Inspection·February 5, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #100 and was noted to have a small skin tear to her right fifth digit at the knuckle. It appeared the skin tear was from the wheelchair. LPN #100 applied a secure care ankle bracelet (monitoring device), treated the skin tear, redirected resident to her room and initiated 15-minute checks. · On 01/18/24, Resident #01 ' s care plan was reviewed by Registered Nurse (RN) #200 and was revised to include the resident was at risk for elopement as a result of the incident and interventions for the secure care ankle bracelet. · On 01/29/24 at approximately 3:30 P.M., a thorough investigation was completed by the DON. The investigation included interviews with staff working 01/17/24 during the time frame, review of the medical record, and verification the doors were working properly. · On 01/29/24, 35 residents had a wandering evaluation completed by RN #200 and RN #201. Eleven residents were identified at risk for wandering/elopement (#01, #04, #06, #07, #12, #17, #18, #19, #23, #24, #27). · On 01/29/24, 62 staff were educated on elopement and the missing persons policy and identifying hazards and risk and modifying interventions as appropriate by the DON, Activity Director (AD) #202, Environmental Services Supervisor (ESS) #203, and the Administrator. Any staff member not educated by 01/29/24 would not be permitted to work until education was completed. · On 01/29/24 at approximately 2:30 P.M., the DON and the Administrator were educated on elopement, missing persons policy and on completing a thorough investigation by the RNCES #180. · On 01/30/24, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held which included Medical Director (MD) #210 (via phone), the Administrator, DON, Minimum Data Set (MDS) Coordinator RN #200, Infection Prevention Licensed Practical Nurse (IPLPN) #205, Case Manager RN #201, ESS #203, Resident Services Coordinator (RCS) #202, and Business Office Manager (BOM) #206 to discuss elopement procedures and the incident. · Interviews on 01/30/24 from 7:57 A.M. through 8:49 A.M. revealed LPN #120, RN #121, and State Tested Nursing Assistant (STNA) #123 had been educated on the elopement policy, hazards and risks, and identifying resident interventions as appropriate. · On 01/30/24 at 10:40 A.M., an Elopement Drill was completed and there were no concerns were identified with the drill. Staff followed the elopement policies and procedures as directed. · Interviews on 01/30/24 from 4:18 P.M. to 4:21 P.M. revealed LPN #112 and RN #113 had been educated on the elopement policy, hazards and risks, and identifying resident interventions as appropriate. · Beginning on 01/31/24, the DON or designee will randomly audit/observe five residents who exhibit wandering behavior three times a week for four weeks to ensure the behavior is care planned, the care plan includes appropriate interventions to address elopement risk, and staff are implementing the interventions in accordance with the plan of care. · Review of the medical records on 01/31/24 for Resident #6, Resident #12, and Resident #18 identified as an elopement risk revealed their care plans and elopement risk assessments were updated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 2 of 6 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 02/05/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Although the Immediate Jeopardy was removed on 01/31/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Residents Affected - Few Review of the medical record revealed Resident #01 had an admission date of 10/13/23. Diagnoses included urinary tract infection, chronic kidney disease, insomnia, chronic pain, spinal stenosis, and radiculopathy of the lumbar region. Review of the quarterly MDS assessment dated [DATE] revealed Resident #01 had mild cognitive impairment. The resident required the supervision/touching assistance of one staff for bed mobility, transfers, and ambulation. The resident used a walker and a wheelchair. The resident exhibited no wandering behavior. Review of a wandering risk assessment dated [DATE] revealed the resident was at low risk for wandering. Review of the plan of care initiated 10/14/23 revealed no interventions for wandering or elopement risk until the care plan was revised on 01/18/24 after the resident eloped from the facility. Interventions included an elopement prevention device per physician ' s orders, check function of elopement device every shift and as needed, check placement of elopement prevention device every shift, redirect exit seeking behaviors as needed, and staff to be aware of resident ' s location at all times. Review of a nurse ' s note dated 1/15/24 at 2:37 P.M. revealed the resident returned from the hospital and continued to appear confused. The resident stated people were trying to kill her, take her to the basement, and throw her in the furnace. The nurse and the resident ' s family were unable to redirect the resident ' s behavior. The resident was noted to have a urinary tract infection and had a prescribed antibiotic. Review of a wandering risk assessment dated [DATE] revealed the resident was at moderate risk for wandering and identified a recent change in condition due to a urinary tract infection. There were no interventions added for the increased wandering risk. Review of a nurse ' s note dated 01/17/24 at 2:36 P.M. revealed the resident ' s confusion getting better and the nurse would continue to monitor. Review of an incident report dated 01/17/24 at 11:00 P.M. revealed Resident #01 was confused and wandered to the porch of the facility. Resident #01 stood up from her wheelchair attempting to open the door and cut her right pinky finger at the knuckle from the wheelchair lock. The laceration was bleeding and left a trail. When redirected and asked what she was doing the resident stated, I am waiting on my folks to get here. Resident #01 repeated the statement three times. The resident was redirected in the facility to her room. Vitals were taken as a precaution, which were within normal limits. The laceration was washed with soap and water, and a bandage gauze was placed on it. A wanderguard (monitoring device) was placed on the resident as intervention for her confusion. Resident #01 was also placed on 15-minute checks. Further review of the incident report revealed no witnesses were identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 3 of 6 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 02/05/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of a change in condition progress note dated 01/18/24 at 2:05 A.M. revealed the resident was confused and had wandered to the porch of the facility. While attempting to stand and open the door, the resident cut her right fifth finger on the wheelchair creating a laceration. The resident recently returned from the hospital with diagnosis of urinary tract infection and remained confused upon her return to the facility. The resident stated she was waiting on her folks to get her. The resident ' s vital signs were within normal limits and the resident was treated for bleeding from the finger laceration. The resident ' s family and facility administrator were notified. An SBAR (situation, background, assessment, recommendation) form was completed for the physician. The resident was redirected to her room and a wanderguard was placed on the resident ' s ankle. Review of a nurse ' s note dated 01/18/24 at 9:30 A.M. revealed Nurse Practitioner #400 was notified of Resident #01 ' s wandering and skin tear. Review of a nurse ' s note dated 01/18/24 at 11:39 A.M. revealed the family was going to transport the resident to the emergency room due to increased paranoia and refusal to eat and drink. Review of hospital documentation dated 01/18/24 at 2:09 P.M. revealed the resident was treated for a urinary tract infection and pneumonia. Review of the weather report from wunderground.com revealed on 01/17/24 at 10:52 P.M. the air temperature was 22 degrees Fahrenheit. Review of a statement dated 01/18/24 from the Administrator revealed she had received a call from LPN #100 stating Resident #01 had wandered onto the porch with the pharmacy delivery man. The pharmacy delivery driver (#50) called the facility to let the nurse know he was here and when LPN #100 went to the front door, Resident #01 was standing outside with him next to the first pillar. LPN #100 noted the resident ' s fifth finger was bleeding from a skin tear. The resident told LPN #100 she was waiting for her folks to come get her. The resident was easily redirected and returned inside with the nurse and PPD #50. Resident #01 had parked her wheelchair between the set of doors. LPN #100 stated she felt the resident had just gone outside because she was not cold, specifically stating her ears and neck were warm. LPN #100 applied a wanderguard to the resident and was completing notifications. Interview on 01/29/24 at 8:57 A.M., Resident #01 revealed she went outside to the parking lot a couple of weeks ago. Resident #01 stated she was outside for around seven or more minutes. Resident #01 revealed she was not wearing a winter coat and was cold. Resident #01 thought it was daylight outside. Resident #01 revealed she was not walking well so she stayed in the parking lot. Resident #01 stated she just wanted to go outside. Resident #01 revealed a guy was delivering stuff to the building and asked if I needed help to open the door and I did. Interview on 01/29/24 at 9:05 A.M., RN #102 revealed Resident #01 was treated for a urinary tract infection at the hospital and came back confused. RN #102 revealed the resident went outside and was locked out until the pharmacy driver found her. RN #102 revealed the resident was evaluated the following day in the emergency room and treated for a urinary tract infection and pneumonia. Interview on 01/29/24 at 9:11 A.M., the Administrator revealed LPN #100 notified her around 11:40 P.M. on 01/17/24 that Resident #01 had walked outside, and the pharmacy delivery driver was outside. The Administrator was unaware how long the resident was outside. The Administrator revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 4 of 6 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 02/05/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few doors were not locked to go outside but the doors were locked to get back into building. The Administrator revealed the doors were locked around 9:00 P.M. until around 7:00 A.M. The Administrator revealed Resident #01 had never tried to leave the facility before. The Administrator stated the immediate intervention was to place a wanderguard on the resident. Interview on 01/29/24 at 12:00 P.M., the DON revealed she had not completed an investigation of Resident #01 ' s elopement. The DON revealed she had not considered the incident an elopement because the resident had not left the property, was not outside long and was attended to by the pharmacy delivery driver (#50). The DON also verified there was no documentation staff had completed the nurse ' s intervention for 15-minute checks on the resident after she was back inside the facility. Interview on 01/29/24 at 1:39 P.M. with Resident #01 ' s Family Member #240 revealed someone from the facility called and notified her Resident #01 got out, cut her finger, was found by a driver outside, and was brought back into the building. Family Member #240 revealed she thought she was notified around 11:30 P.M. Interview on 01/29/24 at 2:05 P.M., PDD #50 revealed on 01/17/24 as he was pulling up to the facility, he saw an older lady outside the facility. PDD #50 revealed the resident was not wearing a winter coat. PDD #50 revealed the temperature was in the teens that night. PDD #50 revealed the resident was bleeding from her hand and everything she touched had blood on it. PDD #50 revealed he asked the resident if she needed assistance, and she denied needing assistance. PDD #50 revealed he touched the resident ' s arm to make sure she knew he was talking to her because she was acting confused. PDD #50 revealed the resident ' s arm was still warm. PDD #50 revealed the resident told him she was waiting by the pillar on the porch for someone. PDD #50 revealed the facility doors were locked. PDD #50 checked his call log and revealed he called the facility nurse at 10:55 P.M. and she came to the door less than a minute later. PDD #50 revealed he pointed at the resident so the nurse would know the resident was outside. PDD #50 revealed he held the door while the nurse got the resident back in the building. Interview on 01/29/24 at 2:26 P.M., LPN #100 revealed on 01/17/24 she received during report that Resident #01 had recently returned from the hospital with a urinary tract infection and was still confused. LPN #100 revealed she began her medication pass and Resident #01 had refused her medications including antibiotics at approximately 9:30 P.M. and again at 10:15 P.M. LPN #100 revealed she completed her medication pass around 10:45 P.M., later than normal. LPN #100 revealed it was a busy night with a heavy medication pass. LPN #100 revealed the smokers were upset they could not go outside because it was less than 10 degrees Fahrenheit outside. LPN #100 revealed she took a break after her medication pass was completed. LPN #100 revealed the phone rang just before 11:00 P.M. and it was the pharmacy driver saying he was here. LPN #100 revealed she rounded the corner on her way to let the driver in and noticed a phone on the floor. LPN #100 revealed she next noticed a wheelchair inside the front entrance double doors. LPN #100 revealed she went to move the wheelchair to open the door and noticed blood where you would lock the wheelchair and more blood on the door where you would push it open. LPN #100 revealed she then saw Resident #01 outside by the pillar holding onto the pillar. LPN #100 revealed the resident was wearing light colored sweatpants, a shirt, grippy slipper socks, and a pink fleece jacket. LPN #100 revealed the resident was also wearing a gait belt. LPN #100 revealed the aides said they were just in her room and were going to get her ready for bed, but the resident had not wanted to go to bed. LPN #100 revealed she assessed the resident and found the location of the bleeding on her fifth finger. LPN #100 revealed the resident ' s fingertips were cold but everything else was warm. LPN #100 revealed she took the resident to her room and wrapped up her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 5 of 6 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 02/05/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few finger, placed a wanderguard on the resident, then told the aides to begin 15-minute checks on the resident. LPN #100 revealed she then called the Administrator and resident ' s family. Interview on 01/29/24 at 3:03 P.M., STNA #120 revealed on 01/17/24 she was assigned to care for Resident #01. STNA #120 revealed the resident was confused and she had checked on the resident multiple times that evening. STNA #120 revealed she assisted the resident to the bathroom and was going to put her in bed, but the resident stated she was not ready for bed. STNA #120 revealed she left the resident around 10:45 P.M., took the trash outside and went to assist another resident. STNA #120 revealed she had left the resident ' s gait belt on her so she could assist the resident to bed later. STNA #120 revealed when she exited another resident ' s room around 11:00 P.M., Resident #01 was with LPN #100 who was applying pressure to the resident ' s finger. STNA #120 revealed it was cold outside but could not recall how cold it was. STNA #120 revealed the resident had blue and pink on and thought she might have had a pink fleece jacket on and may have had shoes on. STNA #120 revealed she heard LPN #100 tell the oncoming third shift staff to complete 15-minute checks on Resident #01. Interview on 01/30/24 at 8:42 A.M., Registered Nurse Clinical Education Specialist (RNCES) #180 revealed elopement assessments were completed on residents upon admission and quarterly. RNCES #180 revealed the facility had no policy on elopement assessments. RNCES #180 revealed there were no new interventions put in place for Resident #01 due to her increased confusion. RNCES #180 revealed if the resident had a change in condition, the clinical team would review the individual resident, determine why there was a change, and the expectation would be to put something different in place if warranted. RNCES #180 revealed she believed the clinical team had not had a chance to review the resident. RNCES #180 revealed she educated the Administrator and DON regarding the definition of an elopement and completing an investigation. RNCES #180 revealed anytime there was an incident, an investigation should be completed. In a follow-up interview, RNCES #180 revealed Resident #01 ' s Physician #210 and Nurse Practitioner #400 were not notified of the incident until the following day. Review of the policy, Missing Resident Policy, approved 05/09/17, revealed no guidelines for preventing or investigating a resident elopement. This deficiency represents non-compliance investigated under Complaint Number OH00150439. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365575 If continuation sheet Page 6 of 6