Health inspection·October 31, 2019

F 0550 privacy bag at all times. Level of Harm - Minimal harm or potential for actual harm Review of careplan revealed Resident #25 had suprapubic catheter and intervention included to place drainage bag in appropriate holder. Residents Affected - Few Observation was conducted on 10/28/19 at 10:12 A.M. and at 5:02 P.M. of Resident #25 resting in bed and catheter drainage bag was visible to the hallway and was not covered in a dignity bag. Interview was conducted on 10/28/19 at 5:02 P.M. with LPN #235 and she verified Resident #25's catheter bag was not covered to provide dignity. Review of facilities Resident Rights Policy dated 08/16/18 revealed all residents have the right to be treated with respect and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 2 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on review of resident funds, staff and resident interview and facility policy review the facility failed to ensure personal funds money could be obtained on the weekends. This affected one (Resident #11) of four residents reviewed for personal funds. The facility identified 36 residents with personal funds. The facility census was 62. Residents Affected - Few Findings include: Review of resident funds for Resident #11 revealed she had not made any withdrawals on the weekends from 08/01/19 through 09/30/19. Interview with Resident #11 on 10/28/19 at 10:33 A.M. revealed she didn't think she could take money out on the weekends from her personal account. Interview with Business Office Manager (BOM) #225 on 10/31/19 at 2:12 P.M. revealed there was a petty cash box left on the weekends at the charge nurse's station that only had $40.00 in it and stated that was all that was allowed on the weekends. She stated typically the residents get what they want before the weekend. Interview with Registered Nurse #241 on 10/31/19 at 2:28 P.M. who worked on the unit revealed she worked weekends and said there was a petty cash box left on the weekends for residents who wanted to withdraw money from their personal accounts. She stated if a resident needed more than $40.00 the resident would have to wait until Monday morning when the BOM was in the office. Review of policy entitled Resident Trust Fund dated 12/01/18 revealed it was a federal requirement that petty cash was to be available 24 hours/7 days a week. A locked cash box will be given to the nurse manager every evening and on the weekends with $50.00 cash in the box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 3 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, staffing schedule review, phone email review, staff interview and facility policy review, the facility failed to implement their abuse policy when background checks were not conducted prior to employment and the facility allowed an employee to continue to work when the background check was not received within 30 days. This affected one State Tested Nursing Aide (STNA) #210 of nine personnel records reviewed for background checks. STNA #210 was permitted to work two shifts on Hallway #3, after the 30 days had elapsed. The facility identified Hallway #3 had 14 residents (#4, #6, #10, #12, #14, #23, #37, #39, #44, #46, #47, #48, #54 and #207) who resided there. The census was 62. Residents Affected - Some Findings include: Review of the personnel file for STNA #210 revealed she was hired on 09/18/19. The file lacked a background check. Review of staffing schedule dated 10/26/19 and 10/30/19 revealed STNA #210 worked Hallway #3 from 6:00 P.M. to 6:30 A.M. Review of the administrator's phone email on 10/31/19 at 3:00 P.M. revealed he had submitted the background check for STNA #210 on 09/23/19. Interview with the administrator on 10/31/19 at 3:20 P.M. revealed he had submitted the background check for STNA #210 on 09/23/19 and he had not received it back within the allotted timeframe of 30 days. The Administrator revealed he he did not realize 30 days had passed. He verified STNA #210 worked on 10/26/19 and 10/30/19 but denied any concerns. He verified he didn't implement the policy. Review of facility policy entitled Abuse, Neglect and Misappropriation of Property revised 05/08/19 revealed under the subheading of screening revealed criminal background checks will be conducted prior to permanent employment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 4 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify a resident and/or the residents representative in writing the reason for the transfer to the hospital. This affected one (Resident #52) of two residents reviewed for transfer and discharge. The facility census was 62. Findings include: Review of Resident #52's medical record revealed an admission date of 07/07/17 with pertinent diagnosis of: chronic obstructive pulmonary disease, adult failure to thrive, atrial fibrillation, osteoarthritis, congestive heart failure, generalized anxiety disorder, chronic kidney disease, and major depressive disorder. Review of the 09/30/19 Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and required extensive assistance for bed mobility, transfer, dressing and persona hygiene. Resident #52 was always continent of bowel and bladder and used a wheelchair to aid in mobility. Review of a late entry progress note dated 10/15/19 revealed the resident was having increased behaviors, each episode was becoming more frequent and more aggressive. The resident was sent out to a behavioral hospital on [DATE]. Further review of the medical record revealed no documented instance where the resident and/or residents representative were notified in writing of the reason for the transfer to the hospital. Interview with the Administrator on 10/31/19 at 12:06 P.M. verified the facility did not notify the resident and/or residents representative in writing of the transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 5 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and staff interview the facility failed to ensure a resident with a newly evident mental disorder was referred for a pre-admission screening and resident review (PASARR) upon a significant change. This affected one (Resident #47) of one resident reviewed for PASARR. The facility census was 62. Findings include: Record review of Resident #47 revealed an admission date of 11/30/17 with pertinent diagnoses of: Parkinson disease, left femur fracture, adult failure to thrive, muscle weakness, basal cell carcinoma of skin of scalp, anxiety disorder, psychosis, bipolar disorder, depressive episodes, osteoarthritis, pain, cognitive communication deficit, vitamin deficiency, vitamin b12 deficiency, hypertensive heart disease, chronic hepatitis, idiopathic hypotension, and nicotine dependence. Review of a 07/26/19 significant change Minimum Data Set (MDS) assessment revealed the resident was rarely or never understood and requires extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. The resident used a wheelchair to aid in mobility and was always incontinent of bowel and bladder. Review of the medical record on 10/29/19 revealed new diagnosis of bipolar disorder on 05/16/19, and anxiety disorder on 06/23/19. There was not a new PASARR completed for the new diagnosis with the significant change. Interview with the Administrator on 10/30/19 at 9:28 A.M. verified they did not complete a PASARR when Resident #47 had a significant change and new diagnosis of bipolar disorder and anxiety disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 6 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review the facility failed to develop a comprehensive care plan to address the behavioral and refusal of care needs. This affected one (Resident #155) of one resident reviewed for the behavioral/emotional care area. The facility census was 62. Findings include: Review of Resident #155's record revealed an admission date of 08/22/19 with diagnoses including major depressive disorder recurrent with severe psychotic symptoms,, primary insomnia, other speech and language deficits following cerebral infarction (stroke), type two diabetes mellitus, and other encephalopathy (a brain disease that alters brain function or structure. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #155 had severely impaired decision making skills and short/long term memory problems. The MDS further revealed Resident #155 needed the extensive assistance of two people for bed mobility, dressing, toileting and personal hygiene and was totally dependent on the assistance for transfers and bathing. Resident #155 had behaviors and incidents of refusing care. Review of Resident #155's care plan dated 09/18/19 revealed no documentation related to the refusal of care of behaviors. Review of the nursing progress notes dated 09/21/19 at 4:02 P.M. revealed Resident # 155 was pulling away and attempted to swing at the nurse during blood glucose monitoring. The nurse documented the resident refused and did not obtain the blood sugar or administer insulin per sliding scale. Review of the nursing progress note dated 09/22/19 at 9:30 A.M. revealed Resident #155's husband requested blood glucose monitoring be done to the resident's ear lobe, the resident became agitated and punched the nurse in the stomach. The blood glucose monitoring was not completed and no insulin was given per sliding scale. Review of nursing progress noted dated 10/03/19 at 12:19 P.M. revealed Resident # 55 attempted to strike the nurse when obtaining accucheck and administering insulin. Review of Resident #155's physician order dated 10/03/19 revealed an order for Humalog U-100 Insulin sliding scales with instructions to call the physician if blood sugar levels were less than 60 or greater than 400 and further instructions on the number of units of medication to give based on the blood glucose levels. Review of the Medication Administration Record (MAR) dated 10/01/19-10/31/19 revealed that Resident #155 refused Humalog U-100 insulin on 10/03/19, 10/06/19, 10/07/19, 10//08/19, 10/10/19, 10/14/19, 10/23/19, 10/24/19 10/27/19, 10/28/19 and 10/30/19. Interview with the Corporate Director of Nursing (DON) #205 on 10/31/19 at 8:39 A.M. revealed the facility did not have any behavior documentation for Resident #155 as they recently switched computers and the information from the old system was not transferred into the new system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 7 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with State Tested Nurses Aid (STNA) # 219 on 10/31/19 at 11:10 A.M. verified that Resident #155 hits the nursing staff but was not usually combative with the STNA's. STNA #219 stated Resident #155 was mostly combative during shots and insulin administration. Interview with Licensed Practical Nurse (LPN) #252 on 10/31/19 at 11:14 A.M. confirmed that Resident #155 was a challenge and resistant to care when performing a finger stick and that behaviors were documented in the skilled notes. Interview with STNA #269 on 10/31/19 at 11:19 A.M. verified that Resident #155 was often resistant to care and that she fights the staff when care was given. Interview with the Director of Nursing (DON) on 10/31/19 at 11:35 A.M. confirmed that Resident #155 did not have a care plan or interventions for the refusal of care of behaviors. Review of the facility policy titled Comprehensive Care Plans dated 07/19/18 revealed a person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs and goals and preferences. The policy further revealed the resident has the right to refuse to participate in the development of the care plan, medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's medical record. In the case of a resident refusal or declination of care or treatment that poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or treatment being declined, the risk the declination poses to the resident and the efforts made by the team to educate the resident and representative as appropriate. The attempts to find alternative mans to address the identified need/ risk shall be documented in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 8 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update and revise resident care plans. This affected one (Resident #18) out of 20 residents reviewed for accurate care plans. The facility census was 62. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/08/12 with diagnoses of heart failure, aphasia, urinary tract infection, diabetes mellitus, dementia, paraplegia, and urinary retention. Review of the quarterly minimum data set assessment dated [DATE] revealed cognitive status was not assessed and Resident #18 had range of motion impairments to upper and lower bilateral extremities. Review of physical therapy discharge note dated 08/23/19 revealed Resident #18 was educated on the importance of continuing to wear hip abductor brace in order to decrease contractures and improve neutral position. Staff to get him up out of bed daily and apply the abductor brace daily. Physical therapy discharge instructions included 24 hour care and brace. Review of Resident #18's care plan revealed he was at risk for pain related to joint contracture to leg. Resident #18 had activity of daily living deficit and risk for complications related to dementia and paraplegia. The care plans were silent of any intervention for use of hip abductor. Review of physician note dated 10/19/19 revealed Resident #18 had poor cognition. Review of physician orders dated October 2019 revealed no order for any brace or hip abductor. Observation was conducted on 10/28/19 at 10:45 A.M. with Resident #18 and he was sitting up in wheel chair with hip abductor in place. Interview was conducted on 10/30/19 at 3:13 P.M. with State Tested Nursing Assistant (STNA) #209 and she stated Resident #18 does wear hip abductor when up in his chair. Interview was conducted on 10/30/19 at 4:59 P.M. with Registered Nurse (RN) #205 and he verified Resident #18's care plan was not updated to reflect use of hip abductor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 9 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 medical record review, observation and interview the facility failed to provide appropriate care for residents with catheters. This affected one (Resident #25) out of six residents with catheters. The facility census was 62. Findings include: Review of the medical record for Resident #25 revealed an admission date of 07/20/12 with diagnoses of paraplegia, bladder disorder, depression, and neuromuscular dysfunction of the bladder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #25 had some moderate cognitive deficits and presence of a catheter. Review of physician orders dated October 2019 revealed supra pubic catheter to straight drain and privacy bag at all times. Review of careplan revealed Resident #25 had suprapubic catheter and intervention included to keep drainage bag below the level of the bladder. Observation was conducted on 10/28/19 at 5:08 P.M. of Resident #25 resting in bed and catheter drainage bag was placed up by Resident #25's head on the bed frame and not below level of the bladder. Interview was conducted at the time of the observation with Licensed Practical Nurse #235 and she verified Resident #25's catheter bag was not properly placed below the level of the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 10 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #31 revealed an admission date of 08/12/19. Medical diagnoses included renal failure and traumatic brain injury. Residents Affected - Few Review of the admission MDS dated [DATE] revealed the resident was severely cognitively impaired. Functional status was supervision for bed mobility, eating and toileting and he was a limited assistance for transfers. He was coded for dialysis. Review of physician orders dated 08/12/19 revealed thin liquids with 1500 cubic centimeters (cc) fluid restriction. Review of progress notes, treatments administration records and medication treatment records from 08/12/19 through 10/30/19 revealed they were silent for documentation of consumption of fluids for the resident. Review of care plan dated 10/14/19 for Resident #31 revealed the resident was at risk for nutritional or hydration risk related to fluid overload. Intervention was to monitor intake of fluids. Review of a progress note dated 10/29/19 at 11:48 A.M. referring to an email from dialysis revealed the center was concerned about the resident's weight. The note revealed he had an adjustment to his phosphate binders, but weight gain was an issue. The center revealed they planned to speak to Registered Dietician (RD) #500 for the facility. Further review of the progress notes revealed the resident had not been out to the hospital for anything. Interview with Dietary Manager (DM) #203 on 10/31/19 at 10:59 A.M. revealed she knew the resident was on a fluid restriction and he received 750 milliliters a day from dietary. She stated she didn't see him getting extra fluids in the facility and she had educated the staff on his fluid restriction. Interview with State Tested Nursing Aide (STNA) #242 on 10/31/19 at 11:06 A.M. who was caring for the resident on this day revealed she had been passing water and ice to Resident #31. She stated he drank a lot of water. She said it wasn't on her care tracker to provide a fluid restriction for the resident. Interview with LPN #213 on 10/31/19 at 11:19 A.M. revealed she wasn't aware of a fluid restriction for the resident and had not been implementing it. She stated this was probably an order that got missed during the transfer from one charting program to another. Interview with RD #500 on 10/31/19 at 11:34 A.M. revealed Resident #31 was on a fluid restriction. When asked if she educated the staff about the fluid restriction she replied they should know what to do for a fluid restriction. She stated she received an email from the dialysis center and stated she knew about the elevated phosphorus levels but didn't see about the weight gain. Interview with the DON on 10/31/19 at 12:00 P.M. revealed there wasn't any documentation for the fluid restriction. She stated it was put in the system as a dietary order only and the nurse couldn't sign off on it since it wasn't in the nursing side of the electronic charting. A policy was requested, but not received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 11 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and facility policy review the facility failed to notify the physician of a significant weight loss for Resident #50 and failed to implement fluid restrictions for Resident #31. This affected two (Resident's #31 and #50) of two residents reviewed for change in condition. The facility census was 62. Residents Affected - Few Findings include: 1- Review of Resident #50's medical record revealed an admission date of 05/21/19 and a readmission date of 09/26/19 with diagnoses including anemia, muscle weakness, dysphagia following cerebral infarction, mild intellectual disabilities and anorexia. Review of the Minimum Data Set (MDS) quarterly review dated 10/17/19 revealed Resident #50 was moderately cognitively impaired and required the extensive assistance of two people for bed mobility and transfers. The resident required extensive assistance of one person for dressing and toileting, and supervision and set up care for eating. Resident #50 had a weight loss of five percent (%) or more in one month and/or 10 % or more in six months and was not on a physician prescribed weight loss program. Review of Resident #50's care plan dated 06/11/19 revealed the resident was at risk for malnutrition and weight loss with interventions and goals of weight maintained within acceptable parameters, consult with dietician and follow recommendations, keep physician and significant other/designated family member informed of any weight loss, monitor and record percentage of food intake and monitor for weight loss. Review of Resident #50's discontinued physician orders revealed Ensure clear eight ounces (a nutritional supplement) three times a day for the diagnoses of body mass index of 19.9 or less was ordered on 07/24/19 and discontinued on 10/17/19. Review of Resident #50's physician order dated 10/17/19 revealed an order for a regular diet with mechanical soft consistency and thin liquids. Review of Resident #50's dietary progress note dated 10/21/19 at 11:52 A.M. revealed weight today 109.4 pounds, down a few pounds since the beginning of the month. Weight loss 11.2 % in 30 days. The note further revealed the resident looked as if she was gaining and was eating well. That food preferences were known and a weight gain was expected and would be monitored. No documentation that the physician was notified of the weight loss was found in the resident chart. Interview with Social Services Director #256 on 10/31/19 at 10:53 A.M. revealed that Resident # 50 continued to have weight loss. Interview with the Director of Nursing (DON) and Corporate DON #205 on 10/31/19 at 12:15 P.M. revealed that the nurse was responsible for notifying the physician of a significant weight loss and there was no documentation that the physician was notified. The DON stated that the dietician writes down the weight loss information on her monthly audits and that audit was provided to the facility but the physician was not notified of the weight loss. Interview with the Dietician #300 on 10/31/19 at 12:38 P.M. confirmed that Resident #50's weight loss was documented on the monthly audits and Dietician #300 did not notify the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 12 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Change of Condition dated 07/10/18 revealed the facility will evaluate and document changes in the resident's health, mental or psychosocial status in an efficient and effective manner to document actions to include a significant change in the resident's physical, mental or psychosocial status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 13 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy review the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) was completed correctly and timely, behaviors were monitored for an antipsychotic medication, and recommendation from the pharmacy was completed. This affected one (Resident #1) of five reviewed for unnecessary medications. In addition, the facility failed to ensure resident's blood sugars were reported to the physician and pharmacy recommendations were completed. This affected one (Resident #42) of five reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 06/17/09. Medical diagnoses included hypertension, atrial fibrillation, diabetes, depression, anxiety, manic depressive, and schizophrenic. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. Her functional status was supervision for bed mobility, transfers, toileting and eating. Review of physician orders dated 07/11/18 revealed Seroquel (anti-psychotic) 25 milligrams (mg) to be given every day. Review of AIMS dated 11/14/18 revealed Resident #1 scored a two for mild jaw movement, a three for moderate trunk movements, and a three for moderate severity of abnormal movements. If there was a score of three or four in only one of the seven body areas the resident should be referred for a complete neurological exam. Further review of the AIMS revealed there wasn't any completed after 11/14/18. Review of pharmacy recommendations for Resident #1 revealed her name was not on the pharmacy form dated 05/09/19 which indicated there was a pharmacy recommendation. Further review of the record revealed it was silent for a pharmacy recommendation and the resident was not out to the hospital during the time frame. Further review of the medical record for behaviors for Resident #1 revealed from 07/01/19 through 10/31/19 behaviors were only monitored during the month of October 2019. Interview with the Director of Nursing (DON) on 10/30/19 at 3:14 P.M. revealed she didn't have any documentation for behaviors except for October, 2019 and the records could have been lost when they changed charting systems. Interview with Corporate Director of Nursing (CDON) #205 on 10/30/19 at 4:50 P.M. revealed the AIMS was probably wrong, but would check for a neurological assessment for Resident #1. He verified the AIMS should be done every six months. Observation of Resident #1 on 10/31/19 at 8:45 A.M. revealed she had no abnormal movements related to medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 14 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #235 on 10/31/19 at 9:42 A.M. revealed Resident #1 had a long history of opening and closing of her mouth and rocking back and forth. She stated that she documented on the AIMS incorrectly on 11/14/18. She stated it was more of behaviors instead of from the medications. Follow up interview with CDON #205 on 10/31/19 at 11:10 A.M. verified there wasn't any recommendations that could be found by the facility or the pharmacy. Review of policy entitled Psychotropic Medications revised 09/05/18 revealed AIMS will be completed prior to intimating use of an antipsychotic medication and as required and every six months. Further review of the policy revealed to monitor psychotropic drug use daily noting any adverse effects such as increased somnolence or functional decline. Further review of the policy revealed the pharmacist will perform a monthly drug regimen review including a review of the resident's medical chart. The pharmacist will document on a separate report of any irregularities and notify the attending physician, medical director and the DON. The consultant pharmacist and the nursing care center will follow up on recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 days. 2. Medical record review revealed Resident #42 was admitted on [DATE]. Medical diagnoses included anxiety, depressive disorder and diabetes. Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact. Functional status was extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of pharmacy recommendations for Resident #42 revealed her name was not on the pharmacy form which indicated there was a pharmacy recommendation dated 10/17/18 and 02/11/19. Further review of the medical record revealed there was no pharmacy recommendations for 10/17/18 or 02/11/19 and the resident was not out to the hospital during the time frame. Review of physician orders dated 06/09/19 through 07/23/19 revealed Novolog sliding scale to call the physician if blood sugar was less than 60 and more than 400. Further review of physician orders dated 07/23/19 revealed to discontinue the Novolog and resident was to only receive Novolin 130 units with every meal. Also received new order to stop faxing blood sugars weekly and go to faxing every three weeks. Further review of orders dated 07/30/19 for Resident #42 revealed Humulin R U-500 Kwikpen insulin to administer 130 units if under 200 and to administer 140 units if more than 200. There were no other parameters. Review of blood sugars from 07/01/19 through 09/27/19 for Resident #42 revealed as follows: 07/01/19-54 07/05/19 -520 07/22/19-487 07/27/19-455 08/11/19-509 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 15 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 08/25/19-466 Level of Harm - Minimal harm or potential for actual harm 08/26/19-527 08/28/19-407 Residents Affected - Few 08/28/19-53 09/27/19-453 Review of progress notes dated 07/01/19 through 09/27/19 for Resident #42 revealed there wasn't any notification made to the physician for the above mentioned blood sugars. There wasn't any faxes that could be produced for the resident from 07/01/19 through 09/27/19. Interview with LPN #235 on 10/30/19 at 2:41 P.M. revealed the facility faxed the blood sugars to the endocrinologist, but couldn't produce any. She said the physician didn't want them to call with high or low blood sugars. She verified there wasn't any Situation, Background, Assessment and Recommendation (SBAR) or events in the charting for the resident's high and low blood sugars. Interview with LPN #213 on 10/31/19 at 10:20 A.M. revealed she charted those blood sugars that were high and low and she said there wasn't any order to call the physician for these blood sugars. She said the blood sugars are faxed every two weeks to an endocrinologist, but couldn't produce any faxes that they were done. She said nursing practice would tell her to call the physician, but now we have parameters for the blood sugars to call physician for less than 60 or greater than 400. Interview with Registered Nurse (RN) #241 on 10/31/19 at 10:28 A.M. revealed she had not put a note in the chart. RN #241 said she would have called the doctor for low blood sugars. She said the original order was to fax the blood sugars every two weeks to the endocrinologist, but it didn't have any parameters and she didn't call for clarification. Interview with CDON #205 on 10/31/19 at 11:10 A.M. verified there wasn't any pharmacy recommendations that could be found by the facility or the pharmacy for Resident #42 Review of policy entitled Psychotropic Medications revised 09/05/18 revealed the pharmacist will perform a monthly drug regimen review including a review of the resident's medical chart. The pharmacist will document on a separate report of any irregularities and notify the attending physician, medical director and the DON. The consultant pharmacist and the nursing care center will follow up on recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 Review of policy entitled Change of Condition dated 07/10/18 revealed the facility will evaluate and document changes in a resident's health status in an efficient and effective way and relay the evaluation information to the physician and document actions to include a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 16 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and facility policy review the facility failed to properly store and date food items to prevent contamination and spoilage. This had the potential to affect 59 of 62 residents as the facility identified there residents (Resident #39, #155, and #207) who did not eat by mouth . The census was 62. Findings include: Observation of the kitchen on 10/28/19 at 8:48 A.M. revealed a loaf of sliced white bread in a plastic crate open to air and stored in the dry food storage room in the corner where all the bread and buns were stored. Interview with Dietary Manager #203 on 10/28/19 8:53 A.M. verified the loaf of bread was open to air and should be closed when stored. Observation of the kitchen on 10/28/19 at 9:00 A.M. revealed a package of hot dog buns dated 10/17/19 stored with the bread products and a package of elbow macaroni noodles that were opened and undated. Interview with Dietary Aid # 264 on 10/28/19 at 9:05 A.M. confirmed that the package of hot dog buns were dated for 10/17/19 and that facility was supposed to use the bread prior to the expiration date stamp. Dietary Aid #264 verified the open package of elbow macaroni noodles was not dated and that all food items were to be dated when they were opened so staff could verify the product was still fresh. Review of the facility policy titled Food Storage dated 08/09/17 revealed any expired or outdated food products should be discarded and all products should be inspected for safety and quality and be dated upon receipt and when they are prepared. Leftovers should be dated according to the leftover policy and to cover, label and date each product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 17 of 18 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and facility policy review the facility failed to ensure infection prevention procedures were followed. The facility failed to properly clean Resident #205's perineal area during indwelling Foley catheter care. This affected one (Resident #205) of two residents reviewed for catheter care. The facility census was 62. Residents Affected - Few Findings include: Record review of Resident #205 revealed an admission date of 10/22/19 with diagnoses of: fracture of unspecified parts of unbearable spine and pelvis, fracture of upper end of right humerus, orthostatic hypotension, anemia, cerebral infarction, polyneuropathy, and retention of urine. Review of a physician order dated 10/23/19 revealed change Foley catheter as needed. Observation of indwelling Foley catheter care for resident #205 on 10/30/19 at 3:22 P.M. revealed Licensed Practical Nurse (LPN) #252 got her materials ready including soap, water, wash cloths, and a wash basin. LPN #252 preceded to clean the Foley catheter tubing with soap and water and then rinsed the catheter tubing. LPN #252 did not clean the resident's perineal (vaginal) area during the catheter care. Interview with LPN #252 on 10/30/19 at 4:55 P.M. verified that she did not clean Resident #252's perineal area during catheter care, and she only cleaned the catheter tubing. Review of the facility policy titled Catheter Care Procedure dated 05/23/18 revealed to use non dominant hand to gently separate labia to fully expose urethral meatus and catheter. Provide perineal hygiene using soap and warm water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 18 of 18