Health inspection·February 20, 2025

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure the physician visited Resident #36 as required. This affected one resident (#36) of three residents reviewed for physician services. The facility census was 90. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 10/28/24 with diagnoses including congestive heart failure, diabetes, anxiety, hypertension, and cancer of the head, neck and face. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] reveal Resident #36 was cognitively intact. He was independent and eating, required setup help for oral hygiene, partial to moderate assistance for personal hygiene, and was dependent on staff for toileting and showering. Review of the physicians' notes revealed Resident #36 was last seen by his physician on 11/06/24. Interview on 02/19/24 at 7:54 A.M. with Resident #36 revealed he had not been seen by the physician since he was admitted to the facility. (The medical record revealed the resident was seen by the physician one time since admission on [DATE]). Interview on 02/20/25 at 12:21 P.M. with the Director of Nursing (DON) confirmed she had no documented evidence that Resident #36 was seen by the physician except for the visit on 11/06/24. Review of the facility policy titled Physician Visits and Frequency of Visits, dated 11/20/19, revealed the physician would take an active role in supervising the care of residents including medical services, medication management, physical, occupational and speech therapy, nursing care, nutritional interventions, social work and activities and visit as required. This deficiency represents noncompliance investigated under Master Complaint Number OH00161928. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 2 of 4 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 02/20/2025 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 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, interview and facility policy review, the facility failed to ensure [NAME] #204 washed her hands after leaving Resident #45's room and entering Resident #23's room. This affected two residents (#23 and #45) out of four residents reviewed for infection control and had the potential to affect 23 residents (#6, #7, #9, #10, #14, #18, #19, #22, #23, #30, #32, #36, #37, #38, #41, #45, #56, #66, #71, #72, #74, #76 and #78) identified by the facility that were on EBP. The facility census was 90. Residents Affected - Few Findings include: Observation on 02/19/25 at 1:46 P.M. of the 500-hall revealed [NAME] #204 was in Resident #45's room talking with her. [NAME] #204 exited resident #45's room and walked down the hall and into Resident #23's room. There was a sign indicating EBP on the outside of Resident #23's room. An interview with [NAME] #204, upon exiting Resident #23's room, revealed she did see the sign indicating Resident #23 was on EBP; however, she did not wash her hands before or when entering the room. She also confirmed she did not wash her hands before leaving Resident #45's room and did not know if Resident #45 was on any type of infection control precautions. Review of the medical record for Resident #45 revealed an admission date of 10/09/19 with diagnoses including Alzheimer's disease, kidney disease, arthritis, depression, colon cancer, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired. She was independent with eating, required supervision for oral and personal hygiene, partial assistance with toileting and dressing, and substantial assistance for showering. Review of Resident #45's physician's orders for February 2025 revealed an order for EBP for extended-spectrum beta-lactamase (ESBL) in her urine (a type of urinary tract infection). The order began on 10/23/24. Review of the care plan dated 01/07/25 revealed Resident #45 required EBP for a history of multi drug resistant organisms (MDRO). Interventions included staff cleaning hands before entering and upon leaving the resident's room. Review of the medical record for Resident #23 revealed an admission date of 06/01/17 with diagnoses including dementia, stroke, depression, anemia, and kidney failure. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. He was independent with eating, required partial assistance for oral hygiene, substantial assistance for personal hygiene, and was dependent on staff for toileting and showering. Review of the physicians' orders for February 2025 revealed an order for EBP for a wound. The order began 04/02/24. Review of the care plan dated 12/20/24 revealed Resident #23 required EBP due to a wound. Interventions included staff cleaning hands before entering and upon leaving the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 3 of 4 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 02/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/19/25 at 2:12 P.M. with the Director of Nursing (DON) confirmed Resident #45 was on EBP. She confirmed all staff should wash their hands upon entrance and exit of a resident's room, regardless of whether or not they have made contact with the resident, if they are on EBP. Review of the facility policy titled Isolation- Categories of Transmission Based Precautions, dated 03/26/24, revealed signs would be placed at the entrance of the room indicating what precautions were needed to be taken for that particular resident. For residents on EBP, staff would wash hands immediately when entering the room and again upon leaving the room. Signs would be placed at the entrance of the room indicating what precautions needed to be taken for that particular resident. This deficiency represents noncompliance investigated under Complaint Number OH00161506. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366129 If continuation sheet Page 4 of 4