Inspection·May 4, 2023

F 0561 because the shower schedules did not match. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #197's medical record revealed admission occurred on 04/17/23 with medical diagnoses including small bowel obstruction, high blood pressure, anemia, malnutrition, and a colostomy. Residents Affected - Few Review of the admission activities assessment dated [DATE] revealed Resident #197's preferred grooming time was listed as 2:00 P.M. Review of the admission assessment dated [DATE] revealed Resident #197 was cognitively intact and required extensive assistance with personal hygiene and bathing. Interview with Resident #197 on 05/01/23 at 8:34 A.M. stated she was woken up throughout the night around 3:00 A.M. and 5:30 A.M. and did not like it. Resident #197 stated she has told the facility and they have not changed anything. Interview with Resident #197 on 05/02/23 at 10:02 A.M. stated she was awoken at 5:30 A.M. that morning and received a sponge bath. Resident #197 stated she thought that was ridiculous and she did not want to be awoken for any care. Review of the facility's shower schedule for the hallway where Resident #197 resided revealed she was scheduled for showers on Wednesdays and Saturdays on the 7:00 A.M. shift to 3:00 P.M. shift with no listed preference times. Interview with Resident #197 and the Director of Nursing on 05/03/23 at 8:46 A.M. confirmed Resident #197 received a bed bath at 5:30 A.M. and was woken up from a dead sleep. The interview confirmed Resident #197 did not want woken in the middle of the night for her bed baths. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 2 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self-reported incident, resident and staff interviews, and review of an abuse policy, the facility failed to prevent resident to resident abuse. This affected two (#18 and #29) of two residents reviewed for abuse. The census was 38. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 09/26/12. Diagnoses included major depressive disorder, hemiplegia and hemiparesis affecting the left non-dominant side, hypertension, and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had intact cognition. Resident #18 required the extensive assistance of two staff for bed mobility and the extensive assistance of one staff for transfers. The resident was independent with moving around the facility in a wheelchair. Review of the plan of care for Resident #18, revised on 07/20/22, revealed Resident #18 had the potential to demonstrate verbally and physically abusive behaviors related to poor impulse control. 2. Review of Resident #29's medical record revealed admission to the facility occurred on 03/06/23. Resident #29 had medical diagnoses including alcoholic cirrhosis, depression, and high blood pressure. Review of Resident #29's quarterly assessment dated [DATE] revealed he was cognitively intact, independent with bed mobility, transfers, eating, toileting, dressing, and moving around the facility in a wheelchair. Review of a nursing progress note dated 04/17/23 at 1:37 A.M. revealed Resident #18 was getting upset with his roommate (Resident #29) and Resident #29 was advised to stay on his own side of the room. Resident #18 and Resident #29 were going to bed at this time. Review of a nursing progress note dated 04/20/23 at 8:55 P.M. revealed Resident #18 was sitting with two other residents waiting to go out to smoke. Resident #18 became agitated when Resident #29 would not get out of his face and continued to taunt him. Resident #18 punched Resident #29 in the face. The residents were separated. Resident #18 was noted later with a small amount of blood on his index finger which was cleansed. Review of self-reported incident (SRI), with Tracking #234245, revealed on 04/20/23 at 8:55 P.M., there was a resident-to-resident altercation that identified Resident #29 was verbally agitating Resident #18, and Resident #18 got frustrated and struck Resident #29. Further review of the SRI revealed Resident #29 was intoxicated at the time of the incident. Review of Resident #29's progress notes dated 04/21/23 at 12:34 A.M., written by Registered Nurse (RN) #210, revealed Resident #29 was sitting with two other residents (#18 and #22) and refused to leave when asked to do so by the other residents. One of the other residents (#18) punched Resident #29 in the face. The residents were separated and educated and Resident #29 was educated that if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 3 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few other residents did not want his company, then he should respect that and leave them alone. Resident #29 kept approaching them after separation and continued to talk to them and it was necessary to separate them several times. State Tested Nurse Aide (STNA) #258 came and took them all out for their cigarette break, and asked Resident #29 if he felt safe in room for the night. Resident #29 indicated he did not feel safe so he was placed in another room. Resident #29 was observed with a small scratch to the right eyebrow. Review of the social services notes dated 04/21/23 at 10:15 A.M. revealed Resident #29 was checked on and he confirmed he wanted to stay in the room he was moved to. Interview with Resident #18 on 05/01/23 at 9:48 A.M. stated Resident #29 was his former roommate and was drunk so Resident #18 hit him. Resident #18 confirmed Resident #29 was moved out of the room the evening the incident occurred. Resident #18 stated he asked about a week before the incident to be allowed to change rooms and nothing occurred. Resident #18 stated he told Social Services Designee (SSD) #231 he wanted a roommate change because his roommate was a drunk and he had been in sobriety for the past 12 years. Resident #18 stated SSD #231 told him she would get back to him about it. Interview with Resident #29 on 05/01/23 at 9:28 A.M. stated Resident #18 threatened to kill him, and punched him in the face. Resident #29 stated he was startled by the punch and told staff he could not be roommates with Resident #18 any longer. Resident #29 confirmed the staff moved his room immediately, so he did not have to be around Resident #18. Resident #29 confirmed he and Resident #18 now smoke in different locations. Interview with Resident #22 on 05/02/23 at 8:33 A.M. stated she had not seen anything and could not remember what occurred on 04/20/23 between Resident #18 and Resident #29 other than yelling for the nurse. Interview with Social Service Designee (SSD) #231 on 05/02/23 09:24 A.M. stated Resident #18 did not like having roommates and previously ran other residents out of the room. SSD #231 stated Resident #18 told her in the past that Resident #29 came on his side of the room and he did not liked it. SSD #231 denied Resident #18 asked for a room change a week prior to the resident-to-resident altercation on 04/20/23. Additional interview completed with Resident #29 on 05/02/23 at 2:14 P.M. stated he was drinking on 04/20/23 when the incident with Resident #18 occurred. Resident #29 stated he was drinking a bottle of vodka in his room and dropped his cup onto the floor. Resident #29 stated the spilled vodka got on Resident #18 and he was extremely mad. Resident #29 stated after he was punched by Resident #18 he told State Tested Nurse Aide (STNA) #258 he was in fear for his life. Resident #29 stated STNA #258 immediately took care of him and moved him to another room. Resident #29 confirmed he felt safe following the incident. A phone interview was completed with Registered Nurse (RN) #210 on 05/02/23 at 9:33 A.M. and stated she was passing medications on 04/20/23 around 8:50 P.M. RN #210 stated Resident #18, #22, and #29 were sitting in a circle near the side door getting ready to smoke. RN #210 confirmed she could see them from her location and she went into a room to give medications and heard Resident #22 yell for a nurse. RN #210 stated Resident #29 told her he was punched in the face. RN #210 stated she separated Resident #18 and Resident #29 and she summoned STNA #258 to assist her and take the residents out to smoke. RN #210 stated Resident #29 told her he was in fear for his life. RN #210 confirmed when they came back in from smoking, STNA #258 moved Resident #29 to another room away from Resident #18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 4 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0600 and RN #210 confirmed she never had known the residents to argue before. Level of Harm - Minimal harm or potential for actual harm Interview with STNA #258 on 05/02/23 at 3:44 P.M. stated he was working with two other nurse aides and two nurses on the hallway where Resident #18 and Resident #29 both resided. STNA #258 stated he was aware Resident #29 was a drinker and Resident #18 was a 12-year recovering alcoholic and they were in the same room together. STNA #258 stated Resident #29's drinking was a trigger for Resident #18 because he was a recovering alcoholic. STNA #258 stated RN #210 asked him to take the residents outside following the incident and STNA #258 identified Resident #29 told him he was hit by Resident #18 in the face. STNA #258 stated Resident #18 was aggravated at that time and they were jawing back and forth at each other and calling each other names. STNA #258 stated he kept them separated and moved Resident #29 to a new room when they went back inside. STNA #258 confirmed Resident #18 and Resident #29 had been avoiding each other since that time. STNA #258 identified Resident #18 expressed his dislike for Resident #29 many times before the 04/20/23 incident occurred. STNA #258 stated the whole situation could have been avoided if they would have listened to Resident #18 sooner. STNA #258 stated he saw a difference in Resident #18's demeanor since Resident #22 moved into his room. Residents Affected - Few Interview on 05/04/23 at 7:56 A.M. with the Administrator stated Resident #29 and Resident #18 used to get along great. The Administrator stated Resident #29 had not started drinking alcohol in the facility until Easter weekend when he finally got access to all his funds and began using a delivery service for alcohol. The Administrator stated Resident #18 told a nurse he was not bothered by Resident #18's drinking, and stated the resident had not asked for a room change prior to the incident on 04/20/23. Review of the facility's abuse policy, dated October 2003, revealed the facility will not tolerate abuse, neglect, exploitation of it residents, or the misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, and misappropriation of resident property. The staff should immediately report all such allegation to the Administrator and to Ohio Department of Health. The policy identified abuse is defined in the policy as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 5 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of a self-reported incident (SRI), staff interview, and review of an abuse policy, the failed to thoroughly investigate an allegation of abuse. This affected two (#18 and #29) of two residents reviewed for abuse. The facility census was 38. Residents Affected - Few Findings include: Review of a self-reported incident (SRI), with Tracking #234245, revealed on 04/20/23 at 8:55 P.M., Resident #18 struck Resident #29 in the face. The SRI identified there were three residents (#18, #22, and #29) sitting in a circle when this occurred. The SRI included no statements or interviews with other residents who resided in the area or all the staff working at that time. The SRI included interviews with Resident #18, Resident #22, and Resident #29 and a statement Registered Nurse (RN) #231 who was working at the time of the incident. The facility concluded abuse occurred following their investigation. Interview with the Administrator on 05/03/23 at 8:26 A.M. confirmed the facility did not interview any other residents following the 04/20/23 incident between Resident #18 and Resident #29 to ensure no other issues occurred. The interview confirmed there were no other staff interviews completed to determine if there were issues occurring between Resident #18 and Resident #29 prior to the 04/20/23 incident, except for an interview with RN #210. Further interview with the Administrator confirmed the lack of a thorough investigation into the physical abuse allegation, and confirmed all residents in that area should have been questioned to ensure Resident #18 had not physically abused anyone else. The interview confirmed all staff present and those recently caring for Resident #18 and Resident #29 should have been questioned. Review of the facility's abuse policy, dated October 2003, revealed all alleged violations involving abuse, neglect, and misappropriation of resident property should be thoroughly investigated. The policy revealed to investigate allegations the following would occur; interview the resident, the accused, and all witnesses. Witnesses include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, and/or alleged victims the day of the incident. The policy identified if the allegation involved abuse or neglect, interview other residents as appropriate to determine if they were affected by the accused staff member or resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 6 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, and policy review, the facility failed to have a physician order for respiratory services and equipment. This affected one (#35) of one resident review for respiratory services. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #35's medical record revealed admission to the facility occurred on 04/28/23. Resident #35 was in the facility from 02/24/23 through 03/23/23 and 03/26/23 through 04/25/23. Resident #35 had medical diagnoses including pulmonary high blood pressure, anxiety, and obstructive sleep apnea. Review of Resident #35 hospital records dated 02/16/23 revealed he used a bilevel positive airway pressure (BiPap) device for obstructive sleep apnea, interstitial lung disease, severe pulmonary hypertension, and oxygen on exertion. Review of Resident #35's admission assessment dated [DATE] identified he was cognitively intact. Observation and interview with Resident #35 on 05/01/23 at 10:10 A.M. revealed Resident #35 had an oxygen concentrator in the room that was observed to be on; however, Resident #35 was not using the oxygen at this time. Interview with Resident #35 at that time stated he used a BiPap device with oxygen at night time. Review of Resident #35's physician orders identified nothing in regards to use of a BiPap device and oxygen. The record identified no orders related to liter flow of the oxygen and or settings for the BiPap device. Interview with the Director of Nursing (DON) on 05/02/23 at 10:15 A.M. confirmed there were no physician orders in Resident #35's medical record for use of oxygen and a BiPap device. Review of the facility's respiratory services policy, dated 04/01/23, revealed staff should verify physician orders specifying liter flow for oxygen. Review of the facility's BiPap therapy policy, dated 04/01/23, revealed the devices require a physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 7 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure a blood pressure medication was administered per physician orders. This affected one (Resident #27) of three residents observed for medication administration. The facility census was 38. Residents Affected - Few Findings include Review of the medical record revealed Resident #27 had an admission date of 11/03/21. Diagnoses included atrial fibrillation, congestive heart failure, hypertension, type two diabetes mellitus and cardiomyopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. Review of Resident #27's physician orders revealed a physician order dated 04/21/23 revealed to decrease the blood pressure medication metoprolol to 25 milligrams (mg) daily and hold if the systolic blood pressure was less than 100 millimeters of mercury (mmHg) or heart rate was less than 60 beats per minute. Observation on 05/02/23 at 8:38 A.M. revealed Resident #27's blood pressure was 99/61 mmHg. The resident's heart rate was 66 beats per minute. Interview on 05/02/23 at 8:38 A.M. with Licensed Practical Nurse (LPN) #221 stated Resident #27 had no parameters for administering blood pressure medications. Observation on 05/02/23 at 8:42 A.M. revealed Licensed Practical Nurse (LPN) #221 administered one tablet of metoprolol 25 mg to Resident #27. Interview on 05/02/23 at 1:13 P.M. with LPN #221 verified the physician ordered to hold Resident #27's metoprolol for a systolic blood pressure less than 100. LPN #221 verified the resident's metoprolol should have been held that morning. LPN #221 stated the nurse who entered the physician order had not entered the parameters into the electronic medication administration record. Review of the facility policy, Medication Administration-General Guidelines, last reviewed 03/30/22, revealed medications were administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 8 of 9 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #40's medical record revealed admission to the facility occurred on 04/29/23 with medical diagnoses including Alzheimer's disease, urine retention, and a dehisced surgical wound. The medical record identified Resident #40 was allergic to bananas. Review of Resident #40's meal tray and meal ticket on 05/01/23 at 11:36 A.M. revealed no evidence of any food allergies. Review of Resident #40's meal ticket from the breakfast tray on 05/02/23 at 8:36 A.M. did not include any food allergies listed. Interview with Resident #40 on 05/04/23 at 10:33 A.M. confirmed he was allergic to bananas: however, did not think he was served bananas since being here. The resident identified his throat would swell if he ate one. Interview on 05/04/23 at 10:25 A.M. with [NAME] #227 stated food allergies were listed on each resident's diet card, as applicable, and the kitchen did not maintain any other list of allergies. A follow-up interview on 05/04/23 at 10:40 A.M. with [NAME] #227 confirmed the diet card for Resident #40 did not identify an allergy to bananas, and the diet card for Resident #8 did not identify an allergy to alcohol. Review of the four-week rotating menu and available choices menu (of alternate options) revealed the kitchen provided for either a banana or form of fruit salad for 24 of the 84 meals (across the 28 days). The alternate menu did not include bananas. Based on interview with staff and residents, review of resident medical records, review of meal tickets, and review of the menu, the facility failed to accommodate food-related allergies. This affected two (#8 and #40) of four residents reviewed for food allergies. The census was 38. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted on [DATE] and had diagnoses that included Parkinson's disease, schizophrenia, major depressive disorder, and anxiety. The medical record identified an allergy to alcohol on the home page screen and the allergy page. The record included a physician order for a calorie-restricted, mechanical soft diet. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #8, dated 04/12/23, revealed the resident had a moderate degree of cognitive impairment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 9 of 9