair and no documented reason to tilt the wheelchair back. On 06/12/19 at 3:50 P.M., interview with Physical Therapy Assistant (PTA) #210 revealed the resident was previously on hospice, who provided a high back tilting wheelchair because the resident would rear back (thrust) herself at times while in the wheelchair. PTA #210 said the resident was discontinued from hospice services and the high back wheelchair belonged to hospice and was removed from the facility. On 11/20/18, a new custom tilt wheelchair was provided for the resident at her family's request. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 8 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/12/19 at 6:20 P.M., interview with the DON, with Administrator present, revealed the pummel cushion was an intervention after a fall on 05/18/18. The facility staff documented the pummel cushion was applied daily however, Resident #14 did not have a pummel cushion in her wheelchair. On 06/13/19 at 8:00 A.M. and 9:10 A.M., the resident was observed with the wheelchair tilted backwards with her feet off the floor and the lap buddy was loosely applied and positioned at an angle. On 06/13/19 at 9:28 A.M., interview with PTA #210 revealed the resident does do pelvic thrusting when in a wheelchair. He said the resident's current wheelchair was delivered to the facility on [DATE] but the resident had not been treated by skilled therapy services or evaluated for positioning or devices since she received the current wheelchair. He verified the resident had a pummel cushion in her prior wheelchair but this one was custom and did not have a pummel cushion. On 06/13/19 at 9:40 A.M., observation of the resident positioned in her wheelchair with PTA #210 revealed he adjusted the chair and when it was upright her feet were able to be flat on the floor. He verified the resident did not have a pummel cushion in the wheelchair. On 06/13/19 at 12:32 P.M., the resident was observed sitting in common area, near her husband, and the lap buddy was off but it was not sounding. On 06/13/19 at 12:34 P.M., interview with RN #211 verified the lap buddy was detached from the wheelchair but it was not alarming. She was not able to reapply because the resident had thrusted her pelvic towards the front of the wheelchair. RN #211 called the DON for assistance in repositioning the resident. The DON moved the resident next to her husband with the wheelchair upright and the resident's feet on floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 9 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review the facility failed to ensure proper infection control measures were implemented for care and treatment of Resident #27's urinary (Foley) catheter. This affected one of two residents reviewed for urinary catheters. Findings include: Resident #27 was admitted on 06/0-6/18 and diagnoses included obstructive uropathy, a condition in which urine can't properly flow through the ureter, bladder or urethra due to some sort of blockage resulting in a urine back-up into the kidneys. Review of the physician orders revealed he had a urinary catheter in place to drain his bladder since his admission and the catheter was to be changed every two weeks. On 06/11/19 at 11:50 A.M., Resident #27 was observed in the main dining in his wheelchair with his catheter collection bag in a privacy bag, laying mostly laying on its side on the floor. There was a puddle of fluid under and around the bag. Also there were wet areas eight feet around the wheelchair including tire marks from the wheelchair and shoe prints from the residents as he moved through the wet areas on the floor. Many residents and staff were in the dining room but the fluid on the floor was no noticed by anyone. On 06/11/19 at 11:55 A.M., interview with State Tested Nurse Aide (STNA) #105 verified the residents catheter bag was leaking and the fluid on the floor was urine. At 11:57 A.M., Licensed Practical Nurse (LPN) #601 approached the area, verified the catheter bag was leaking urine onto the floor and took the resident back to his room to change the bag. The surveyor accompanied LPN #601. On 06/11/19 at 12:01 P.M., LPN #601 put on gloves (without first her washing hands), removed the catheter bag from the privacy bag and verified the urine collection bag was leaking and was most likely caused from it dragging on the floor, causing small pin holes in the bag. LPN #601 verified she was going to change the tubing and the catheter drainage bag. She removed her gloves and left the room. At 12:04 P.M., LPN #601 returned to the room with new tubing and catheter bag in packaging but no privacy bag. She did not wash her hands before putting on gloves. She then removed the catheter items from the package and placed them directly on the resident's bed. She then disconnected the catheter tubing at the top, then touched the tubing, moved the resident's feet by touching his shoes, she inadvertently placed the shoes on the catheter bag and then moved the catheter bag from under the residents shoes and picked it up off the floor and discarded it in the trash. She then picked up the new tubing and catheter drainage bag off the bed with the same soiled gloves and without changing her gloves and washing her hands, she attached the new tubing and drainage bag to the flexible tube which was inserted into the resident's bladder. LPN #601 then noticed the resident's pants were wet in the peri area. She laid the contaminated catheter drainage bag on the floor, removed the residents soiled pants, touched all of the parts of the urinary tubing and drainage bag, used a towel to wipe up the puddle of urine on the floor, then used the same towel to wipe out the inside and outside of the privacy bag to cover the urinary drainage bag. She then obtained a clean pair of pants from the closet and placed them on the resident. She assisted the resident to stand up, moving the wheelchair by touching the arm rests and then locking the wheelchair with the same gloves hands. After the resident stood up, she pulled up his pants and assisted him into the wheelchair, touching the resident's clothing. She then placed the catheter drainage bag into the contaminated privacy bag and hung it on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 10 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 the wheelchair so it was positioned off the floor. She then removed her gloves and washed her hands. Level of Harm - Minimal harm or potential for actual harm On 06/11/19 at 12:15 P.M., interview with LPN #601 verified the above concerns including the catheter drainage bag being dragged on the floor, contaminating it and causing tears in the bag, laying the sterile urinary drainage tubing and drainage bag on the resident's contaminated bed, reusing the contaminated privacy bag and not properly washing her hands and changing her gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 11 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to modify Resident #56's diet resulting in non-significant weight loss. This affected one of five residents reviewed for nutrition. Residents Affected - Few Findings include: Record review revealed Resident #56 was admitted on [DATE] with diagnoses including dementia without behavioral disturbance and muscle weakness. Review of a social service note dated 04/29/2019 revealed Licensed Social Worker (LSW) #110 was informed Resident #56 was missing her dentures by the resident's daughter and began the process of replacing them. There was no mention of LSW #110 notifying nursing or the dietician of the lost dentures. The minimum data set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and exhibited physical behaviors towards others and rejection of care. This assessment indicated she required extensive assistance of two staff for transfers and only needed staff set-up only for eating meals. The care plan dated 05/03/19 revealed she had a challenged nutrition/hydration status and swallowing problems. Interventions included a regular, no salt added, diet with all staff informed of her special dietary and safety needs. The care plan said she normally ate meals in the dining room for staff assist with meals as she permits. Review of dietician notes from 12/28/18 to 06/06/19 revealed a gradual decline in weight. The dietician indicated he/she had no knowledge of the missing dentures until speaking with the resident's daughter on 06/06/19 . At that time the resident's diet was changed to a mechanical soft diet with weekly weights as the resident allowed. Review of weights for Resident #56 from 12/28/18 to 06/12/19 revealed she sustained a 4% weight loss. Interview on 06/10/19 at 11:52 A.M. with Resident #56's daughter revealed the resident has lost weight in the past three to four months since losing her dentures. The facility continued to send the resident a regular diet, even though they were aware she lost her dentures, until the daughter spoke to Dietary Manager (DM) #113 on 06/06/19. The daughter said she requested the resident receive a mechanical soft diet since she could not chew well without her dentures. The daughter also stated the resident preferred to eat in her room and staff do not assist the resident with meals. Observation of Resident #56 on 06/10/19 from 12:38 P.M. to 12:50 P.M. revealed staff delivered the resident's tray to her in her room and provided set-up. The resident sat on the edge of the bed picking at her mechanical soft meal without any staff cueing or assistance. Observation of Resident #56 on 06/11/19 from 7:48 A.M. to 8:10 A.M. revealed staff delivered the resident's tray to her room and provided set-up. The resident ate less than 25% of the french toast and drank the nutritional supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 12 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident #56 on 06/11/19 from 12:20 P.M. to 12:45 P.M. revealed staff delivered the resident's tray to her room and provided set-up. The resident sat on the edge of her bed and picked at her food. The resident ate less than 25% of the mechanical hot dog, drank the nutritional supplement and ate the Italian ice. Interview on 06/12/19 at 7:53 A.M. with Dietary Manager (DM) #133 revealed the resident's daughter requested a mechanical soft diet on 06/06/19 because the resident had lost her dentures. DM #113 was not aware prior to that time that the resident had lost her dentures. The resident's diet was changed to mechanical soft and oatmeal was added for breakfast and lunch per the daughter's request. The DM reported the resident usually ate in her room unless the daughter was there, then the resident would eat in the dining room with the daughter assisting her. Interview on 06/12/19 at 7:59 A.M. with Registered Dietician (RD) #111 reported the resident's diet should have been downgraded when the resident lost her dentures. The dietician verified the resident should not have continued with a regular diet without a speech evaluation and without her dentures. Interview on 06/12/19 at 8:07 A.M. with Licensed Social Worker (LSW) #110 verified Resident #56's daughter reported the resident's missing dentures to her on 04/29/19. LSW #110 was in the process of replacing them as the resident's insurance recently approved a new set of dentures. LSW #110 verified there was documentation to indicate nursing staff or the dietician had been notified when Resident #56 lost her dentures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 13 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 assess Resident #64 for as needed oxygen and failed to ensure oxygen was administered appropriately and as ordered by the physician for Resident #64 and Resident #74. This affected one of one residents reviewed for Hospice care and one of one residents reviewed for respiratory care. The facility census was 97. Residents Affected - Few Findings include: 1. Resident #64 was admitted to the facility on [DATE] and had diagnoses included Alzheimer's disease, anxiety disorder, muscle weakness and chronic obstructive pulmonary disease. The resident was receiving Hospice care. The resident had a physician's order dated 05/23/19 for oxygen (O2) at two liters per minute per nasal cannula for oxygen saturation (measure of the oxygen percentage of the blood) below 92% as needed to maintain her O2 saturation. On 06/10/19 at 10:52 A.M. Resident #64 was observed in a Broda chair (reclining chair) in her room. She had on O2 per nasal cannula per an O2 concentrator at two liters per minute. On 06/11/19 at 2:46 P.M. Resident #64 was observed in bed, turned slightly to the left side with a body pillow to her right side. She had the O2 nasal cannula in both nostrils. The cannula tubing was attached to the the O2 concentrator at the bedside. The O2 concentrator was not turned on. The observation was verified with Registered (RN) #115 on 06/11/19 at 2:50 PM. RN #115 checked the resident's O2 saturation with a pulse oximeter (device used to measure blood oxygen percentage) and it was alternating between 81% and 82%. This was verified with RN #115 at the time of the observation. RN #115 stated the resident's order was for O2 at two liters per nasal cannula as needed for an O2 saturation below 92%. RN #115 turned the O2 concentrator on and increased the O2 to three liters to get the resident's O2 saturation up to 89%. She said she would contact Hospice for an order to increase the liters of oxygen as needed to maintain oxygen saturation levels. RN #115 obtained a new order from Hospice for O2 at two to five liters per minute as needed to maintain the resident's O2 saturation at 90% or above and to check the resident's O2 saturation levels every shift. Review of the treatment administration records and nursing progress notes for Resident #64 indicated no evidence the facility assessed the resident's O2 saturation on 05/26/19, 05/28/19, 05/29/19, 05/31/19, 06/02/19, 06/03/19, 06/04/19, 06/05/19, 06/06/19, 06/07/19, 06/08/19, 06/09/19 or 06/10/19 to determine the resident's O2 saturation percentage and need for the administration of O2 or it's effectiveness. There was no evidence the resident's O2 saturation was assessed by the facility on 06/11/19 until surveyor intervention. Review of Hospice notes for Resident #64 dated 06/12/19 at 11:30 A.M. written by Certified Nurse Practitioner (CNP) #117 revealed the resident's O2 saturation was 84% on room air. The note stated, Patient sitting in Broda chair in room, oxygen cannula in nostrils (tubing disconnected from tank corrected/RN informed) eyes closed. On 06/13/19 9:10 A.M. the CNP note was verified with the Director of Nursing (DON), who said she was unaware of the incident. Said she would contact Hospice and get clarification on which RN was informed. On 06/13/19 at 9:35 A.M., interview with RN #118 revealed she worked the day shift on 06/12/19 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 14 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 the resident's unit. She said she was not informed of the resident's O2 tubing being disconnected and was not aware the CNP visited Resident #64. On 06/13/19 at 1:25 P.M., interview with the DON revealed the Hospice agency had not returned her call regarding the incident on 06/12/19. Residents Affected - Few 2. Record review of Resident #74 revealed an admission date of 04/30/18 and diagnoses included chronic obstructive pulmonary disease, malignant neoplasm (cancer) of bronchus or lung, morbid obesity with alveolar hypoventilation (breathing at an abnormally slow rate) and obstructive sleep apnea. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition and required extensive assist of two staff for daily activities and was totally dependent on two staff for transfers. She was unable to walk. Review of care plan dated 05/10/18 for Resident #74 revealed she had chronic obstructive pulmonary disease, history of lung cancer and obstructive sleep apnea and required oxygen daily yet still had periods of dyspnea (shortness of breath) with exertion and at rest. Interventions included oxygen therapy and use of Bilevel Positive Airway Pressure (BiPap) as ordered by the physician. Review of current physician orders for June 2019 revealed Resident #74 was to have continuous oxygen at five liters per minute. Observation on 06/10/19 at 9:50 A.M. revealed Resident #74's oxygen nasal cannula (a lightweight tube that delivers oxygen) tubing was wrapped around her side rail and not connected to her oxygen concentrator. Interview on 06/10/19 at 9:52 A.M. with Licensed Practical Nurse (LPN) #600 verified Resident #74's oxygen was not connected to the oxygen concentrator. She said Resident #74 required extensive assist with bed mobility and was totally dependent with transfers. She verified Resident #74 was to receive oxygen at five liters per minute continuously. Review of facility policy dated 05/20/18, Oxygen Administration, revealed staff should check the tubing connected to the oxygen cylinder to assure it is free from kinks and observe the resident upon set-up and periodically thereafter to be sure oxygen was tolerated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 15 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a comprehensive pain management program was in place related to the use of as needed pain medications for Resident #18. This affected one of one residents reviewed for pain management. Residents Affected - Few Findings include: Resident #18 was admitted to the facility on [DATE] which diagnoses which included dementia and psychosis. Review of the admission pain assessment dated [DATE] indicated the resident had osteoporosis and the resident was able to voice when she had pain. There was no indication where the resident had pain. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and was on a pain management regimen. The resident ambulated independently with a walker and was able to reposition independently. Review of the current comprehensive care plan revealed there was no plan of care for pain management for Resident #18. Review of the physician's order dated 03/26/19 revealed staff were to provide 650 milligrams (mg) of acetaminophen every four hours as needed for pain. Further review of the physician's order dated 03/26/19 revealed staff were to administer a narcotic combination medication, Hydrocodone-acetaminophen 5-325 mg every eight hours as needed for pain. There were no parameters when to give either of the medications. Review of the March 2019 Medication Administrator Record (MAR) revealed no as needed pain medications were given. Review of the April 2019 MAR revealed no plain acetaminophen was given and on 04/22/19 the resident had a pain score of five and the narcotic pain medication was given. Review of the nursing notes revealed there were no assessments of where Resident #18 had, no description of the pain or that any other non-medication interventions were provided. Review of the medical record revealed there was no evidence a pain tracking form was initiated. Review of the May 2019 MAR revealed no acetaminophen was given but the narcotic pain medication was given 24 times, on 05/04/19 two doses, 05/05/19 two doses, 05/06/19 one dose, 05/10/19 two doses, 05/14/19 one dose, 05/17/19 two doses, 05/18/19 two doses, 05/19/19 two doses, 05/20/19 two doses, 05/23/19 two doses, 05/24/19 two doses, 05/28/19 two doses and 05/29/19 two doses, with pain scores between two and nine. Review of the nursing notes revealed there was no evidence of non-medication interventions were provided and no evidence acetaminophen was offered prior to the narcotic pain reliever. Review of the June 2019 MAR revealed the narcotic was given twice on 06/01/19, 06/02/19 and 06/03/19 for pain scores of eight, acetaminophen was given for a pain score of five on 06/11/19, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 16 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0697 narcotic was given on 06/12/19 for a pain score of two and on 06/13/19 for a pain score of eight. Level of Harm - Minimal harm or potential for actual harm On 06/11/19 at 11:30 A.M., Resident #18 was observed sleeping in bed and there was no indication of pain. Residents Affected - Few On 06/11/19 at 5:18 P.M., the resident was observed eating in the dining room and there was no indication of pain. On 06/13/19 at 11:50 A.M., the resident was observed ambulating in the hall with her walker and there was no indication of pain. On 06/13/19 at 11:51 A.M., interview with the resident revealed she was not reliable. She indicated her only pain was in her lower back at times when she was on her feet too much. She said if she laid down to rest, it felt better. The resident denied knee pain but stated she had a problem with her thinking and could not always remember things. On 06/13/19 at 1:15 P.M., interview with Registered Nurse (RN) #120 and the Director of Nursing (DON), with the Administrator present, revealed the pain management policy was not implemented, the facility did not have a pain tracking form, did not attempt non-medication interventions prior to administering as needed pain medications, did not obtain parameters for when to use the acetaminophen versus the narcotic pain medication, verified there was no plan of care to address Resident #18's pain and verified the narcotic was the first medication given without attempting the acetaminophen. These staff also verified there was no review of why a narcotic was given for a pain score of two and verified despite the residents increased use of the narcotic pain medication in May 2019, there was no re-assessment of Resident #18 to determine the reason for the increased need for pain medications. The DON indicated it was the nurse's judgement as to when to give medications but said there was no system in place to ensure the resident did not receive unnecessary medications or to ensure other non-medication interventions were attempted for pain management. Review of the pain management policy and procedure, dated 03/12/13, revealed when administered, all pain medications require a tracking form and it would be completed to ensure effective pain management. When rating pain via the pain flow sheet form, a pain intensity scale would be used with zero being no pain and 10 being the most severe pain. Also nursing was to track the characteristics, frequency, and side effects, if any, of the medications. The tracking form would also include non-medication interventions use to relive pain and would be used in addition to a pain evaluation form which was to be completed on admission and quarterly. The purpose of these form was to track the effectiveness of pain management. All residents ordered pain medications would be assessed and monitored via the pain flow sheet. The form would be implemented prior to administering pain medications. If the pain medication and/or interventions were ineffective the physician would be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 17 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the coordination of care related to medications, fluid restrictions (FR) and dietary needs for Resident #293, who received hemodialysis (HD). This affected one of one residents reviewed for HD. Residents Affected - Few Findings include: Resident #293 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease requiring HD three days a week and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the physicians orders for April, May and June 2019 revealed there were no orders indicating the location of the HD site and no order for nurses to monitor the vascular access site (the site where the person is attached to the dialysis machine) on Resident #293 to ensure it was functioning properly, including listening for a bruit (use of a stethoscope to hear the blood flowing through the implanted vascular access device) and feeling the thrill (touching the access site to feel the blood flowing through). Review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) for April, May and June 2019 revealed there no evidence that nursing staff were monitoring Resident #293's vascular access site for a bruit and thrill or for signs and symptoms of infection or bleeding according to the dialysis and dialysis communication policies and procedures. Review of the current physicians orders revealed Resident #293 went to HD on Tuesdays, Thursdays and Saturdays but there were no times listed for the treatments. Further review revealed orders for daily medications including Renvela (a phosphate binder used to prevent low levels of calcium in the body and should always be taken with food) three times a day at 6:00 A.M., 12:00 P.M. and 5:00 P.M. for twice daily for April 2019 at 8:00 A.M. and 12:00 P.M. in June 2019. The June 2019 MAR medications included Alphagan eye drops for glaucoma at 9:00 A.M., Darbepoetin Alfa injection for anemia at 6:00 A.M., Doxazosin Mesylate for high blood pressure at 9:00 A.M., Fish Oil capsule at 9:00 A.M., Lasix , a diuretic, at 9:00 A.M., Lisinopril for high blood pressure at 9:00 A.M., Metoprolol tartrate for high blood pressure at 9:00 A.M., Nepro, a nutritional liquid supplement, at 9:00 A.M., PreserVision, an eye supplement, at 9:00 A.M. and Vitamin D at 9:00 A.M. There were no physician orders directing nursing staff to hold any of these medications including on HD days. Review of the MARs revealed the resident started HD at 9:35 A.M. Review of the current plan of care for HD revealed staff were to monitor and document peripheral edema (swelling in the hands, lower legs, and feet), report to physician any signs or symptoms of infection to the access site, swelling, warmth or drainage, bleeding, hemorrhage, bacteremia and/or septic shock. Prior to going to HD, staff were to obtain baseline vital signs (temperature, blood pressure, heart rate and respirations) and complete an assessment of the HD site and document this information. After returning from HD, staff were to observe the HD site for signs and symptoms of bleeding, infection, increased fluid volume including labored breathing, increased blood pressure, swelling, neck vein distension, hypovolemia (low blood volume) including poor skin turgor, tachycardia (rapid heart rate) and hypotension (low blood pressure). There was no indication of the type of HD access (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 18 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 site Resident #293 had or where it was located. Level of Harm - Minimal harm or potential for actual harm Review of the April 2019 MAR revealed Renvela was ordered at 6:00 A.M., however the breakfast meal was not delivered to the resident until after 8:00 A.M. Further review revealed the Renvela was not given at 12:00 P.M., daily as ordered on 04/02/19, 04/04/19, 04/06/19, 04/09/19, 04/13/19, 04/16/19, 04/18/19, 04/20/19, or 04/25/19 because the resident was not in the facility. Review of the HD communication sheets revealed there was no documentation on the above days that any medications were sent to HD. The only documentation on the forms from the facility were the resident's vital signs including temperature, pulse, respirations and blood pressure. There were no assessments of the vascular access site. The communication forms on dialysis day from 04/18/19 and 04/20/19 where not in the medical record. There was no evidence the Renvela was given as ordered on HD days including 04/25/19. Further review of the nursing notes did not indicate what, if any medications were sent to HD. Residents Affected - Few Review of the May 2019 HD communication forms revealed communication forms were only completed on 05/04/19, 05/09/19 and 05/14/19 and the only information from the facility included pre-dialysis vital signs. There were no documented assessments of the vascular access site. Review of the June 2019 MAR revealed Renvela was not given at at 8:00 A.M. on 06/11/19 or on 06/01/19, 06/06/19, 06/11/19 at 12:00 P.M. because the resident was out of the facility. Further review of the HD communication form revealed the only form in the medical record was dated 06/11/19 and did not say if the Renvela medication was given at 8:00 A.M. or 12:00 P.M. as ordered. The only pre-dialysis documentation from the facility were the resident's vital signs. There were no assessments of the vascular access site. Further review of the MAR for 06/11/19 revealed the following medications ordered at 9:00 A.M. were not given because the resident was out of the facility: Nepro, PreserVision, medications for high blood pressure including Lisinopril, Metoprolol tartrate, Doxazosin Mesylate, Alphagan eye drops, fish oil capsule, Vitamin D and Lasix. There were no corresponding nursing notes regarding these medications and no evidence the physician was notified the medications were not given as ordered. On 06/11/19 at 11:30 A.M., interview with State Tested Nurse Aide (STNA) #105 revealed Resident #293 left for HD between 8:30 A.M. and 9:00 A.M., after breakfast, and returned between 2:30 P.M. and 3:00 P.M. On 06/12/19 at 5:50 P.M., interview with Licensed Practical Nurse (LPN) #213 revealed he was not sure what the process was if a resident was at HD when medications were due and would have to ask someone. On 06/12/19 at 6:10 P.M., interview and record review with the Director of Nursing (DON) verified the April, May and June 2019 MAR's revealed Resident #293's medications were not given as ordered and no reason was given in the nursing notes, there was no evidence the physician was notified the medications were not given, there was no documentation on the HD communication forms or other evidence that the medications were sent with the resident to HD on these days and no times were recorded to determine when the resident was out of the facility. On 06/12/19 at 6:25 P.M., interview and record review with Registered Nurse (RN) #119 of the April, May and June 2019 MAR's verified all medications were not given as ordered and a 3 was written, which indicated the resident was out of the facility. RN #119 verified there was no evidence the physician was notified, no documentation on the HD communication forms or other evidence medications were sent with the resident to HD on the days and no specific times when the resident was out of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 19 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 facility. Level of Harm - Minimal harm or potential for actual harm On 06/13/19 at 9:18 A.M., interview with RN #211 verified she gave the resident his 9:00 A.M. medications about 8:00 A.M. before he left for HD and she did not send any medications with the resident to HD. Residents Affected - Few On 06/13/19 at 11:10 A.M., interview and record review with RN #120 of the above documentation verified the facility did not ensure medications were given as ordered, did not ensure the HD care plan was followed, did not ensure HD communication sheets were completed as planned by the facility and the facility did not ensure the HD communication forms were returned after each HD treatment as planned. On 06/13/19 at 12:53 P.M., interview with the DON, RN #120 and the Administrator reviewed the above concerns and verified they were not aware the medications were not given as ordered or that the physician was not notified the medications were not given as ordered. The DON verified the assessments did not document the type and/or location of the residents HD vascular access site and verified there was no documentation to indicate nursing staff monitored the vascular access site for the bruit and thrill and for signs and symptoms of infection or bleeding. The DON said the HD access site was in the resident's left forearm. Review of the dialysis policy and procedure, dated 05/27/14, revealed the purpose was to monitor residents for the following problems: fluid and electrolyte imbalance, cardiovascular/hemodynamic instability, pain and infection. Prior to sending the resident to HD, staff were to obtain the resident's baseline vital signs and the baseline status of the dialysis site, assess for bruit and signs or symptoms of infection of bleeding. When the resident returned from HD they would be observed for signs and symptoms of fluid volume overload including labored breathing, increased blood pressure, edema and neck vein distension, poor skin turgor, tachycardia and hypotension, bleeding in regards to the dialysis site, infection of the dialysis site, they would obtain vital signs, obtain blood sugar and assess dialysis site for signs and symptoms of bleeding and infection every hour for three hours. Nursing staff were to document the name of person completing the assessment, vital signs prior to and after HD, the dialysis site assessment and blood sugar assessment. Review of the dialysis communication policy and procedure, dated 05/27/14, revealed communication would be maintained to promote the overall well being of the resident. The facility would send a HD communication sheet with the resident to HD. The facility would complete the pre-HD vital signs and whether Pliocene/Prilocaine cream needs reordered. The HD center was responsible to complete the form and send back to the facility to include post HD vitals, pre and post HD weights, medications administered and any issues during HD. If the HD communication sheet was not returned, the facility would be responsible to call the HD center to obtain the needed information. If the medications could not be given at the facility prior to the resident leaving for HD, the medications would be sent for administration by the HD center. The HD center would communicate with the administrator by documenting on the communication record or calling the facility. An additional concern was identified with Resident #293's fluid restriction (FR) and his ordered diet. Review of the nutrition at risk care plan dated 02/19/19 revealed Resident #293 was on a 1500 cc FR per day with 1000 cc provided from dietary on the meal trays and 500 cc's provided by nursing staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 20 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current HD plan of care revealed to staff were to communicate with HD on a regular basis related to blood work and weights. Staff were to follow the FR of 1500 cubic centimeters (cc's) a day with 1000 cc's provided from dietary and 500 cc's provided by nursing/STNA's. There was no information as to how much fluid Resident #293 was to receive on each of the meal trays. Further review of the [NAME] (documentation for individual residents needs to assist the STNA's in providing individualized care) did not indicate the distribution of the FR from dietary (including how much fluid per meal) and nursing. Review of the dietary progress notes dated 03/29/19, 04/26/19, and 05/19/19 revealed the resident was on a physician ordered FR and modified renal diet, but there was no evidence the dietitian ensured the FR and diet were being followed as ordered. She was not aware of any fluid logs or intake logs kept in the resident's room. Review of the 04/11/19 STNA fluid intakes at meals records revealed Resident #293 consumed 600 cc's for breakfast, unknown intake for lunch because the resident was at HD, and 300 cc's for dinner. On 04/21/19, the resident consumed 360 cc's for breakfast, 600 cc's for lunch and 600 cc's for dinner. The nurse was responsible for transcribing the meal intakes onto to the MAR. Review of the MAR for these dates, reveled the fluid intake amounts recorded by the nurse did not match the fluid intake recorded by the STNA's. Review of the STNA documentation of fluid intakes during meals on 05/03/19 revealed the resident received 360 cc's for breakfast, 360 cc's for lunch and 600 cc's for dinner, which totaled 1320 cc's, which exceeded the 1000 cc limit from dietary. On 05/04/19 the resident received 600 cc's for breakfast, was at HD for lunch and had 600 cc's for dinner, which totaled 1200 cc's, which exceeded the 1000 cc limit from dietary. On 05/26/19, the STNA recorded the resident received 480 cc's for breakfast, 360 cc's for both lunch and dinner, which totaled 1200 cc and exceeded the 1000 cc limit form dietary. Review of the MAR for 05/26/19 revealed the nurse recorded Resident #293 consumed 120 cc's of total fluid on first shift (this includes meals, supplements and fluid given with medications), 640 cc's of total fluid on second shift and 120 cc's of total fluid on third shift which did not coordinate with the meal intakes documented by the STNA. Review of the dietary progress note dated 06/06/19 revealed the resident was still on a FR and modified renal diet. There was no documentation the dietitian ensured the FR or diet were being followed as ordered. Review of the STNA fluid intake for meals dated 06/11/19 revealed the resident consumed 120 cc's for breakfast, the resident was at HD for lunch and not applicable for dinner despite the resident observed consuming 660 cc's for dinner. Further review of the MAR for 06/11/19 revealed the resident consumed a total of 500 cc's for the day, which did not match the 660 cc's consumed at dinner. On 06/11/19 at 3:10 P.M., interview Resident #293 revealed he did not think he had to follow any special diets and or restrictions of his fluid intake. On 06/11/19 at 5:20 P.M., Resident #293 was observed at the dinner meal eating in the activities dining room. The room was monitored by activities staff during the meal. Resident #293's meal tickets revealed the resident was on a modified renal with a K+ restriction (potassium restriction) but it did not list a FR. Under the likes section, it indicated Resident #293 liked one cup of coffee and four ounces of lemonade. Under preferences, it said she liked a cup of vanilla fat free pudding and under dislikes it listed iced tea and jello. The resident was to received two servings of soup with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 21 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the meal. Activities Director #211 and Activities Assistant (AA) #112 were in the room. The resident was provided four ounces (120 cc) of lemonade, half a cup of baked beans in juice (60 cc), 12 ounces of hot chocolate (240 cc), one cup (240 cc) broccoli cheddar soup, a cup of pudding and a banana. On 06/11/19 at 5:30 P.M., interview with the resident's wife revealed she was not aware the resident had to watch any certain foods or was supposed to be limited on his fluid intake. She said he was not on any restrictions that she was aware of. On 06/11/19 at 5:38 P.M., interview with Activities Director #211 revealed the activities staff oversaw the meals in the activities dining room. She verified Resident #293 resident liked soup and got one to two servings with most meals. She said she was aware the resident was on a FR but said she did not know soup was a fluid and did not count it when totaling the fluid intake. On 06/11/19 at 5:50 P.M., Resident #293 had eaten all the pudding, soup, lemonade, hot chocolate and banana. This was a total of 660 cc's of fluid intake for the meal. On 06/11/19 at 5:55 P.M., Activities Director #211 was re-interviewed and verified the fluid intake was calculated incorrectly as she only counted the hot chocolate and lemonade for his fluid intake which totaled 360 cc's. She verified she did not include the soup and the juice from the baked beans as fluid intake. She verified the resident ate the banana and thought it was okay (bananas contain potassium). Review of the meal ticket revealed she did not know what a K+ restriction was and did not know bananas contained K+ (potassium). On 06/12/19 at 8:23 A.M., the breakfast tray was observed to be delivered to Resident #293 and it contained 240 cc's of coffee and 120 cc's of juice. At 9:00 A.M., the resident had consumed all of the liquids for a total of 360 cc's. Review of the STNA fluid intake for meals dated 06/12/19 revealed the fluid intake for breakfast was 480 cc's, which was more then what he was observed to drink. Review of the MAR, recorded by the nurse, for day shift revealed the resident consumed a total of 240 cc's. The documentation by the STNA and the nurse did not match what the resident was actually observed to consume at breakfast. On 06/12/19 at 3:40 P.M., interview with the Dietary Manager (DM) #113 revealed a modified renal diet limited salt, sugar, tomatoes, potatoes, bananas and citrus. There was no difference in the protein levels from a regular diet because the HD residents were given protein supplements instead. She verified Resident #293's meal ticket stated K+ restriction and verified all facility staff may not know what that means. She verified the resident should not have a banana because of the potassium in the banana which was restricted in the resident's diet. She verified the meal ticket did not indicate the resident was on a FR. She verified under the likes section of the meal ticket for each meal she allowed for 360 cc's of fluids per meal which exceeded the 1000 cc dietary allowance. She did not educate the activities staff on Resident #293's FR. She verified one cup mugs held 240 cc's, juices provided 120 cc's, soup bowls held 240 cc's. She verified the resident was to receive two bowls of soup, for a total of 480 cc's for the dinner meal unless the kitchen ran out of soup. She verified the baked beans were not drained and had 60 cc's liquid. She verified the resident consumed 660 cc's of fluid on 06/11/19 for the dinner meal. On 06/12/19 at 4:00 P.M., interview with Registered Dietitian (RD) #111 verified the above concerns and verified there was no evidence of monitoring to ensure the FR or prescribed diet were being followed. She verified the meal ticket was not comprehensive and did not explain the restrictions for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 22 of 23 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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 0698 all staff to understand. Level of Harm - Minimal harm or potential for actual harm On 06/12/10 at 5:00 P.M., phone interview with dialysis RD #212 revealed the resident should be on a FR and renal diet. Residents Affected - Few On 06/12/19 at 5:50 P.M., interview with Licensed Practical Nurse (LPN) #213 revealed he did not add the fluids from the meal intakes when documenting the resident's total fluid intake for the day. He said he only included fluids given by him. On 06/12/19 at 6:10 P.M., interview with the DON revealed the nurses documented fluid intake per shift and STNA's documented this in the task section for each meal and at the end of each shift the nurses were to add the meal intake to the MAR to ensure the FR was being followed. On 06/13/19 at 12:53 P.M., interview and record review with the DON, RN #120 and the Administrator verified the identified concerns with Resident #293's fluid restriction and diet not being followed, intakes not properly calculated, documented and monitored and the lack of education to the staff, resident and his wife related to his diet orders and fluid restrictions. They indicated they were not aware the FR was not being followed as planned. The DON said it was her responsibility to educate staff. Review of the FR policy and procedure, dated 12/16/12, revealed restricting fluid intake may be needed to maintain optimum health. Staff were to ensure physician's orders were in place, review the care plan and/or daily assignment sheet, [NAME] (a document with each resident's individual daily needs as a guide for the STNA's). Staff were to be accurate when recording fluid intake, encourage the resident and family to stay within the limits of the restriction, ensure the intake and output record was maintained in the resident's room. Document any refusal's of the resident to adhere to the FR and notify the supervisor if the FR was not being followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 23 of 23