Health inspection·December 18, 2025

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure residents were properly assessed for appropriateness before being placed on the secured memory care unit. This affected one (#49) of one resident reviewed for restraints. The facility census was 46. Findings include: Review of the medical record for Resident #49 revealed an admission date of 07/15/25. Diagnoses included fibromyalgia, malnutrition, dementia with mood disturbance, and kidney disease.Review of hospital discharge paperwork dated 07/15/25 revealed Resident #49 had been living at home, was hospitalized , and found to have a urinary tract infection (UTI). The hospital documentation revealed the resident had a dementia/Alzheimer's diagnosis and had wandered while in the hospital.Review of the elopement assessment dated [DATE] revealed Resident #49 was not a risk of elopement.Review of the care plan dated 07/16/25 revealed Resident #49 was at risk for elopement with interventions to reside on the locked/secured unit.Review of the progress note from the facility nurse practitioner dated 09/04/25 revealed Resident #49 had a diagnosis of dementia and was on the antidepressant medication citalopram 20 milligrams (mg) daily. It was noted the resident requested to see her personal primary care doctor outside of the community. The nurse practitioner note revealed it was not facility policy to see a provider outside the community and a care conference will be held to discuss further steps.Review of the progress note from the facility physician dated 09/23/25 revealed Resident #49 had routine follow ups and was followed by psychiatry for her psychiatric conditions. The resident was diagnosed with dementia with behavioral disturbances and was on medication (citalopram) with a plan to continue the medication and follow up with psychiatry for ongoing management. After surveyor intervention, the note was amended on 12/18/25 and documented Resident #49 was not referred to psychiatry as it was entered in the note by artificial intelligence (AI) by error. Resident #49 was to continue to be managed by the nurse practitioner for ongoing medical conditions.Review of the elopement assessment dated [DATE] revealed Resident #49 was not a risk of elopement.Review of Resident #49's care conference documentation dated 10/20/25 revealed no mention or discussion on using a different physician and no mention of psychiatric services.Review of the progress note dated 10/20/25 revealed Resident #49 scored a zero and had no history of elopements or wandering.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition.Review of the progress note dated 12/01/25 revealed a nurse practitioner was in to see Resident #49 and placed a new order for psychiatric services at the resident's request.Review of Resident #49's physician order dated 12/01/25 revealed an order for a psychiatric (psych) consultation (consult) for therapy and dementia management.Review of the psychiatric consents dated 12/04/25 revealed Resident #49 signed consent to receive psych services.Review of the progress note dated 12/08/25 from the nurse practitioner reported the resident had enough capacity to make this decision in reference to changing her code status.Review of Resident #49's medical record found no evidence of any assessment prior to being placed on the secured memory care unit.Interview on 12/15/25 at 10:51 A.M. with Resident #49 revealed she was placed in the memory care unit improperly and stated she got confused when she had a UTI and went to the hospital. She revealed she was diagnosed with Alzheimer's disease and stated it was not an accurate diagnosis. Resident #49 stated her sister had Alzheimer's disease and her son thought her UTI confusion was the onset of dementia and Alzheimer's disease. She confirmed she felt like a trapped prisoner and reported she was not aware of any assessment that led to her being placed on the locked unit, and reported she had been asking to see her regular primary care doctor and even get an evaluation from psychiatry for Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 2 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete several months with no success in hopes of proving it was just a big misunderstanding and she could go back home.Interviews on 12/18/25 from 10:44 A.M. to 2:00 P.M. with Regional Nurse #200 confirmed the facility did not have information from prior to the hospital on Resident #49's baseline diagnosis and also confirmed the facility did not complete any assessment for her appropriateness before being placed on the locked/secured memory care unit. Regional Nurse #200 revealed the facility had two elopement assessments indicating Resident #49 had no history or risk of elopement. Regional Nurse #200 reported residents have the right to request another physician and the facility should assist in facilitating communication to see if the outside physician was willing to accept the resident as a patient. Regional Nurse #200 stated she reviewed the documentation with the facility and medical team and determined the mention of psychiatric services was a type-o, although she acknowledged facility staff should be reviewing physician notes for any changes in the resident's needs without surveyor intervention. She revealed the medical team was agreeable to the resident seeing psych services.Review of facility policy titled, Restraint policy, dated 11/02/16, revealed residents had the right to be free from restraints. The resident shall have the ability of freedom of movement with the context of their functional capacity as assessed by the facility. Event ID: Facility ID: 365318 If continuation sheet Page 3 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to monitor behaviors with psychotropic medication use. This affected two (#2 and #56) of five residents reviewed for psychotropic medications. The facility census was 46.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers.Review of the care plan dated 03/04/25 revealed Resident #2 was at risk for complications related to psychotropic medication use related to a diagnosis of depression. Interventions included educate on risks, benefits, and side effects of Zoloft, give medications as ordered, and monitor, document, and report to physician signs and symptoms of depression unaltered by medications.Review of the medical record for Resident #2 revealed there was no documentation for behavior monitoring.Interview on 12/17/25 at 2:07 P.M. with Regional Director of Clinical Services (RDCS) #200 verified behaviors for psychotropic use should be monitored for use of the medication. RDCS #200 also verified there was no documentation for monitoring behaviors for Resident #2.2. Review of the medical record for Resident #56 revealed an admission date of 12/08/25. Diagnoses included periprosthetic fracture around an internal prosthetic right knee joint, fracture of the tibia, and major depressive disorder.Review of the admission MDS assessment dated [DATE] revealed Resident #56 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require setup with eating, and partial assistance with toileting, bathing, dressing, and transfers.Review of the care plan dated 12/10/25 revealed Resident #56 was at risk for advance effects/complications due to psychotropic medication use. Interventions included to monitor behaviors and record every shift, monitor for side effects of medication use, notify physician of any adverse side effects, and use of non-pharmacological interventions and document effectiveness.Review of the physician order dated 12/10/25 revealed Resident #56 was ordered the antianxiety medication clonazepam one (1) milligram (mg) to give one tablet by mouth three times a day for anxiety.Review of the medical record for Resident #56 revealed behavior monitoring was not completed on the mornings of 12/10/25, 12/12/25, 12/13/25, and 12/14/25.Interview on 12/18/25 at 10:48 A.M. with RDCS #200 verified no behaviors were monitored or documented on the above dates for Resident #56.Review of the facility policy titled, Psychotropic Drugs, dated 2017, revealed a psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. As needed or pro re nata (PRN) psychotropic drugs should only be used when the resident had a specific condition for which psychotropic drugs were indicated and one of the following existed including used to manage unexpected harmful behavior that cannot be managed without psychotropic drugs. Event ID: Facility ID: 365318 If continuation sheet Page 4 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure care conferences were completed in a timely manner. This affected two (#2 and #35) of four residents reviewed for care conferences. The facility census was 46. 1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers. Review of the care conferences for the last 12 months for Resident #2 revealed care conferences were only completed on 04/21/25 and 09/19/25. Interview on 12/17/25 at 10:16 A.M. with Social Service Director (SSD) #156 verified care conferences were to be completed quarterly, and Resident #2 only had two care conferences for the last 12 months. 2. Review of the medical record for Resident #35 revealed an admission date of 08/19/21. Diagnoses included chronic respiratory failure with hypoxia, diabetes, depression, dependence on ventilator status. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 indicating Resident #35 had intact cognition. Review of Resident #35's interdisciplinary meeting notes revealed a care conference was held on 04/10/25 and included several members of the interdisciplinary team. Review of the interdisciplinary meeting notes revealed a care conference was held on 09/30/25 and documented only Resident #35 was in attendance. Interview on 02/15/25 at 10:19 A.M. with Resident #35 revealed she was not invited to regular care conferences. Interview on 12/17/25 at 10:30 A.M. with SSD #156 confirmed Resident #35 only had evidence of two care conferences in the last year. She also acknowledged the care conference dated 09/30/25 appeared to have been staff just completing the form and not having an actual care conference as they resident was the only one who attended. SSD #156 also confirmed the two conferences were done over five and a half months apart. Review of facility policy titled, Care Plan Policy, dated 05/2025, revealed the resident shall have the opportunity to discuss their goals of care and have involvement from an interdisciplinary team including Physician, Registered Nurse, State Tested Nursing Aide a member of the food services team and other appropriate staff involved in the residents care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 5 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 medical record review, resident representative interview, and staff interview, the facility failed to provide showers to residents who were dependent on staff for assistance. This affected one (#8) of four residents reviewed for activities of daily living. The facility census was 46.Findings included:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, atrial fibrillation, acute respiratory failure with hypoxia, chronic kidney disease (stage II), candidiasis, acute embolism and thrombosis of a deep vein of a lower extremity, hypo-osmolality and hyponatremia, congestive heart failure, atrial fibrillation, hypertension, and traumatic brain injury. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 11/06/25, revealed he had mild cognitive impairment. Review of section GG revealed the resident was assessed to needed substantial/maximum physical assistance from staff for showers/bathing.Review of Resident #8's current care plan revealed he had an activities of daily living (ADL) self-care performance deficit. His interventions included requiring one to two staff participation with bathing. Also, there was no care plan and/or interventions related to Resident #8 refusing showers and a plan to implement if he did refuse showers.Review of Resident #8 shower logs/documentation, dated September to November 2025, revealed three missing showers in September 2025, seven missing showers in October 2025, and eight missing showers, with four refusals, in November 2025.Interview with Resident #8's representative on 12/15/25 at 1:34 P.M. revealed concerns related to the amount of baths/showers the facility offered Resident #8. Resident #8's representative did not feel Resident #8 was offered a bath/shower as often as he should have them. Interview with Regional Director (RD) #200 on 12/17/25 at 2:30 P.M. and on 12/18/25 at 8:40 A.M. confirmed the facility did not have a care plan for Resident #8 and refusing showers and they have not had to address his refusals. RD #200 confirmed there was confusion in Resident #8 shower schedule as to which days he was supposed to get showers. His shower log records in the electronic medical record had bathing scheduled for Mondays, Wednesdays, and Fridays until sometime in November 2025 (RD #200 could not confirmed what specific date the resident's schedule switched), but the schedule the nurse aides look at to give residents showers, had Resident #8 listed as getting showers on Tuesdays and Fridays. RN #200 stated there were multiple days in which a shower was not offered on a Monday, Wednesday, or Friday, because of the confusion as to when the resident's showers should be. Therefore, the resident was not offered showers as scheduled, because there was no clear schedule when he should be offered them. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 6 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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, staff interview, medical record review, and policy review, the facility failed to ensure timely implementation of a therapy recommended splint and failed to ensure orders were followed regarding contractures. This affected one (#9) of one residents reviewed for range of motion. The facility census was 46.Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/28/21. Diagnoses included quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, dependence on ventilator status, anoxic brain injury, epilepsy, and heart disease.Review of the plan of care dated 02/28/24 revealed Resident #9 had an alteration in musculoskeletal status related to extremity contractures with interventions to anticipate needs, use supportive devices, hand roll or equivalent in the right palm as ordered, and treatment per orders to fingers, elbows, and wrists. The care plan dated 10/16/24 revealed the resident was unable to make her needs known due to brain injury. Resident #9 did not speak and needs shall be anticipated by staff.Review of Resident #9's physician orders dated 07/15/25 revealed an order for fingers on bilateral hands to be washed and thoroughly dried between all fingers, cover each finger webspace with remedy antifungal powder, and weave interdry between fingers daily and as needed. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00 indicating impaired cognition stating resident was unable to respond.Review of Resident #9's occupational therapy assessment dated [DATE] revealed proper hand function was limited by need for a right hand finger/digit splint. Resident #9 demonstrated need for a right hand splint to promote hand alignment during functional tasks. The assessment revealed the resident's range of motion was impacting caregiver performance with hygiene and per staff report, the resident typically did not move limbs independently. The occupational therapist recommended a palm protector type splint for positioning and finger separator to promote open palm and finger separation for hand hygiene.Observation on 12/15/25 at 10:02 A.M. of Resident #9 revealed she had bilateral contractures of her hands/wrists. Resident #9 had what appeared to be a thin fabric in her right hand and no materials in the left hand.Interview and observation on 12/16/25 at 1:50 P.M. with Licensed Practical Nurse (LPN) #133 confirmed typically Resident #9 had a towel in her left hand, but it fell out easily and no intervention was present for the left hand. LPN #133 also confirmed Resident #9 had interdry between her fingers on the right hand, verified this was the only item in place, and the interdry fabric was a moisture wicking towelette that was to be changed twice daily. LPN #133 confirmed Resident #9 did not have a splint in place and she had never seen one used for Resident #9.Interview on 12/16/25 at 2:25 P.M. with Certified Occupational Therapy Assistant (COTA) #210 confirmed she assessed Resident #9 on 12/11/25 and recommended a hand roll/splint with finger separators. COTA explained it was similar to a pedicure toe separator along with a palm protectant. She revealed Resident #9 was able to open her hand enough to get a rolled towel in it, but staff were concerned about hygiene and rough material of the towel. COTA #210 revealed she spoke with a supervisor who was to speak with facility management about getting a splint ordered.Interview on 12/16/25 at 2:50 P.M. with Infection Control Registered Nurse (ICRN) #144 revealed the therapy staff sent electronic mail (email) regarding the recommendation of a splint for Resident #9 and stated they were still awaiting approval from the Administrator prior to ordering. IC RN #144 confirmed the therapy team sent two to three options on 12/11/25 that could be ordered from an online retailer. ICRN #144 confirmed the facility had orders for bilateral hand rolls that were not in place and interdry fabric between bilateral fingers which was only in place on the right hand.Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 7 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 on 12/16/25 at 3:00 P.M. with Therapy Manager #215 revealed she spoke with facility management on 12/11/25 and were just waiting on approval from facility and for the device to be ordered for Resident #9.Review of facility policy titled, Range of Motion Policy, dated 04/29/16, revealed a resident with limited range of motion shall receive appropriate treatment and services to increase range of motion and/or prevent further decrease in range in motion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 8 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to check for placement of a gastronomy tube prior to administering medications through the tube. This affected one (#36) of six residents reviewed for medication administration. The facility census was 46.Findings include:Review of the medical record for Resident #36 revealed an admission date of 03/27/25. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. The resident was assessed to require substantial assistance with toileting, bathing, dressing, and transfers.Observation on 12/16/25 at 7:58 A.M. revealed Licensed Practical Nurse (LPN) #163 did not check verify placement or check for residual tube feeding prior to administering medications through Resident #36's gastrostomy tube (g-tube).Interview on 12/16/25 at 8:05 A.M. with LPN #163 verified she did not check for placement and residual prior to administering medications because there was not an order.Interview on 12/18/25 at 10:43 A.M. with Regional Director of Clinical Services #200 verified nurses should check for gastric residual prior to administering medications through a g-tube.Review of the facility policy titled, Medication Administration - General Guidelines, dated 10/17/07, revealed medications were administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. If the resident was tube-fed, medications were crushed finely to prevent clogging the tube. Event ID: Facility ID: 365318 If continuation sheet Page 9 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were ingested during medication administration prior to leaving the resident's room. This affected one (#14) of six residents reviewed for medication administration. The facility census was 46.Findings include:Review of the medical record for Resident #14 revealed an admission date of 05/02/24. Diagnoses included type II diabetes mellitus, chronic kidney disease, and myocardial infarction.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require setup with eating, supervision with toileting and bathing, and substantial assistance with dressing and transfers.Observation on 12/16/25 at 8:26 A.M. revealed Licensed Practical Nurse (LPN) #133 administered medications to Resident #14 and left the room before Resident #14 took her medications.Interview on 12/16/25 at 8:29 A.M. with LPN #133 verified she thought Resident #14 took her medications prior to leaving the room but confirmed she did not see the resident ingest the medications.Review of the facility policy titled, Medication Administration - General Guidelines, dated 10/17/07, revealed the resident was always observed after administration to ensure the dose was completely ingested. Event ID: Facility ID: 365318 If continuation sheet Page 10 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview, and policy review, the facility failed to ensure timely follow-up on pharmacy recommendations during monthly medication reviews. This affected one (#24) of five residents reviewed for unnecessary medications. The facility census was 46.Findings include:Review of Resident #24's medical record revealed an admission dated of 04/24/17. Diagnoses included heart failure, unspecified dementia with other behavioral disturbances, type II diabetes, atrial fibrillation (A-fib), major depressive disorder, anxiety disorder, unspecified psychosis disorder, hypertension, insomnia, and history of transient ischemic attack (TIA).Review of a note to the attending physician/prescriber dated 01/16/25 revealed Resident #24 was continued on the anticoagulant medication rivaroxaban (Xarelto) 15 milligrams (mg) by mouth once daily with supper upon her readmission. Further review revealed the anticoagulant Eliquis five (5) mg by mouth twice daily would be the new recommended dose if feasible. Review of the physician/prescriber response signed and dated on 01/16/25 revealed to begin Eliquis 2.5 mg by mouth twice daily due to falls.Review of Resident #24's medication administration record (MAR) from 01/01/25 to 01/31/25 revealed an order for rivaroxaban 15 mg daily with a start date of 01/14/25 and a discontinued date of 02/04/25.Review of Resident's #24 MAR from 02/01/25 to 02/28/25 revealed an order for rivaroxaban 15 mg daily with a start date of 02/04/25 and a discontinued date of 02/27/25. The review also revealed an order for Eliquis 2.5 mg with a start date of 02/27/25.Interview with Director of Nursing (DON) #157 on 12/18/25 at 1:04 P.M. confirmed the medication recommendation to start Eliquis 2.5 mg by mouth twice daily was acknowledged and signed on 01/16/25. DON #157 stated according to the facility pharmacy policy, the facility usually has 30 days to enact the change from a pharmacy recommendation. DON #157 stated Resident #24 returned to the facility from a hospital visit dated 02/02/25 to 02/04/25 with orders from the hospital to continue rivaroxaban 15 mg. Review of the consultant pharmacist's medication regimen review dated 03/19/25 revealed a recommendation to remove the pain level attached to the aspirin order and change the diagnosis to A-fib and history of TIA. Review of the pharmacist's medication regimen review follow up section revealed the word done and a set of initials.Review of Resident #24's medical record revealed a current order for aspirin 81 mg with a start date of 02/04/25. The review of Resident #24's medical record revealed the diagnosis for aspirin 81 mg order was listed as displace fracture of olecranon process without intraarticular extension of the right ulna, subsequent encounter for closed fracture with routine healing. Interview with DON #157 on 12/18/25 at 1:04 P.M. confirmed the current aspirin 81 mg order from 02/04/25 did not have the recommended diagnosis of A-fib and history of TIA. DON #157 was not sure why the diagnosis for the medication was not changed.Review of the policy titled, Medication Regimen Review and Recommendation, dated 10/08/25, revealed non-emergency recommendations should be addressed by the end of the following month. Event ID: Facility ID: 365318 If continuation sheet Page 11 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, medical record review, staff interview, review of food preparation menu and instructions, and policy review, the facility failed to prepare pureed food to a form that was safe and appropriate. This affected three (#20, #29, and #30) of three residents who had puree diet ordered. The facility census was 46.Findings include:Observation on 12/17/25 from 10:30 A.M. to 10:45 A.M. revealed [NAME] #150 placed cooked chicken, broccoli, and rice casserole into the blending canister to be pureed. She blended it, then used the spatula in which she scooped the unpureed casserole into the canister into a clean pan for the pureed food. While pouring the pureed casserole into the clean pan, two full pieces of rice were noticed by the surveyor in the puree. [NAME] #150 stated she was happy with how the food form looked, but then was told about the two full pieces of rice. She scooped them out at that time. Then, she began to puree a second batch of casserole. After pureeing the casserole and placing that batch into the existing pan of pureed casserole, the surveyor requested a taste test. There were small grains of rice still in the puree. Review of facility chicken, broccoli, and rice casserole menu and puree instructions revealed the puree instructions were described as blend the food until smooth using small amounts of chicken broth to result in smooth product.Interview with [NAME] #150 on 12/17/25 at 10:40 A.M. confirmed after pureeing the second batch of casserole and placing it in the pan, she confirmed it was to the form that was acceptable to her and she would serve it. When asked about the grainy pieces in the pureed form, she stated it was very difficult to puree rice fully. She confirmed a pureed texture should be smooth and able to hold its form.Interview with [NAME] #149 on 12/17/25 at 10:40 A.M. confirmed she tried the pureed casserole from the pan and agreed with the surveyor that it needed to be blended further to be more smooth. Observation on 12/17/25 at 10:42 A.M. confirmed [NAME] #150 placed the pureed casserole back into the blender and blended it to an acceptable texture.Review of Resident #20, Resident #29, and Resident #30's medical records confirmed all three had dietary orders for pureed texture diets, which included the chicken, broccoli, and rice casserole.Review of facility regular pureed diet policy, dated 04/29/25, revealed the regular pureed diet was designed for the resident who has some difficulty in swallowing or chewing, or who has poor coordination of tongue and lips. The texture of the food is smooth, thick, and moist, holds shape, required little or no chewing, and is easy to swallow. Event ID: Facility ID: 365318 If continuation sheet Page 12 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against potential contamination and spoilage. This had the potential to affect all 43 residents in the facility that receive food from the kitchen. The facility identified three (#9, #36, and #55) residents with active orders for nothing by mouth. The facility census was 46. Findings include:Observation on 12/15/25 at 8:57 A.M. revealed four opened containers of food items with no date marking in the walk-in refrigerator including one bag of yellow cheese slices, one bag of white cheese, one bag of pepperoni slices, and one package of bacon. Observation on 12/15/25 at 8:59 A.M. revealed two opened and undated bags of egg patties, one of the bags of egg patties was stored with the bag open allowing exposure to air in the freezer. Further observation of the walk-in freezer at this time revealed three bags of opened and undated vegetables, including zucchini, corn, and sweet potato fries. Interview on 12/15/25 at 9:10 A.M. with [NAME] #150 revealed opened containers of perishable food items should be date marked. Further interview at this time with [NAME] #150 confirmed there were several undated food items in both the walk-in refrigerator and the walk-in freezer. Review of facility policy titled, Storage of Perishable Foods, reviewed 03/2025, revealed all perishable goods are to be refrigerated at the appropriate temperature and in an orderly and sanitary manner. Further review of the policy revealed prepared or leftover foods should be stored tightly covered, clearly labeled, dated, and used within three days or discarded. Additional review of the policy revealed foods such as cheese and other dairy products may be served until the use by date on the package, or the use by date when the date is on the box should be transferred to a label on the package. Event ID: Facility ID: 365318 If continuation sheet Page 13 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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, review of a facility Legionella plan and testing and monitoring documents, medical record review, and staff interview, the facility failed to ensure measures to address and prevent Legionella growth within the facility were maintained and conducted as required and failed to ensure infection control measures were maintained following urinary catheter care for a resident (#6). This had the potential to affect all 46 residents residing in the facility. The census was 46. Findings include: 1. Review of the document titled, Legionella Policy - Environmental, revealed Legionella prevention control measures of quarterly testing of chlorine levels, weekly testing of water temperatures, monitor and flushing pipes in rooms and areas that were not in use, monitor kitchen ice machines, eye wash stations, water filters, sinks and showers in resident rooms and central showers, circulation tubs and drinking fountains, water filters to be changed bi-annually, and kitchen appliances to be maintained and cleaned per manufacturer guidelines. Further review revealed the plan did not specify what monitor meant and how the areas would be checked or evaluated. Residents Affected - Many Review of facility maintenance logs revealed the facility had no evidence of water filters being changed bi-annually. The documentation mentioned a filter change 04/2025. Review of temperature logs revealed the facility was testing room temperatures weekly with a goal temperature to be between 110 to 117 degrees Fahrenheit (F). The plan did not specify how to respond when temperatures measured outside that range. The logs revealed in January 2025, three temperatures were low and 15 were high. In February 2025, five temperatures were low and 27 were high. In March 2025, one temperature was low and 36 were high. In April 2025, two temperatures were low and 40 were high. In May 2025, one temperature was low and 52 were high. In June 2025, three temperatures were low and 51 were high. In July 2025, one temperature was low and 42 were high. In August 2025, five temperatures were low and 41 were high. In September 2025, 42 temperature were high. In October 2025, 35 temperatures were high. In November 2025, 32 temperatures were high. Review of flushing logs revealed no evidence of flushing vacant or infrequently used rooms from 01/01/25 to 06/30/25 and the last week in November 2025. The facility provided no evidence related to eye wash stations, sink and showers in resident rooms and central showers, circulation tubs, and drinking fountains and if these areas were monitored for potential Legionella concerns. Interview on 12/17/25 from 3:30 P.M. to 4:50 P.M. with Project Manager (PM) #250 confirmed the facility did not have documentation of what facility meant by monitor. He also confirmed the facility had no additional documentation related to missing dates of flushing plumbing, missing dates of changing water filters, and confirmed facility had no documentation related to eye wash stations, sink and showers in resident rooms and central showers, circulation tubs and drinking fountains. PM #250 confirmed the facility monitored but was unable to explain what that meant and revealed the facility did not use plumbing for eye wash stations and did not think they had drinking fountains. He also confirmed the Legionella plan/policy referred to an appendix B which then referred to logs which included the parameters and confirmed the plan did not include details on control measures, acceptable ranges and steps to take if outside the acceptable parameters. 2. Review of the medical record for Resident #6 revealed an admission date of 08/21/25. Diagnoses included fracture of the right acetabulum, anxiety disorder, and history of malignant neoplasm of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 14 of 15 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 365318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160 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 prostate. Level of Harm - Minimal harm or potential for actual harm Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. The resident was assessed to require setup with eating, was dependent with toileting, and required substantial assistance with bathing, dressing, and transfers. Resident #6 was assessed with an indwelling catheter. Residents Affected - Many Review of the care plan dated 10/13/25 revealed Resident #6 had a urinary (Foley) catheter related to urinary retention and obstructive uropathy. Interventions included catheter care every shift, change the catheter bag as needed, notify the physician with changes in bowel or bladder habits, provide incontinence care with each incontinent episode and as needed, and provide moisture barrier cream after each incontinent episode and as needed. Review of the physician order dated 08/21/25 revealed Resident #6 was ordered indwelling catheter care every shift. Observation on 12/17/25 at 3:46 P.M. revealed urinary catheter care was completed on Resident #6 by Certified Nurse Aide (CNA) #176. CNA #176 did not remove gloves after providing catheter care and then proceeded to touch Resident #6's bedside table and bed controls. Interview on 12/17/25 at 3:54 P.M. with CNA #176 verified she did not change her gloves after providing Resident #6's urinary catheter care and then touched the bedside table and bed controller with soiled gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 15 of 15