Inspection·March 20, 2024

F 0550 morbid obesity, and depression. Level of Harm - Minimal harm or potential for actual harm Review of Resident #32's physician's orders revealed an order dated 01/12/24 for lantus (long-acting insulin) 70 units subcutaneous daily in the morning and an order dated 01/06/24 for insulin aspart (short-acting insulin) 20 units subcutaneously daily in the morning. Residents Affected - Few Observation on 03/11/24 at 10:43 A.M., revealed Resident #32 seated in his manual wheelchair approximately two feet outside of the entrance to his doorway facing the hallway. He was seated directly next to Registered Nurse (RN) #257's medication cart. RN #257 was present at the medication cart and was preparing Resident #32's ordered insulin. RN #257 obtained a syringe and withdrew 70 units of lantus (a long-acting insulin). RN #257 then obtained a second syringe and withdrew 20 units of insulin aspart (a short-acting insulin). RN #257 performed his checks against the Medication Administration Record and applied gloves. RN #257 then approached Resident #32, informed him that he had his ordered insulin to administer and lifted up Resident #32's shirt, cleansed two separate areas to Resident #32's abdomen, and administered Resident #32's two injections. RN #257 did not ask the resident's permission to administer the subcutaneous injections in the hallway, nor did he make any attempt to return the resident back into his room to provide privacy during the administration. Interview with RN #257 on 03/11/24 at 10:53 A.M., verified he administered Resident #32's insulin in a common area and did not ask permission, nor attempt to provide privacy, during the administration of his insulin. Review of the policy titled, Medication Administration General Guidelines, revised September 2018, revealed the facility should provide for privacy as appropriate. Review of the policy titled, Resident Rights, revised 09/15/23, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. When providing care and services, the stakeholders (staff) will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination. The policy additionally indicated residents have the right to privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 2 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident's choice for showers was honored. This affected one (#22) of two residents reviewed for choices. The facility census was 54. Findings include: Review of the medical record revealed Resident #22 had an admission date of 02/14/24. Diagnoses included osteomyelitis, type two diabetes mellitus, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required partial/moderate assistance with bathing and showers. Review of the shower schedule revealed Resident #22 was scheduled for showers on second shift on Wednesdays and Sundays. Review of the care plan for activities of daily living revealed the resident requested showers on Wednesdays and Sundays. Review of shower documentation revealed the resident had not received a shower on 03/10/24 (Sunday) or 03/13/24 (Wednesday). Interview on 03/11/24 at 8:30 A.M., with Resident #22 revealed he had not received a shower as requested on 03/09/24 (Saturday) or 03/10/24 (Sunday). Resident #22 was visibly upset and yelling. Interview on 03/18/24 at 11:39 A.M., with the Assistant Director of Nursing (ADON) #280 verified there was no documentation the resident had received a shower of 03/10/24 and 03/13/24. ADON #280 revealed the resident had received a partial bed bath on 03/12/24 and a shower on 03/15/24. Interview on 03/18/24 at 3:58 P.M., with Registered Nurse (RN) #221 revealed the facility had no policy regarding resident choices or resident showers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 3 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, staff interview, family interview, record review, and review of facility incident reports, the facility failed to ensure a resident's responsible party was notified of a fall and subsequent transfer to the emergency department. This affected one (#46) of two residents reviewed for notification of change in condition. The facility census was 54. Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's Minimum Data Set (MDS) 5-day assessment, dated 02/26/24, revealed the resident had a Brief Interview for Mental Status score of 08, indicating moderately impaired cognition. The resident had no recorded hallucinations or delusions, and was noted to have wandered during one to three days during the 7-day look-back period. The resident required substantial/maximum assistance with activities of daily living (ADLs) and required partial/moderate assistance with transfers and mobility. Review of Resident #46's fall risk assessment, dated 02/26/24, revealed a score of 26 which indicated the resident was at high risk for falls. Review of Resident #46's interdisciplinary progress notes revealed a note dated 03/09/24 at 8:40 A.M., which stated the resident returned from the local emergency room. The note explained a bandage was intact to Resident #46's left forehead, and he had skin tears present to his right knee and left forearm. The note immediately prior to this progress note was dated 03/07/24. There was no mention of what incident or event led to Resident #46's emergency department visit on 03/09/24, or any recorded nursing action taken, in Resident #46's medical record. There was no notation that Resident #46 had sustained a fall. Review of an incident report dated 03/09/24, completed by Agency Licensed Practical Nurse (LPN) #308 revealed Resident #46 experienced a fall in the hallway of the memory care unit on 03/09/24 at 3:58 A.M. The report indicated Resident #46 hit his head on the wall, had his first neurological assessment and then was sent out of the facility to the emergency room. The report listed a name for family member whom was notified but the name did not match any listed contacts in Resident #46's medical record. Observation on 03/10/24 at 8:10 A.M., revealed Resident #46 seated in a recliner in the dining room common area. He had a bandage in place to his left forehead and purple and blue bruising around his left eye. The resident was alert only to self and unable to recall what had happened. Interview on 03/10/24 at 2:46 P.M., with a family member of Resident #46 revealed they were the first listed contact in Resident #46's record, and received no notification of Resident #46's recent fall or subsequent emergency department visit, nor were there any missed calls or voicemail messages. Interview on 03/12/24 at 8:10 A.M., with LPN #210 revealed she worked day shift, 7 A.M. to 7 P.M. on 03/09/24 and she was the nurse when Resident #46 returned from the emergency department. LPN #210 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 4 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verified Resident #46's family member visits daily, and had not been notified of Resident #46's fall or emergency department transfer earlier in the day. LPN #210 stated the family member's first indication that the resident had fallen was arriving to the unit and seeing the hospital wrist band on Resident #46, and then the bandage to Resident #46's left forehead. LPN #210 verified she had been told by the family member they had not gotten a call, and neither had the other listed contact in Resident #46's medical record. LPN #210 stated Resident #46 had been at the facility for approximately 3 months and had phoned the resident's family member before, and knew there were accurate contact information for the listed emergency contacts. Interview on 03/13/24 at 4:33 P.M., with Assistant Director of Nursing (ADON) #280 verified there was no progress note or documentation in Resident #46's electronic medical record related to the 03/09/24 fall. ADON #280 stated she was not aware the resident's listed contacts were not notified. ADON #280 stated she had no idea there was notification or that the event was not recorded in the medical record. Review of the policy titled Notification of Change in Condition, dated 09/15/23, revealed the facility must notify the resident representative(s) when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly, and/or a decision to transfer or discharge a resident from the facility. Documentation of notification or notification attempts should be recorded in the resident's electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 5 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was accurately completed. This affected one (#8) of one resident reviewed for PASRR. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a PASRR results dated 08/02/24 revealed the resident required a referral for a level two evaluation. Further review of the medical record revealed the facility never updated the resident's PASRR with accurate psychiatric diagnoses. Interview on 03/13/24 at 2:24 P.M., Social Worker (SW) #348 verified the resident had a diagnosis of mental health disorders when she transferred to the facility and this was not marked on the PASRR and Section E indication of serious mental illness was not correct and a new PASRR should have been completed upon admission. Review of the policy Pre-admission Screening and Resident Review (PASRR), last revised 09/15/23, revealed prior to or on admission, Social Services was required to verify that PASRR had been completed by the applicable qualifying individual as required per state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 6 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 review of the medical record, staff interview, and policy review, the facility failed to ensure a resident was included in quarterly care planning and invited to a quarterly care plan conference. This affected one (#41) of one resident reviewed for care planning. The facility census was 54. Findings include: Review of the medical record revealed Resident #41 had an admission date of 10/10/23. Diagnoses included chronic systolic heart failure, type two diabetes mellitus, hypertension, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the progress notes revealed the resident's last care plan conference was on 10/25/23. Interview on 03/10/24 at 11:16 A.M., with Resident #41 revealed he had not been invited to care conference meeting recently. Interview on 03/12/24 at 11:10 A.M., with the Business Office Manager (BOM) #200 revealed the resident's last care conference was on 10/25/23. Interview on 03/12/24 at 1:15 P.M., with Social Worker (SW) #348 verified the resident's last quarterly care conference was 10/25/23 and the resident was overdue for a care conference. Review of the policy titled., Full Life Conference, last revised 08/22/23, revealed no guidelines for the timing of quarterly care conferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 7 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of activities calendars, review of resident council minutes, review of activities director job description, review of policy, family member interview, and staff interviews, the facility failed to ensure a variety of ongoing resident centered activities were offered over various times throughout the day and staff were available to implement the scheduled activities. The deficient practice had the potential to affect all 54 residents in the facility. The facility census was 54. Residents Affected - Many Findings include: Review of the February 2024 Activity Calendar revealed four to five events were scheduled for each weekday of the month other than two Valentines day parties on 02/14/24. Review of the February Activity Staffing schedule revealed two activity time slots for each weekday. Activity staff were missing for the 2:00 P.M., afternoon activity on 02/14/24, 02/20/24, 02/21/24, 02/28/24, and 02/29/24. The days of 02/19/24, 02/26/24, and 02/27/24 did not show staff coverage for any activity on each day. Review of the Elder Council Meeting Minutes dated 02/23/24 revealed the facility is in the process of hiring a new Activity Director and Activity Assistant since the prior staff have or are leaving. Review of the March 2024 activity calendar revealed activities were not offered after 3:00 P.M., for the entire month. Review of the March 2024 activity calendar posted in the memory care unit bulletin board indicated scheduled activities from 10:30 A.M. to 3:00 P.M., near daily. The activity calendar in the memory care unit matched the general activity calendar for non-memory care residents. Interview on 03/10/24 at 11:25 A.M., with Resident#16's family member revealed they did not believe Resident #16 was involved in any activities and the resident cannot tell him if she was. Observation on 03/11/24 at 2:23 P.M., revealed eight residents in dining room on the memory care unit. Activity Director #201 was observed seated at the table on laptop. The television had a black and white movie on, and the volume was very low. Residents were observed asleep in wheelchairs, a few miscellaneous coloring sheets with one- or two-colored pencils were on the table, not in use. Live music was heard outside the unit, no activity ongoing in the unit. Interview on 03/12/24 at 9:03 A.M., with Activity Director #201 and Activity Director #218 revealed Activity Director #201 has been working in her position for two weeks and Activity Director #218 is training her. Activity Director #218 is the Activity Director from another facility. Activity Director #218 revealed she made the March Activity calendar, and she didn't put on any evening activities because the previous activities person left. Activity Director #201 also revealed the facility does not offer evening or weekend activities as of now and her goal is to start offering them in May. Observation on 03/12/24 at 9:38 A.M. revealed Resident #46 was seated in a wheelchair in the dining area in the memory care unit. No ongoing activities were present. An old black and white movie was on the television with the sound very low. The nurse was observed in the dining room administering medications. Ten residents were observed in the dining room. No additional engagement was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 8 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0679 from staff to residents related to activities. Level of Harm - Minimal harm or potential for actual harm Interview on 03/12/24 at 9:38 A.M., with Activity Director #218 revealed she recommends doing late activities at least once a week. She said she was training Activity Director #201 on adding more evening activity ideas. Residents Affected - Many Interview on 03/12/24 at 10:28 A.M., with Activity Director #218 revealed the facility calendar needs worked on. She said once they get themselves in a good place, they need to do more. She said the parent company's expectations are two activity outings a month and one evening activity a week. When asked where these expectations are written down, Activity Director #218 stated I know them in my head. Interview on 03/13/24 at 1:28 P.M., with State Tested Nurse Assistant (STNA) #275 revealed an activity staff member was back here approximately 15 minutes ago and did flashcards with a few of the ladies. Interview on 03/13/24 at 1:32 P.M., with Licensed Practical Nurse (LPN) #203 verified the activity calendar posted on the memory care unit bulletin board indicated scheduled activities from 10:30 A.M. to 3:00 P.M., near daily. The activity calendar in the memory care unit matched the general activity calendar for non-memory care residents. LPN #203 stated an activity staff member came back here a bit ago and did flashcards with one of the residents. Interview on 03/13/24 at 3:27 P.M., with the Administrator revealed Activity Director #355 left on 02/04/24 and Activity Director #201 started on 02/27/24. The Administrator revealed Activity Director #218 came in and did activities multiple times a week. When Activity Director #218 wasn't here, the staff did the activities. Interview on 03/13/24 at 3:35 P.M., with the Administrator revealed Activity Director #201 quit yesterday on (03/12/24). Interview on 03/13/24 at 4:04 P.M., with the Administrator verified there were no organized structured activities offered in the facility daily after 3 P.M. and there is a lack of individualized activities in the memory care unit. Interview on 03/18/24 at 11:41 A.M., with Minimum Data Set (MDS) Nurse #221 revealed there are no residents currently in the facility that have been care planned for the refusal of activities. Interview on 03/19/24 at 9:52 A.M., with the Administrator, revealed February activities had two different time slots at 11:00 A.M. and 2 P.M., where the Administrator said two activities were done each day with an hour scheduled for each activity. The Administrator also revealed Memory Care activities were performed by aides. However, the activities and who attended were not documented. The Administrator verified the previous activities assistant left on 02/10/24. Review of the policy titled, Activity Program, dated 08/22/23 revealed an on-going activities program is designed to support residents in their choice of activities and to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community. Review of the Activities Director Job description, dated December 2018, stated the job included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 9 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0679 creating an ongoing calendar of activities, which creatively meets multiple needs and is accessible and appealing to both men and women of all ages and abilities. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 10 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 Based on observation, staff interview, family interview, record review, and policy review, the facility failed to ensure treatment was provided to address a resident's bilateral lower extremity edema. This affected one (#15) of 19 residents reviewed for quality of care. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 01/15/24. Medical diagnoses included dementia without behaviors, muscle weakness, hypertension and atrial fibrillation. Review of Resident #15's Minimum Data Set (MDS) 3.0 admission assessment, dated 01/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating severely impaired cognition. The resident was not recorded to have any hallucinations or delusions, behaviors, or rejection of care. Review of Resident #15's care plan, initiated 02/07/24, revealed the resident was on diuretic therapy and had a risk for fluid volume imbalances. The care plan reflected a goal that the resident will be free from symptoms of fluid volume imbalances, with listed approaches including to monitor weight as ordered, monitor for signs and symptoms of fluid volume imbalances such as edema, and administer diuretic medication as ordered. Review of Resident #15's physician's orders revealed an order dated 01/22/24 for the diuretic medication furosemide 40 milligram (mg) one tablet daily as needed for edema (swelling) or for a 3 pound (lb) weight gain in one day. Review of Resident #15's daily weights revealed on 01/21/24 the resident weighed 219.8 lbs. On 01/22/24, the resident weighed 227 lbs, reflecting a 7.2 lb weight gain in one day. On 02/25/24, Resident #15 weighed 216.6 lbs. On 02/26/24 the resident weighed 221 lbs, reflecting a 4.4 lb weight gain in one day. On 02/29/24, the resident weighed 221.4 lbs. On 03/01/24 the resident weighed 224.4 lbs reflecting a 3 lb weight gain in one day. Review of Resident #15's progress notes from 01/22/24 to 03/13/24 revealed references to lower extremity edema on 01/23/24, 01/27/24, 01/30/24, and 02/03/24. Review of the Medication Administration Record (MAR) for January 2024, February 2024, and March 2024 to date revealed no as needed doses of furosemide were administered to Resident #15. Observation on 03/10/24 at 11:10 A.M., revealed a family member of Resident #15 returning a pair of scissors to Licensed Practical Nurse (LPN) #300. The family member thanked the nurse for allowing them to borrow the scissors to cut Resident #15's pant legs and socks due to her lower extremity edema. Interview conducted on 03/10/24 at 2:09 P.M., with family members of Resident #15 revealed Resident #15 has had longstanding edema to her bilateral lower extremities. The family members gestured to Resident #15, whom was lying in bed, and stated they just cut slits in the bottom cuffs of her pant legs and gripper socks so they weren't so tight on her swollen legs and feet. They did not believe Resident #15 was on any diuretic therapy, nor did she routinely wear any compression stockings. Observation on 03/11/24 at 7:30 A.M., of Resident #15 revealed her ambulating out of her room into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 11 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dining area. There resident was dressed in a matching green top and pants with slits observed to the end of the pant legs. The resident was wearing gripper socks and her feet and legs appeared swollen. Observation on 03/12/24 at 11:22 A.M., of Resident #15 seated in her recliner chair in her room. Her legs were not elevated in the recliner and remained swollen bilaterally. Her maroon pants and green gripper socks were observed with slits in them. Observation on 03/13/24 at 9:19 A.M., of Resident #15 with Licensed Practical Nurse (LPN) #203 who verified Resident #15 has bilateral lower extremity edema. LPN #203 stated Resident #15 is a daily weight, and has parameters for as-needed diuretic medication if there is a weight gain of a certain amount of pounds. LPN #203 did not believe edema alone was a qualifier for the as-needed medication. Upon observation, LPN #203 stated she was not aware the edema was that bad to Resident #15's bilateral lower extremities to the point the family had to cut her clothing articles to accommodate the edema. Observation and interview on 03/13/24 at 10:23 A.M., with the Assistant Director of Nursing (ADON) #280 revealed a focused assessment of Resident #15's edema was completed. ADON #280 verified Resident #15 to have pitting edema to her bilateral lower legs and feet. ADON #203 verified even with the slits in her socks and pants, the clothing articles are still leaving indentations in the resident's lower extremities. ADON #203 verified the as-needed medication should be given. The ADON exited the resident's room and approached Resident #15's nurse on duty, LPN #203, and instructed her to contact the provider to request the diuretic medication be changed from as-needed to scheduled. Review of the policy titled, Medication Administration General Guidelines, dated September 2018, revealed medications are administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 12 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure incontinence care was completed timely. This affected one (#8) of one resident reviewed for incontinence care. The facility census was 54. Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was always incontinent of bowel and bladder. Review of an incontinence assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was not on a toileting program. Review of the care plan initiated 08/20/23 revealed the resident had episodes of incontinence and required assistance with toileting needs related to diuretic use, impaired mobility, impaired mood/behavioral episodes and impaired vision without glasses. Interventions included to check resident for incontinent episodes and provide peri-care after each incontinent episode, and report changes in bladder status. Observation on 03/11/24 at 9:13 A.M., of incontinence care with State Tested Nursing Assistant (STNA) #215 revealed the resident's brief was saturated and the bath blanket underneath the resident was also soaked with urine. Interview on 03/11/24 at 9:20 A.M., with STNA #215 verified the resident had not been provided incontinence care since her shift began at 6:00 A.M. Interview on 03/11/24 at 11:45 A.M., Resident #8 stated she had not been checked for incontinence since around 9:15 A.M. this morning. Resident #8 stated prior to 9:15 A.M., her incontinence brief had not been changed since 4:30 A.M. Resident #8 stated she was not always aware when she was incontinent. Interview on 03/11/24 at 12:11 P.M., with STNA #215 verified she had not checked the resident for incontinence since 9:15 A.M. this morning. STNA #215 stated she usually completed one round of incontinence care before lunch and one round of incontinence care after lunch. Observation on 03/11/24 at 1:19 P.M.,with the Assistant Director of Nursing (ADON) and STNA #215 provided incontinence care for Resident #8. Resident #8's incontinence brief was saturated with urine. STNA #215 verified this was the first time the resident had been checked for incontinence since 9:15 A.M. this morning. Interview on 03/11/24 at 1:34 P.M.,with ADON #280 revealed incontinence care should be provided every two hours. ADON #280 stated the resident should let us know when she needs incontinence care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 13 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 Review of the undated policy titled, Activities of Daily Living (ADLs), revealed ADL assistance would be provided on a level appropriate to the resident's level of functioning and learning. For those residents who are unable to perform their own activities of daily living, the facility would provide the needed assistance for completion of cares. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 14 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident's pain was timely treated and physician ordered pain medications were available. This affected one (#24) of three residents reviewed for pain management. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record revealed Resident #24 revealed an admission date of 12/19/18. Diagnoses included type two diabetes mellitus, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, pain in right shoulder, gluteal tendinitis right and left hip, trochanteric bursitis right and left hip, radiculopathy cervical region, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident received as needed pain medications and had frequent pain. Review of the care plan last revised 02/07/24 revealed the resident had chronic pain, muscle spasms in his shoulder, back, neck and hip and was seeing a specialist. The resident had greater trochanteric bursitis of both hips, bilateral gluteal tendinitis and osteoarthritis of the right hip. The resident had occipital neuralgia, spinal stenosis, pseudarthrosis. He had a cervical epidural steroid injection upcoming, he would be seeing the orthopedic surgeon for right hip osteoarthritis and he sees the pain clinic. Interventions included to administer medications as ordered, evaluate effectiveness of pain management interventions, adjust if ineffective or adverse side effects emerge, monitor and record any complaints of pain and notify physician if the resident does not demonstrate or state relief or reductions of pain. Review of a physician order dated 02/28/24 revealed the resident had an order for acetaminophen 325 milligram (mg) tablet, take 650 mg by mouth as needed for pain every four hours. Further review of the physician orders revealed an order for Percocet (oxycodone/acetaminophen) 5/325 mg, one table by mouth three times a day as needed for pain. Review of the medication administration record (MAR) revealed the resident had last received Percocet on 03/05/24. Interview on 03/10/24 at 3:17 P.M., with Resident #24 revealed he had not received his Percocet because the medication ran out and the pharmacy had not refilled the medication. The resident stated his pain level was a seven to eight on a one to ten scale in the last three days and just living with it. The resident stated Tylenol was not effective for the pain in his shoulder and lower back. Interview on 03/11/24 at 9:11 A.M., with Resident #24 revealed pain is a four currently and did get Tylenol last night. Observation on 03/11/24 at 9:57 A.M., with Licensed Practical Nurse (LPN) #278 revealed the resident had no Percocet available in the medication cart. Interview on 03/11/24 at 9:57 A.M., LPN #278 revealed the resident last received Percocet on 03/05/24. LPN #278 revealed the pain clinic managed the resident's Percocet. LPN #278 was not sure if the medication had been reordered and stated she would contact the pain clinic. LPN #278 verified there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 15 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 i sno documentation any staff has notified the pain clinic of the need for the medication. Level of Harm - Minimal harm or potential for actual harm Review of a nurse's note dated 03/11/24 at 2:33 P.M., revealed the pain clinic was called at this time regarding refill on resident's Percocet. Residents Affected - Few Interview on 03/19/24 at 8:35 A.M., with LPN #301 revealed the resident's Percocet was finally received on 03/14/24 around 1:00 A.M. Review of the policy titled, Pain Management, last revised 02/08/24, revealed the facility must ensure that pain management was provided to residents who required such services, consistent with professional standards, the comprehensive person-centered care plan, and the resident's goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 16 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 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 Based on medical record review, staff interview, and policy review, the facility failed to ensure physician visits were completed as required. This affected 10 (#01, #08, #15, #16, #19, #24, #34, #39, #41, and #46) of 10 residents reviewed for physician visits. The facility census was 54. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 07/24/10. Medical diagnoses included traumatic brain injury, depression, cognitive communication deficit, and chronic pain. Review of the medical record for Resident #01 revealed he was seen by Medical Director (MD) #600 on 06/19/23. Resident #01 was seen by Nurse Practitioner (NP) #625 on 02/20/24. There were no other documented physician visits for Resident #01. 2. Review of the medical record for Resident #08 revealed an admission date of 08/03/23. Medical diagnoses included Parkinson's disease, anemia, and unspecified psychosis. Review of the medical record revealed Resident #08 was seen by MD #600 on 08/04/23 and again on 01/03/24. Resident #08 was seen by NP #625 on 02/29/24. There were no other documented physician visits for Resident #08. 3. Review of the medical record for Resident #15 revealed an admission date of 01/15/24. Medical diagnoses included dementia without behaviors, muscle weakness, hypertension and atrial fibrillation. Review of the medical record for Resident #15 revealed no evidence she had been seen by MD #600 since admission to the facility. Resident #15 was seen by NP #625 on 02/27/24. There were no other documented physician visits for Resident #15. 4. Review of the medical record for Resident #16 revealed an admission date of 05/11/22. Medical diagnoses included Alzheimer's disease, anemia, chronic kidney disease and hyperlipidemia. Review of the medical record for Resident #16 revealed she was seen by MD #600 on 06/30/23. Resident #16 was seen by NP #625 on 02/22/24. There were no other documented physician visits for Resident #16. 5. Review of the medical record for Resident #19 revealed an admission date of 01/17/19. Medical diagnoses included stage four pressure ulcer of the right hip, type II diabetes mellitus, muscle weakness, need for assistance with personal care and unspecified intellectual disabilities. Review of the medical record for Resident #19 revealed he was seen by Medical Director (MD) #600 on 05/11/23. The resident was not seen again by MD #600 until 11/06/23, which was his most recent visit by the physician. There were no other documented physician visits for Resident #19. 6. Review of the medical record for Resident #24 revealed an admission date 12/19/18. Medical diagnoses included type II diabetes mellitus, iron deficiency anemia, and systolic (congestive) heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 17 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the medical record for Resident #24 revealed he was seen by MD #600 on 09/18/23. Resident #24 was seen by NP #625 on 02/27/24. There were no other documented physician visits for Resident #24. 7. Review of the medical record for Resident #34 revealed an admission date of . Medical diagnoses included Alzheimer's disease, psychotic disorder with delusions, depression, and anxiety. The medical record indicated that Resident #34 signed on with a local hospice provider on 05/25/23 with a terminal diagnosis of end stage dementia. Review of the medical record for Resident #34 revealed she was seen by MD #600 on 08/31/23. She was then seen by the facility Nurse Practitioner (NP) #625 on 03/05/24. There were no other documented physician visits for Resident #34. 8. Review of the medical record for Resident #39 revealed an admission date of 01/13/23. Medical diagnoses included dementia, type II diabetes mellitus, muscle weakness, and cognitive communication deficit. Review of the medical record revealed Resident #39 was seen by MD #600 on 08/31/23. Resident #39 was seen by NP #625 on 03/07/24. There were no other documented physician visits for Resident #39. 9. Review of the medical record for Resident #41 revealed an admission date of 10/10/23. Medical diagnoses included chronic systolic heart failure, anemia, cognitive communication deficit, and type II diabetes mellitus. Review of the medical record for Resident #41 revealed he was seen by MD #600 on 10/11/23. Resident #41 was seen by NP #625 on 03/05/24. There were no other documented physician visits for Resident #41. 10. Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of the medical record for Resident #46 revealed he was seen by MD #600 on 12/15/23. Resident #46 was then seen by NP #625 on 03/07/24. There were no other documented physician visits for Resident #46. Interview on 03/19/24 at 10:44 A.M., with Registered Nurse (RN) #349 verified the physician visits were not completed timely for all ten of the above residents. Review of the policy titled, Physician Visits - Frequency, dated 01/16/24, revealed each resident of the facility will receive the required regulatory visits. The policy states that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission. The policy indicated after the initial 30-day series of visits, residents must be seen by a physician once every 60 days. The first required regulatory visit after admission must be performed by a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 18 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on record review, staff interview, and policy review, the facility failed to perform annual performance review for State Tested Nurse Aides (STNA). This affected three STNAs (#258, #207, and #204) reviewed for personnel records. This had the potential to affect all 54 residents. The facility census was 54. Residents Affected - Many Findings include: 1. Review of STNA #258's personnel record revealed a hire date of 07/06/21. The personnel record contained no evidence of 90-day or annual performance reviews. 2. Review of STNA #207's personnel record revealed a hire date of 11/08/22. The personnel record contained no evidence of 90-day or annual performance reviews. 3. Review of STNA #204's personnel record revealed a hire date of 03/15/18. The personnel record contained no evidence of annual performance reviews. Interview on 03/19/24 at 12:51 P.M., with STNA #258 revealed she had never had a performance review since being employed at the facility. Interview on 03/19/24 at 1:33 P.M., with the Administrator revealed annual reviews were not documented. The Administrator stated he completed performance reviews but did not record them. Review of the policy titled, Performance Reviews, revised on 01/01/24, revealed it is the policy of the company that stakeholders (employees) be reviewed regularly to ensure expectations are being met and ongoing opportunities for growth are provided. The policy indicated the method of evaluation would be an electronic performance assessment within the company's established performance assessment review tool. The policy indicated that performance reviews may be completed electronically or via paper and must be signed by the stakeholder and the supervisor. The review will be uploaded or digitally saved to the stakeholder's record in the company human resources system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 19 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to provide an appropriate and timely response to a resident with suicidal ideation. This affected one (#8) of two residents reviewed for behavioral/emotional care. The facility census was 54. Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a nurse's note dated 12/29/23 at 1:21 P.M., revealed the nurse and nursing assistant provided a bed bath for the resident. During the bed bath the resident verbalized suicidal ideation to the staff. The nurse went to remove the call light that was near the resident's neck and the resident stated, just leave it there so I can go see Jesus faster and asked the nursing assistant to let her fall off the bed so she can go see Jesus sooner. Review of a physician order dated 12/29/23 at 2:20 P.M., revealed an order for 15 minute checks for 24 hours due to suicide protocol. Review of a safety check log dated 12/29/24 revealed 15 minutes checks were initiated on the resident on 12/29/24 at 2:30 P.M. and continued through 12/30/23 until 6:45 A.M. Further review of the medical record revealed there was no follow-up with psychiatric services or the social worker. Additional review revealed the resident was seen by the physician following the incident on 01/03/24. A care plan for suicidal ideation was initiated on 12/30/23. The resident expressed thoughts of suicidal ideation with no intent to harm. Interventions included to provide resident a bell to call for assistance and remove corded call light from reach, report changes in behavioral status to the physician, and resident verbally contracted for safety after expressing thoughts of self-harm via just wrapping this call light around my neck. Resident then stated no intent of self-harm just joking. Review of a physician progress note dated 01/03/24 revealed recently nursing noted the resident had complained of suicidal thoughts, and therefore was put on a regular watch which was discontinued when she had no further verbal or physical activities that would lead to consideration of continued suicidal thoughts. When questioned the resident stated she was upset but not suicidal and denied any suicidal thoughts or processes. Interview on 03/18/24 at 11:01 A.M., with Assistant Director of Nursing (ADON) #280 revealed this was the first and only incident of suicidal ideation for the resident. ADON #280 verified the resident was not seen by psychiatric services following the incident. ADON #280 revealed the resident had refused psychiatric services but had no documentation the resident had refused psychiatric services. ADON #280 revealed the physician gave an order to complete 15-minute checks on the resident and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 20 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is why they had not provided one on one monitoring per their policy. ADON #280 verified the safety checks on the resident were not initiated until 2:30 P.M. on 12/29/23. Interview on 03/18/24 at 1:20 P.M., with Licensed Practical Nurse (LPN) #278 revealed on 12/29/23 during care she noticed the resident's call light near her neck but not wrapped around her neck. The resident told LPN #278 to leave the call light so she could see Jesus quicker. LPN #278 revealed she notified the Director of Nursing (DON) right away. LPN #278 stated she was not sure what the protocol was for suicidal ideation. LPN #278 verified one-on-one monitoring was not initiated because she had not known at the time that was the protocol. LPN #278 revealed 15-minute checks were not immediately initiated because she had to wait to hear from the DON because she had not known what to do. LPN #278 stated she notified the physician after the 15 minute checks were initiated and told the physician they were completing 15-minute checks on the resident. LPN #278 revealed the physician told her to continue monitoring the resident and follow protocol. LPN #278 verified she had not documented the notification to the physician in the medical record. Interview on 03/18/24 at 1:32 P.M., with Registered Nurse (RN) #221 revealed the protocol for suicidal ideation's was to notify the physician and family, start one on one monitoring and usually do a psychiatric referral and the social worker would follow up with the resident. RN #221 verified there was no documentation the social worker followed up with the resident after the incident. RN #221 also verified there was no documentation of monitoring the resident every 15 minutes for the full 24 hours after the incident. Review of the policy titled, Suicide Threats,, last reviewed 05/30/18, revealed resident suicide threats would be taken seriously and addressed appropriately. Staff would immediately report threats of suicide to the DON, the resident would be evaluated by a nurse, and staff would remain with the resident, one to one, until the resident had been cleared by their physician or by a psychiatrist. The Physician and responsible party would be notified and other staff caring for the resident would be notified of the suicide threat and instructed to report changes in the resident's behavior. If the resident remained in the facility, staff would monitor the resident's mood and behavior and update care plans until a physician had determined the risk of suicide does not appear to be present. Details of the situation would be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 21 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, consultant pharmacist interview, and policy review, the facility failed to ensure a resident was free from unnecessary psychotropic medication and failed to ensure behavior monitoring was implemented. This affected one (#46) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's Minimum Data Set (MDS) 5-day assessment, dated 02/26/24, revealed the resident had a Brief Interview for Mental Status score of 08, indicating moderately impaired cognition. The resident had no recorded hallucinations or delusions, and was noted to have wandered during one to three days during the 7-day look-back period. The resident required substantial/maximum assistance with activities of daily living (ADLs) and required partial/moderate assistance with transfers and mobility. The assessment indicated the resident received antipsychotic, antidepressant, and antiplatelet medications. Review of Resident #46's physician's orders revealed the resident had an order for Seroquel (an anti-psychotic medication) 25 mg once daily from 12/15/23 to 02/19/24. On 02/19/24 the Seroquel dose was decreased to 12.5 mg at the direction of Psychiatric Nurse Practitioner (NP) #750. The dose of Seroquel was returned to 25 mg on 03/04/24. Resident #46 had an order dated 02/16/24 for lorazepam (an anti-anxiety medication) 0.5 mg twice daily as needed for restlessness, for a duration of three months with a listed stop date of 0516/25. The resident was also prescribed Trazodone (a serotonin receptor antagonist and reuptake inhibitor antidepressant) 50 mg once daily and Zoloft (a selective serotonin reuptake inhibitor antidepressant) 100 mg daily since admission to the facility on [DATE]. Review of the consultant pharmacist review of Resident #46's medication regimen, dated 12/15/23 indicated the new admission review was completed by Consultant Pharmacist #720. The report indicated there were no clinically significant irregularities noted. The report indicated requests to the facility nursing department to implement behavior monitoring and ensure all medication orders contained a diagnosis. A subsequent medication regimen review, dated 02/14/24 completed by Consultant Pharmacist #720 discussed the potential side effects of antipsychotic medication as development of tardive dyskinesia and recommended a movement test, such as an Abnormal Involuntary Movement Scale (AIMS) be performed initially and at least every six months while Resident #46 was on antipsychotic therapy. Review of the medical record for Resident #46 revealed no target behaviors, behavioral approaches, or routine behavioral monitoring had been implemented for the resident. There was no evidence that an AIMS test had been completed since Resident #46 admitted to the facility on [DATE]. Review of a nursing progress note dated 02/16/24 at 8:11 P.M., revealed Resident #46 was experiencing restless and agitation, with worsening agitation once a family member was ready to leave for the evening. The progress note referenced increasing agitation and a call was placed to Medical Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 22 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (MD) #600 with a request to reinstate the as-needed ativan. The physician provided an order to reinstate Ativan 0.5 mg one tablet twice daily as needed, for a duration of three months. Review of the medical record for Resident #46 revealed he was seen by MD #600 on 12/15/23. Resident #46 was then seen by NP #625 on 03/07/24. There were no other documented physician visits for Resident #46. Neither progress note referenced a clinical rationale for why Resident #46's as-needed anti-anxiety medication lorazepam was extended longer than the 14-day time frame. Interview on 03/11/24 at 12:40 P.M. ,with Licensed Practical Nurse (LPN) #203 revealed Resident #46 liked to tinker with things, and would occasionally attempt to climb over or under items of furniture. LPN #203 stated the resident previously drove a truck and performed the truck's maintenance in his work life. LPN #203 stated behaviors were charted by exception but nothing prompted staff members to document on Resident #46's behaviors. Interview on 03/13/24 at 2:21 P.M., via phone, with Consultant Pharmacist #720 revealed she has been the consultant pharmacist at the facility for over a year. She reviews the medication regimen reviews monthly and makes recommendations as appropriate. Consultant Pharmacist #720 verified she had made a few recommendations since Resident #46's admissions including requesting a stop date for an as-needed anti-anxiety medication, asked nursing to be sure every order contained an appropriate diagnosis and to implement behavior monitoring. Consultant pharmacist #720 stated she had no record of behavior monitoring by the facility staff for Resident #46 following the recommendation she made on 12/15/23. Consultant pharmacist #720 stated the facility had the diagnosis for Resident #46's routine Seroquel listed as Alzheimer's/dementia and verified those are not diagnoses that are listed by the manufacturer as appropriate indications for use of antipsychotic medications. Consultant Pharmacist #720 stated with Resident #46 on both routine Zoloft and Trazodone it does appear Resident #46 was on duplicate antidepressant therapy and verified both of the antidepressant medications can increase the serotonin level in the body. She indicated she was planning to request a Gradual Dose Reduction (GDR) in May 2024, and stated she typically waits until five months following admission to attempt a GDR. Consultant Pharmacist #720 verified the Director of Nursing, Assistant Director of Nursing (ADON), and the Administrator receive her monthly recommendations via email. A follow up interview on 03/19/24 at 4:14 P.M., with the ADON revealed there was no documentation in Resident #46's medical record or provided by the physician for the clinical rationale for a three month long duration on Resident #46's as needed anti-anxiety medication. Review of the policy titled, Psychotropic Medications, revised on 10/19/22, revealed psychotropic medications will be used appropriately for residents with mental illness and/or related disorders. Psychotropic medications include antipsychotics, antidepressants, antianxiety and hypnotic medications. The policy indicated Residents who use psychotropic drugs will receive behavioral interventions in an effort to discontinue these drugs. Residents do not receive psychotropic drugs unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. As needed orders for psychotropic drugs are limited to 14 days. If the provider believes that it is appropriate for the as needed order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the as needed medication order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 23 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, review of cleaning procedure log and review of cleaning schedule, the facility failed to ensure that the kitchen ice machine is kept clean. The deficient practice had the potential to affect 53 residents who receive ice from the machine, excluding Resident #7 (who receives nothing by mouth). The facility census was 54. Findings include: Observation on 03/10/24 at 8:40 A.M., revealed a large amount of a wet black substance inside the ice machine on the top panel. This wet black substance was directly above the ice in the machine. Interview on 03/10/24 at 8:42 A.M., with Dietary Director #336 confirmed the presence of the black substance inside the ice machine. Dietary Director #336 revealed that maintenance cleans the ice machine every one and a half to two months and that the ice is taken out of the machine prior to being cleaned. Interview on 03/10/24 at 11:38 A.M., with Plant Director #259 revealed he just cleaned the ice machine. Plant Director #259 revealed the ice machine is cleaned quarterly and he did not take the ice out when he cleaned the machine. Interview on 03/11/24 at 10:22 A.M., with District Manager #345 revealed the ice machine should be cleaned whenever dirty or at least once a month. District Manager #345 also revealed the managers should be looking at it every day during walk through. Interview on 03/11/24 at 1:12 P.M., with District Manager #345 revealed the kitchen does not have a cleaning policy. They just have a daily cleaning list. Review of the undated cleaning schedule tilted, Healthcare Services Group, Inc. Sunday through Saturday Cleaning Assignments, revealed the scheduled assignments do not indicate the ice machine being cleaned. Review of the undated Log book for ice machine cleaning procedure revealed the staff should sanitize the interior of ice machine per manufacturer's instructions. Clean out and sanitize the ice bin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 24 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, staff interview, hospice staff interviews, physician interview, family interview, record review, and policy review, the facility failed to ensure the medical records were complete and accurate. This affected three (#46, #34, and #19) of 20 residents reviewed for accurate medical records. The facility census was 54. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's interdisciplinary progress notes revealed a note dated 03/09/24 at 8:40 A.M., which stated the resident returned from the local emergency room. The note explained a bandage was intact to Resident #46's left forehead, and he had skin tears present to his right knee and left forearm. The note immediately prior to this progress note was dated 03/07/24. There was no mention of what incident or event led to Resident #46's emergency department visit on 03/09/24, or any recorded nursing action taken, in Resident #46's medical record. There was no notation that Resident #46 had sustained a fall. Review of an incident report dated 03/09/24, completed by Agency Licensed Practical Nurse (LPN) #308 revealed Resident #46 experienced a fall in the hallway of the memory care unit on 03/09/24 at 3:58 A.M. The report indicated Resident #46 hit his head on the wall, had his first neurological assessment and then was sent out of the facility to the emergency room. The report listed a name for family member whom was notified but the name did not match any listed contacts in Resident #46's medical record. Observation on 03/10/24 at 8:10 A.M., revealed Resident #46 seated in a recliner in the dining room common area. He had a bandage in place to his left forehead and purple and blue bruising around his left eye. The resident was alert only to self and unable to recall what had happened. Interview on 03/10/24 at 2:46 P.M., with a family member of Resident #46 revealed they were the first listed contact in Resident #46's record, and received no notification of Resident #46's recent fall or subsequent emergency department visit, nor were there any missed calls or voicemail messages. Interview on 03/12/24 at 8:10 A.M., with LPN #210 revealed she worked day shift, 7 A.M. to 7 P.M. on 03/09/24 and she was the nurse when Resident #46 returned from the emergency department. LPN #210 verified Resident #46's family member visits daily, and had not been notified of Resident #46's fall or emergency department transfer earlier in the day. LPN #210 stated the family member's first indication that the resident had fallen was arriving to the unit and seeing the hospital wrist band on Resident #46, and then the bandage to Resident #46's left forehead. LPN #210 verified she had been told by the family member they had not gotten a call, and neither had the other listed contact in Resident #46's medical record. LPN #210 stated Resident #46 had been at the facility for approximately 3 months and had phoned the resident's family member before, and knew there were accurate contact information for the listed emergency contacts. Interview on 03/13/24 at 4:33 P.M., with Assistant Director of Nursing (ADON) #280 verified there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 25 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was no progress note or documentation in Resident #46's electronic medical record related to the 03/09/24 fall. 2. Review of the medical record for Resident #34 revealed an admission date of 04/05/21. Medical diagnoses included Alzheimer's disease, psychotic disorder with delusions, depression, and anxiety. The medical record indicated that Resident #34 signed on with a local hospice provider on 05/25/23 with a terminal diagnosis of end stage dementia. Resident #34 had a code status of Do Not Resuscitate Comfort Care (DNRCC) assigned to her profile in the electronic health record. Review of the hospice section of Resident #34's medical record revealed only the hospice election form, dated 05/25/23, was contained in the resident's medical record. The record contained no evidence of Resident #34's hospice plan of care, any physician certification or recertification, name and contact information for the hospice personnel assigned to the resident, instructions on how to access the hospice provider's 24-hour on-call system, or who the attending hospice provider was. Review of the advance directive form, dated 11/26/22, revealed a signed Do Not Resuscitate Comfort Care Arrest (DNRCC-A) form was uploaded to Resident #34's electronic documents on 12/01/22. A signed DNRCC form, dated 05/25/23, revealed the form was uploaded into Resident #34's record on 03/11/24. Review of Resident #34's care plan developed by the facility, initiated on 05/26/23 and last revised on 03/13/24, indicated Resident #34 was currently receiving hospice services by a local hospice provider. The care plan provided the name of the hospice company, a phone number, and a name of a contact overseeing Resident #34's care. Interview on 03/11/24 at 9:14 A.M., with Assistant Director of Nursing (ADON) #280 verified Resident #34 is a hospice resident, and her code status should be DNRCC. ADON #280 recalled Resident #34's code status changed when she elected for hospice care, but was unsure why the signed form was not contained in Resident #34's medical record. A follow up interview on 03/11/24 at 3:54 P.M., with ADON #280 revealed she was able to locate the signed DNRCC form, and it had been uploaded to Resident #34's electronic medical record. ADON #34 verified prior to now, the medical record did not accurately record the signed, official advance directive document. Interview on 03/13/24 at 8:01 A.M., with Licensed Practical Nurse (LPN) #203 revealed she sees hospice staff visit Resident #34 regularly, but was unsure the specific days that Resident #34 receives hospice care, or who her usual hospice staff providers were. LPN #203 stated if she needed something from the hospice provider, she just calls the main number. LPN #203 believed all hospice records were contained in the hospice tab of Resident 34's electronic medical record but she had never gone looking for the records. Interview on 03/13/24 at 10:13 A.M., with ADON #280 revealed the facility does not have any hospice books or papers kept on Resident #34's nursing unit. The facility does not utilize physical charts, all documents are scanned into and stored in the electronic medical record. ADON #280 stated she thought hospice provided papers once or twice a month but was not exactly sure of the process or who coordinated the collaboration with the outside hospice providers. Interview on 03/13/24 at 10:49 A.M., with Medical Record Staff #274 revealed she was up to date on all scanning and filing of documents into the electronic health record. Medical Record Staff #274 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 26 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she does not receive routine documentation from the hospice provider for Resident #34 and does not know who in the facility is responsible for obtaining hospice records. Interview on 03/13/24 at 11:27 A.M., with a receptionist at the hospice provider's office revealed the listed contact on the hospice care plan was the hospice external marketer. The receptionist provided a name of Resident #34's hospice case manager, Case Manager (CM) #500. Interview on 03/13/24 at 11:33 A.M., with Hospice CM #500 revealed she had been Resident #34's hospice case manager for the last three months. Prior to that there was no consistent case manager assigned to Resident #34. Hospice CM #500 stated she visits twice weekly and as needed, and an aide visits twice weekly and as needed to perform personal care, such as showers. Hospice CM #500 stated she does not provide or bring copies of hospice records, and believed those were provided by the hospice office staff. Hospice CM #500 indicated she had no designated point of contact at the facility, but after visiting would update the nurse on duty. Interview on 03/13/24 at 12:25 P.M., with ADON #280 revealed she just received a summary of Resident #34's hospice care over the fax machine, and provided a copy dated as received via fax on 03/13/24 at 11:30 A.M. The hospice summary, effective 01/20/24 to 03/19/24, provided an overview of Resident #34's hospice orders, plan of care, and durable medical equipment provided, and a certification that Resident #34's prognosis is six months or less. ADON #280 verified this was the only hospice record for Resident #34 and was just received a few moments prior. Review of the policy titled Hospice Program, revised 09/15/23, revealed hospice providers who contract with the facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. The Interdisciplinary Team (IDT) will coordinated care by the facility staff and the hospice provider and will be responsible for collaboration with hospice representative, and ensuring information is obtained from the hospice provider. Information that should be received from the hospice provider include the most recent hospice plan of care, the physician certification and recertification of terminal illness, names and contact information for hospice personnel involved in the care of the resident, instructions for accessing the hospice's 24-hour on-call system, hospice medication information, and information on the hospice physician and applicable attending physician order for the resident. 3. Review of the medical record for Resident #19 revealed an admission date of 01/17/19. Medical diagnoses included stage four pressure ulcer of the right hip, type II diabetes mellitus, muscle weakness, need for assistance with personal care and unspecified intellectual disabilities. Review of Resident #19's Minimum Data Set (MDS) 3.0 annual assessment, dated 12/21/23, revealed the resident had a BIMS score of 15, which indicated intact cognition. The resident was recorded to require partial/moderate assistance with mobility and upper body dressing, and required substantial/maximum assistance with toileting, lower body dressing, and bathing. Resident #19 was identified to have a colostomy and bilateral nephrostomy tubes (to drain urine from the kidney into a drainage bag). He was additionally identified to have one unhealed stage four pressure ulcer (indicating a full-thickness wound with exposed muscle, tendon, or bone) that was not present upon admission. Review of Resident #19's care plan, dated 12/19/19, revealed Resident #19 was admitted to the facility with a stage four pressure ulcer that had since healed and re-opened. Interventions included encouraging and assisting Resident #19 to turn and reposition frequently, keep the resident clean and dry, assess the pressure ulcer on a weekly basis, and to provide treatment as ordered. The care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 27 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 indicated the wound doctor would follow ulcer care. Level of Harm - Minimal harm or potential for actual harm Review of Resident #19's recent wound physician progress note, dated 03/07/24, revealed the resident had a full-thickness wound to his right ischium. The wound was documented as post-surgical in etiology, that Resident #19 has had for greater than 169 days. The wound note listed no other areas of skin impairment or pressure ulcers. Residents Affected - Few Observation on 03/18/24 at 9:14 A.M., with Consulting Wound Doctor #310 and Assistant Director of Nursing (ADON) #280 revealed the resident had an open wound with visible depth to his right ischium (hip) area. The area was free from signs and symptoms of infection, had minimal drainage and no odor. Both CWD #310 and ADON #280 verified the wound was free from signs of infection and had improved in size and appearance from the prior week. Interview on 03/18/24 at 9:23 A.M., with CWD #310 verified the wound's etiology as pressure in nature and stated the wound should be classified as a pressure ulcer. CWD #310 stated the provider who saw Resident #19 for his wounds prior to her had it coded as post-surgical, and she never investigated further or researched the etiology. CWD #310 verified the would should be documented as pressure and she would be documenting the wound as such this week going forward. CWD #310 verified her prior notes were inadequate dating back to June 2023 when she began seeing Resident #19 for his wounds. Interview on 03/18/24 at 9:41 A.M., with Minimum Data Set Coordinator (MDS Coordinator) #221 verified the resident admitted to the facility years ago with the stage four wound to the right ischium. Resident #19's wound had in the past healed briefly a few times, but had opened back up on multiple occasions, which is why the wound was not coded as present upon admission. MDS Coordinator #221 stated Resident #19's wound to his right ischium has always been pressure in etiology. Review of the policy titled, Skin Integrity, revised 09/15/23, revealed the facility will ensure a resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing and infection. All areas of skin integrity impairment, including pressure ulcers, should be documented on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 28 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and resident interview, the facility failed to ensure residents were provided clear communication on what an arbitration agreement proposes and how to accept or decline the arbitration agreement. This affected four (#46, #203, #201, and #302) of four residents reviewed for binding arbitration. The facility census was 54. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 12/14/23. The resident was admitted with diagnoses including Alzheimer's disease, spondylosis, acute kidney failure, dysphagia, depression, and dementia. Review of the arbitration agreement for Resident #46 revealed that it was unsigned and the column next to Signer refused to sign the arbitration Agreement says no. 2. Review of the medical record for Resident #201 revealed an admission date of 07/21/23. The resident was admitted with diagnoses including hydrocephalus, urinary tract infection, hypokalemia, anxiety disorder, depression, insomnia, and mild intellectual disabilities. Review of the arbitration agreement for Resident #201 revealed that it was signed. 3. Review of the medical record for Resident #203 revealed an admission date of 03/07/24. The resident was admitted with diagnoses including osteomyelitis of left ankle and foot, type 2 diabetes mellitus, atherosclerosis, non-pressure chronic ulcer of other part of right foot limited to breakdown of skin, and non-pressure chronic ulcer of other part of left foot with unspecified severity. Review of the arbitration agreement for Resident #203 revealed that it was unsigned and the column next to Signer refused to sign the Arbitration Agreement says no. 4. Review of the medical record for Resident #302 revealed an admission date of 03/06/24. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, type 2 diabetes mellitus with hyperglycemia, bipolar disorder, major depressive disorder, anxiety disorder, brief psychotic disorder, and emphysema. Review of the arbitration agreement for Resident #302 revealed that it was unsigned and the column next to Signer refused to sign the Arbitration Agreement says no. Review of the arbitration agreement revealed that a resident is not able to accept or deny the arbitration agreement. Interview on 03/12/24 at 3:37 P.M., with the Admissions Coordinator #273 revealed that she was unable to explain the arbitration agreement and what it is about. Admissions Coordinator #273 revealed that she is the person who is to go through the arbitration agreement with new residents. Interview on 03/19/24 at 9:44 A.M., with the Administrator revealed the facility does not have an arbitration policy. The Administrator further revealed that residents who are missing signatures in their Arbitration Agreement are a clerical error and they verbally agreed to the Arbitration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 29 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0847 Agreement during the admission paperwork. Level of Harm - Minimal harm or potential for actual harm Interview on 03/19/24 at 10:07 A.M., with the Administrator revealed that he was unaware there was a mandatory signature line in the Arbitration paperwork. He further stated the electronic system did not indicate a signature was needed to close it out. Residents Affected - Some Interview on 03/19/24 at 12:02 P.M., with Resident #203 revealed no one explained an arbitration agreement to her during admission and that she said she did not sign anything. Interview on 03/19/24 at 2:14 P.M., with Resident #302 revealed that he didn't sign or agree to an arbitration agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 30 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on medical record review, hospice staff interview and staff interview, and policy review, the facility failed to designate a member of the facility's interdisciplinary team to coordinate and communicate with the outside hospice provider and failed to ensure necessary hospice records were obtained by the facility and recorded in the resident's medical record. This affected one (#34) of one resident reviewed for hospice services. The facility identified 5 residents in the facility who received hospice services. The facility census was 54. Findings include: Review of the medical record for Resident #34 revealed an admission date of 04/05/21. Medical diagnoses included Alzheimer's disease, psychotic disorder with delusions, depression, and anxiety. The medical record indicated that Resident #34 signed on with a local hospice provider on 05/25/23 with a terminal diagnosis of end stage dementia. Resident #34 had a code status of Do Not Resuscitate Comfort Care (DNRCC) assigned to her profile in the electronic health record. Review of the hospice section of Resident #34's medical record revealed only the hospice election form, dated 05/25/23, was contained in the resident's medical record. The record contained no evidence of Resident #34's hospice plan of care, any physician certification or recertification, name and contact information for the hospice personnel assigned to the resident, instructions on how to access the hospice provider's 24-hour on-call system, or who the attending hospice provider was. Review of the advance directive form, dated 11/26/22, revealed a signed Do Not Resuscitate Comfort Care Arrest (DNRCC-A) form was uploaded to Resident #34's electronic documents on 12/01/22. A signed DNRCC form, dated 05/25/23, revealed the form was uploaded into Resident #34's record on 03/11/24. Review of Resident #34's care plan developed by the facility, initiated on 05/26/23 and last revised on 03/13/24, indicated Resident #34 was currently receiving hospice services by a local hospice provider. The care plan provided the name of the hospice company, a phone number, and a name of a contact overseeing Resident #34's care. Interview on 03/11/24 at 9:14 A.M., with Assistant Director of Nursing (ADON) #280 verified Resident #34 is a hospice resident, and her code status should be DNRCC. ADON #280 recalled Resident #34's code status changed when she elected for hospice care, but was unsure why the signed form was not contained in Resident #34's medical record. A follow up interview on 03/11/24 at 3:54 P.M. ,with ADON #280 revealed she was able to locate the signed DNRCC form, and it had been uploaded to Resident #34's electronic medical record. ADON #34 verified prior to now, the medical record did not accurately record the signed, official advance directive document. Interview on 03/13/24 at 8:01 A.M., with Licensed Practical Nurse (LPN) #203 revealed she sees hospice staff visit Resident #34 regularly, but was unsure the specific days that Resident #34 receives hospice care, or who her usual hospice staff providers were. LPN #203 stated if she needed something from the hospice provider, she just calls the main number. LPN #203 believed all hospice records were contained in the hospice tab of Resident 34's electronic medical record but she had never gone looking for the records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 31 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0849 Level of Harm - Minimal harm or potential for actual harm Interview on 03/13/24 at 10:13 A.M., with ADON #280 revealed the facility does not have any hospice books or papers kept on Resident #34's nursing unit. The facility does not utilize physical charts, all documents are scanned into and stored in the electronic medical record. ADON #280 stated she thought hospice provided papers once or twice a month but was not exactly sure of the process or who coordinated the collaboration with the outside hospice providers. Residents Affected - Few Interview on 03/13/24 at 10:49 A.M., with Medical Record Staff #274 revealed she was up to date on all scanning and filing of documents into the electronic health record. Medical Record Staff #274 stated she does not receive routine documentation from the hospice provider for Resident #34 and does not know who in the facility is responsible for obtaining hospice records. Interview on 03/13/24 at 11:27 A.M., with a receptionist at the hospice provider's office revealed the listed contact on the hospice care plan was the hospice external marketer. The receptionist provided a name of Resident #34's hospice case manager, Case Manager (CM) #500. Interview on 03/13/24 at 11:33 A.M., with Hospice CM #500 revealed she had been Resident #34's hospice case manager for the last three months. Prior to that there was no consistent case manager assigned to Resident #34. Hospice CM #500 stated she visits twice weekly and as needed, and an aide visits twice weekly and as needed to perform personal care, such as showers. Hospice CM #500 stated she does not provide or bring copies of hospice records, and believed those were provided by the hospice office staff. Hospice CM #500 indicated she had no designated point of contact at the facility, but after visiting would update the nurse on duty. Interview on 03/13/24 at 12:25 P.M., with ADON #280 revealed she just received a summary of Resident #34's hospice care over the fax machine, and provided a copy dated as received via fax on 03/13/24 at 11:30 A.M. The hospice summary, effective 01/20/24 to 03/19/24, provided an overview of Resident #34's hospice orders, plan of care, and durable medical equipment provided, and a certification that Resident #34's prognosis is six months or less. ADON #280 verified this was the only hospice record for Resident #34 and was just received a few moments prior. Review of the policy titled, Hospice Program, revised 09/15/23, revealed hospice providers who contract with the facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. The Interdisciplinary Team (IDT) will coordinated care by the facility staff and the hospice provider and will be responsible for collaboration with hospice representative, and ensuring information is obtained from the hospice provider. Information that should be received from the hospice provider include the most recent hospice plan of care, the physician certification and recertification of terminal illness, names and contact information for hospice personnel involved in the care of the resident, instructions for accessing the hospice's 24-hour on-call system, hospice medication information, and information on the hospice physician and applicable attending physician order for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 32 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure appropriate infection control practices were maintained during medication administration. This affected one (#32) of five residents reviewed for medication administration. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/06/24. Medical diagnoses included type II diabetes mellitus with hyperglycemia, cerebral infarction, muscle weakness, morbid obesity, and depression. Observation on 03/12/24 from 10:36 A.M. to 10:42 A.M., revealed Registered Nurse (RN) #257 prepared 13 tablets or capsules for oral morning medications for Resident #32. While preparing the medications, RN #257 was observed to obtain the ordered medication card or medication bottle, and place each medication into his bare, ungloved hand prior to placing the medication into Resident #32's medication cup. During the medication preparation process, RN #257 was observed to be approached by the Administrator twice at 10:38 A.M. and 10:41 A.M., who verbally informed RN #257 of a call on hold. RN #257 informed the Administrator on both occasions that he was in the middle of preparing medications and would not be able to take the phone call at that time. The prepared medications above were provided to Resident #32 who accepted and took the medications without difficulty. A follow up interview with RN #257 on 03/12/24 at 10:53 A.M., verified he touched all of Resident #32's medications with his ungloved hand and should not have, as that was not an appropriate infection control practice. RN #257 stated he was distracted during Resident #32's medication preparation by the frequent interruptions by the Administrator. Review of the policy titled, Medication Administration policy, dated September 2018, revealed medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. The policy discussed if medications were to be handled, hands are washed with soap and water and gloves applied prior to handling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 33 of 34 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 0947 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review, and staff interview, the facility failed to ensure State Tested Nurse Aides (STNAs) completed the minimum required 12 hours of in-servicing a year. This affected one (STNA #258) of three STNAs reviewed for required in-services. This had the potential to affect all residents in the facility. The facility census was 54. Findings include: Review of STNA #258's personnel record revealed a hire date of 07/06/21. The record revealed STNA #258 only completed 5.10 hours of in-service training between 01/01/23 and 03/19/24. Interview on 03/19/24 at 1:35 P.M., with Registered Nurse (RN) #349 verified STNA #258 did not complete the required in-service training hours for the last year. Interview on 03/19/23 at 3:03 P.M., with the [NAME] President of Clinical Operations (VPCO) #700 verified the facility did not have a policy for staff education but that the staff members must meet the minimum requirements. For STNA staff, they must complete 12 hours of in-servicing annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 34 of 34