Inspection visit

Health inspectionJuly 9, 2025

SIGNATURE HEALTHCARE OF FAYETTE COUNTYCMS #36567926 citations on this visit

26 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 26 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 record review, staff interview, and review of facility policy, the facility failed to ensure written authorization forms for the facility to manage resident funds were appropriately completed for three residents (#34, #55, and #188). Additionally, the facility failed to ensure one resident (#55) received his monthly $50 allowance. The facility census was 54. Residents Affected - Few Findings include 1. Review of the medical record for Resident #55 revealed an admission date of 07/30/24. Diagnoses included epilepsy, anxiety, dementia, diabetes, psychotic disorder, and heart failure. Review of the fund authorization form dated 11/25/24 revealed it was signed by Resident #55 with no witness signature. Review of the fund statements revealed Resident #55 in 01/2025 had an income of $923 from social security and a care cost withdrawal of $938 for an overall income of negative (-) $15. In 02/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. In 03/2025, Resident #55 had an income of $946 twice from social security with no care cost withdrawal. In 04/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal liability of $3,656 to the previous ownership and a delayed care cost on 05/14/25 of $938 for an overall income of $8. In 05/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. In 06/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. Review of facility email communication with the local Jobs and Family Services (JFS) office revealed the facility informed the local JFS representative of Resident #55's social security income and care cost amount and the same day his care cost was adjusted to $896, so he received $50 each month. Review of a facility refund request dated 06/18/25 revealed a request for Resident #55 to receive a refund to the resident fund account in the amount of $233. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 62 Event ID: 365679 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 07/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #55 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. BOM #111 confirmed, according to the instructions on the form, fund authorizations required two signatures of witnesses. Interview on 06/17/25 at 6:17 P.M. with BOM #111 confirmed Resident #55's accounts had errors after transfers of funds and acknowledged the facility had no access to documentation of resident fund statements prior to 12/2024. BOM #111 revealed her understanding was a resident could take out $50 each month but denied knowledge that residents should receive their social security less $50 for care costs to the facility. BOM #111 also acknowledged the resident's account ranged from negative $15 to an overall income of $8 monthly, instead of $50 he should have received. BOM #111 revealed she reached out to the local JFS office about getting Resident #55's care cost down and when asked for evidence of this communication, an email dated 06/17/25 was provided. Interviews on 06/18/25 from 10:00 A.M. to 3:00 P.M. with BOM #111 revealed the facility had agreed to refund Resident #55 $233 of overpayment. Interview on 06/24/25 at 4:00 P.M. with the Administrator confirmed Resident #55's money was returned after surveyor intervention and communication with the local JFS office occurred was initiated by the facility after surveyor intervention. 2. Review of the medical record for Resident #34 revealed an admission date of 10/06/23. Diagnoses included Parkinson's, vascular disease, kidneys disease, and heart failure. Review of the undated fund authorization revealed an illegible signature that was allegedly signed by Resident #34. The form did not contain a witness signatures. Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #34 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. BOM #111 additionally confirmed the signature was illegible and, according to the instructions on the form, fund authorizations required two signatures of witnesses. 3. Review of the medical record for Resident #118 revealed an admission date of 02/08/24 and discharge date of 11/30/24. Diagnoses included epilepsy, alcohol abuse, vascular disease and malnutrition. Review of the fund authorization dated 04/15/24 revealed it was signed by Resident #118. The form did not contain a witness signature. Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #118 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. Review of the facility policy titled RFMS Concepts dated 12/01/24 revealed a resident can elect to have his/her income directly deposited in the Resident Funds Management system. The designated assistant/receptionist will have the resident, representative payee, Power of Attorney, or Guardian complete the RFMS authorization form. The policy did not include language relating to witnessing of authorization forms or practices of accounting and care costs withdrawals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 2 of 62 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 07/09/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, and review of facility policy and procedures, the facility failed to ensure the personalized air conditioner (PTAC) in Resident #55's room was maintained in a clean manner and the facility also failed to maintain plumbing in Resident #48's bathroom to prevent leaking. This affected two residents (#48 and #55) of 30 residents in the sample. The facility census was 64. Findings include 1. Review of the medical record for Resident #55 revealed an admission date of 07/30/24. Diagnoses included epilepsy, anxiety, dementia, diabetes, psychotic disorder and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 05. Interview and observation on 06/16/25 at 10:33 A.M. with Resident #55 confirmed PTAC machine was visibly dirty and had a thick layer of dust on the vent. Resident turned on the PTAC air conditioner and a foul (trash like) smell came from the unit. Interview and observation on 06/17/25 at 3:25 P.M. with Resident #55 revealed the PTAC and vent had not been cleaned with large pieces of debris and a thick layer of dust. Interview and observation 06/17/25 at 3:31 P.M. with Maintenance Director #110 confirmed PTAC unit was dirty with large pieces of debris and a thick layer of dust. He revealed he was responsible for care and maintenance of the PTAC unit. Review of the undated facility policy titled Housekeeping/Environment Services revealed cleaning schedules shall be developed and implemented to assure each area of the facility was maintained. 2. Review of the medical record for Resident #48 revealed an admission date of 03/04/25. Diagnoses included pulmonary disease, heart disease, and visual loss. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. Interview and observation on 06/17/25 at 3:25 P.M. with Resident #48 revealed the bathroom had a leak and when you stepped on the flooring, water beads would seep through the cracks between the floorboards. Interview and observation 06/17/25 at 3:31 P.M. with Maintenance Director #110 confirmed the water beads coming up from bathroom flooring in Resident #48's room. Review of the undated facility policy titled Housekeeping/Environment Services revealed cleaning schedules shall be developed and implemented to assure each area of the facility was maintained. This deficiency represents non-compliance investigated under Complaint Number OH00165179. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 3 of 62 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 07/09/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy and procedures, the facility failed to ensure as needed (PRN) psychotropic medication and antianxiety medication were not ordered for longer than 14 days without a stop date or reassessment for appropriateness. This affected one resident (#21) of five reviewed for unnecessary medication. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's physician order dated 04/02/25 to 06/24/25 revealed an order for Haloperidol (antipsychotic medication) injection solution 5 milligrams per milliliter (mg/ml) with instructions to give 10 mg once every 24 hours as needed (PRN) for severe agitation. Review of Resident #21's Medication Administration Record (MAR) dated April 2025, May 2025 or June 2025 found Resident #21 did not receive any doses of this medication. Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. Interview on 06/24/25 at 10:15 A.M. with Director of Nursing (DON) confirmed Resident #21 had an order for a Haldol injection as needed dated 04/02/25 that was currently active. The DON confirmed the medication had no stop date and also was unable to provide evidence of any reassessment for the medication to continue past 14 days. 2. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. a. Review of Resident #21's physician orders revealed an active order initiated on 03/07/25 for Lorazepam (antianxiety medication) 0.5 milliliters (ml) by mouth with instructions to give every four hours as needed (PRN) for anxiety. Review of Resident #21's Medication Administration Record (MAR) dated March 2025 revealed the resident received the medication once on 03/08/25, 03/11/25, 03/12/25, 03/18/25, 03/20/25, 03/21/25, and 03/24/25, and twice on 03/13/25. Review of Resident #21's MAR dated April 2025 and May 2025 revealed the resident did not receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 4 of 62 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 07/09/2025 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 0605 any doses. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. Residents Affected - Few b. Review of Resident #21's physician orders revealed an overlapping order dated 03/08/25 to 03/12/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's MAR dated March 2025 revealed the resident received the medication once on 03/08/25, 03/10/25 and 03/12/25, and three times on 03/09/25. c. Review of Resident #21's physician orders revealed an overlapping order dated 03/12/25 to 03/12/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed for anxiety and give one tablet by mouth six times a day. Review of Resident #21's Medication Administration Record (MAR) dated 03/12/25 revealed the resident did not receive any doses. d. Review of Resident #21's physician orders revealed overlapping orders dated 03/12/25 to 03/13/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed (PRN) for anxiety. Review of Resident #21's Medication Administration Record (MAR) for 03/12/25 to 03/13/25 revealed the resident received PRN doses intermittently. e. Review of Resident #21's physician orders revealed an overlapping order dated 03/13/25 to 04/23/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tab every four hours as needed (PRN). Review of Resident #21's Medication Administration Record (MAR) revealed in March 2025 the resident received all scheduled doses as ordered and received the PRN the medication dose once on 03/13/25. In April 2025 the resident received all scheduled doses as ordered and did not receive any PRN doses. Review of Resident #21's pharmacy recommendation dated 03/17/25 revealed the resident was receiving the PRN psychoactive medication, Lorazepam 0.5 mg every four hours as needed. The form had the information circled with a note to clarify with pharmacy. The provider wrote they disagreed with the recommendation and documented the reason as hospice. The provider did not sign or date when they reviewed the pharmacy recommendation. Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. f. Review of Resident #21's physician order dated 04/24/25 to 04/24/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours for restlessness anxiety and agitation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 5 of 62 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 07/09/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #21's Medication Administration Record (MAR) dated 04/24/25 revealed the resident did not receive any doses. Interview on 06/24/25 at 10:15 A.M. with Director of Nursing (DON) confirmed Resident #21 had an order for Lorazepam PRN with overlapping dates and duplicate orders from March to April 2025. The DON also confirmed that some of the orders did not have a stop date and others were active over 14 days without a stop date and without any reassessment to continue past 14 days. Review of the facility policy titled Psychotropic's, dated September 2021 revealed the facility shall use psychotropic's appropriately and comply with state and federal regulations for psychopharmacological medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 6 of 62 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 07/09/2025 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 - Potential for minimal harm Based on review of the employee files, staff interview, and review of the facility policy and procedure, the facility failed to complete employee reference checks prior to hire and failed to ensure documented evidence of written policies and procedures pertaining to screening potential new employees with employee reference checks prior to hire. This had the potential to affect all facility residents. The facility census was 64. Residents Affected - Many Findings include: 1. Review of the employee file for Certified Nursing Assistant (CNA) #120 revealed she began employment on 04/09/24. The employee file had no evidence of reference checks being completed prior to hire. 2. Review of the employee file for Certified Nursing Assistant (CNA) #124 revealed she began employment on on 05/31/25. The employee file had no evidence of reference checks being completed prior to hire. 3. Review of the employee file for Licensed Practical Nurse (LPN) #78 revealed she began employment on 06/08/25. The employee file had no evidence of reference checks being completed prior to hire. 4. Review of the employee file for Licensed Practical Nurse (LPN) #79 revealed she began employment around October 2024, the facility was unable to provide an exact start date. The employee file had no evidence of reference checks being completed prior to hire. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing (DON) revealed reference checks were not in the employee files for CNA #120 and #124 and LPN #78 and LPN #79. Interview on 06/24/25 at 4:20 P.M. with the Administrator and Director of Nursing (DON) confirmed the facility had no policy related to employee reference checks. The DON stated this company does not do reference checks. 5. Review of the facility policy titled, Abuse Investigation and Reporting, dated September 2021 revealed no written/documented evidence within the policy related to screening potential staff for a history of abuse, neglect, exploitation or misappropriation, including attempting to obtain information from previous employers and/or current employers. Interview on 06/24/25 at 4:20 P.M. with the Administrator and Director of Nursing (DON) confirmed the facility had no policy related to employee reference checks. The DON stated this company does not do reference checks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 7 of 62 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 07/09/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner. This affected four residents (#17, #47, #54, and #60) of four residents reviewed for timely MDS completion. Residents Affected - Some Findings include: 1. Review of the medical record of Resident #60 revealed an admission date of 02/09/24. Diagnoses included cervical spinal cord injury (C4), quadriplegia, morbid obesity, and chronic osteomyelitis of coccyx. Review of Resident #60's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for all activities of daily living. Further review of the MDS assessment revealed the assessment was completed on 06/09/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #60's MDS assessment, dated 05/17/25 was not completed until 06/09/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #60's MDS dated [DATE] should have been completed by 05/30/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. 2. Review of the medical record of Resident #54 revealed an admission date of 01/04/23. Diagnoses included hemiplegia, epilepsy, and nontraumatic intracerebral hemorrhage. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/30/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #54's MDS assessment, dated 05/14/25, was not completed until 05/30/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #54's MDS dated [DATE] should have been completed by 05/27/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. 3. Review of the medical record of Resident #47 revealed an admission date of 04/21/25. The resident discharged from the facility on 05/20/25 and did not return. Diagnoses included encounter for surgical aftercare following surgery on the digestive system and cerebral infarction. Review of Resident #47's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/12/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #47's MDS assessment, dated 04/28/25 was not completed until 05/12/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #47's MDS dated [DATE] should have been completed by 05/11/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 8 of 62 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 07/09/2025 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 0640 Level of Harm - Minimal harm or potential for actual harm 4. Review of the medical record of Resident #17 revealed an admission date of 04/21/25. Diagnoses included chronic obstructive pulmonary disease and severe protein-calorie malnutrition. Review of Resident #17's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/13/25. Residents Affected - Some Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #17's MDS assessment, dated 04/28/25 was not completed until 05/13/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #17's MDS dated [DATE] should have been completed by 05/11/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. Review of the facility policy titled, MDS Completion and Submission Timeframe's, dated September 2021, revealed resident assessments would be completed and submitted based on the requirements published in the Resident Assessment Instrument Manual (RAI). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 9 of 62 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 07/09/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two Residents (#21 and #25) of 30 residents reviewed in the sample. The facility census was 64. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. a. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #21 had falls on 12/15/24, 02/28/25, 03/05/25, 03/06/25, 03/13/25, and 03/17/25. Review of Resident #21's progress note dated 02/28/25 revealed the resident had a fall by her room door when trying to leave during a fire drill. The resident's wrist was visibly swollen and an X-ray was ordered. Review of the fall investigation dated 02/28/25 revealed Resident #21 had a fall with injury and a swollen wrist. The X-ray returned with no findings of a fracture. Review of the progress notes dated 03/05/25 revealed Resident #21 had a fall and was found on the ground leaning up against the bathroom door. Resident #21 had a hematoma to the right eye brow. Review of the fall investigation dated 03/05/25 revealed Resident #21 had a fall with injury, a hematoma to the right eye brow. b. Review of physician orders dated 03/07/25 to 06/24/25 revealed Resident #21 was ordered Lorazepam 0.5 milliliters (ml) by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's physician orders revealed an overlapping order dated 03/13/25 to 04/23/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tab every four hours as needed. Review of Resident #21's Medication Administration Record (MAR) revealed the resident was receiving the medication every four hours and as needed. Review of physician order dated 04/24/25 for Lorazepam 0.5 mg with instructions to give one tab every four hours for restlessness anxiety and agitation. c. Review of dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. It stated the resident had no broken teeth and no mouth pain or discomfort. The MDS also revealed resident was prescribed antipsychotic medication, but question N0450 was documented as no antipsychotic's were not received. The MDS stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 10 of 62 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 07/09/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for question J1800 had the resident had any falls since admission, entry of reentry of since prior assessment whichever was more recent was marked no indicating the resident had no prior falls. It also did not include any falls with injuries. Interview on 06/16/25 at 11:56 A.M. with Resident #21 revealed she had several broken teeth that needed pulled and had not heard any update on getting extractions scheduled. Interview on 06/24/25 at 11:05 A.M. with Regional Nurse #160 confirmed Resident #21's MDS assessment was marked incorrectly for dental problems and for the use of antipsychotic's. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with the Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #21 had dental problems not accurately marked on the MDS assessment, psychotropic medications ordered and/or administered that were not accurately marked on the MDS, and falls/falls with injury were not marked accurately on the MDS. 2. Review of the medical record for Resident #25 revealed an admission date of 12/30/16. Diagnoses included chronic obstructive pulmonary disease, diabetes, kidney disease and muscle weakness. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #25 had falls on 02/20/25, 03/18/25, 04/14/25, 04/19/25, 05/04/25 and 05/19/25. Review of the fall investigation dated 04/19/25 revealed Resident #25 had an unwitnessed fall at 7:20 A.M. when the resident slid out of bed trying to get up to go to the bathroom. Resident #25 landed on the right side and complained of right arm pain. Resident #25 was noted to have a new skin tear measuring 3 centimeters (cm) by 3 cm on the right elbow. Review of the internal fall investigation document dated 04/19/25 revealed Resident #25 had an injury to the right upper arm (pain) and a skin tear to the right elbow. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 6:45 P.M. when the resident was found on the ground floor with her back on the bottom bar of the overbed table. Resident #25 stated she was going to the bathroom. Abrasions were noted to the back of the resident's head. Review of the internal fall investigation document dated 05/19/25 revealed Resident #25 had an injury, an abrasion to the back of the head. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had assessment that stated for question J1800 had the resident had any falls since admission, entry of reentry of since prior assessment whichever was more recent was marked no indicating the resident had no prior falls and no falls with injury were documented. Resident had not had an updated MDS assessment since the second fall with injury occurred. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with the Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #25 had falls and falls with injury and they were not marked accurately on the MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 11 of 62 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 07/09/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) was updated after a change in the mental health diagnosis for one resident. This affected one resident (#21) out of four reviewed for PASARR. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes and malnutrition. A diagnosis of unspecified psychosis was added to the medical record on 07/02/22 and schizophrenia was added to the medical record as a diagnosis on 07/19/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's most recent PASARR dated 10/24/23 revealed panic/anxiety disorder and another mental disorder were documented (delusional disorder and post-traumatic stress disorder). There was no documented evidence of a new PASARR to reflect the change in mental disorder diagnosis (schizophrenia) after the diagnosis was given. Interview on 06/17/25 at 5:46 P.M. with Social Services (SS) #89 confirmed the facility did not complete an updated PASARR after a change in mental disorder diagnosis. SS #89 confirmed the facility had no process in place to ensure PASARR's were updated when a resident had a change in mental disorder diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 12 of 62 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 07/09/2025 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 review of facility policy and procedure, the facility failed to ensure care plans were developed as appropriate. This affected one resident (#21) of 22 residents reviewed for care planning. The facility census was 64. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphagia, muscle wasting, diabetes, and malnutrition. Review of the social services documentation revealed Resident #21 was approved for Medicaid on 07/17/24. Review of Resident #21's dental consent dated 07/31/24 revealed the resident signed a consent to receive dental services. Review of the dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. The note further stated Medicaid resident-resources were sent to the facility and the appointment should be scheduled with a Medicaid provider, location determined by the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. It stated the resident had no broken teeth and no mouth pain or discomfort. Review of the plan of care on 06/23/25 revealed Resident #21 did not have any care plan related to dental needs. Interview on 06/16/25 at 11:56 A.M. with Resident #21 revealed she had several broken teeth that needed pulled and she had not heard any update on getting extractions scheduled. Interview on 06/17/25 at 5:46 P.M. with Social Services #89 revealed Resident #21 was seen by the dentist 04/16/25, but confirmed a follow up was not scheduled and she was unaware of any recommendations for needs for a follow up. Interview on 06/23/25 from 10:00 A.M. to 2:30 P.M. with Regional Nurse #160 confirmed the facility had no documented evidence of a care plan for dental needs for Resident #21, including having pain and broken teeth and needing significant extractions. Review of facility policy titled Care Plans, Comprehensive Person Centered, dated September 2021 revealed a care plan that included measurable objectives and timetables to meet resident needs shall be developed and implemented for each resident. The interdisciplinary team shall develop a care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 13 of 62 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 07/09/2025 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 - Some 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, staff interview, resident interview, and policy review, the facility failed to ensure care plans were updated/revised as needed and accurate. This affected four (#4, #10, #21, and #55) of 22 residents reviewed for care planning. The facility also failed to ensure care conferences were held on a routine basis. This affected three (#10, #50 and #162) of four residents reviewed for care conferences. Findings include: 1. Review of the medical record of Resident #55 revealed an admission date of 07/30/24. Diagnoses included schizoaffective disorder, Parkinson's disease, and epilepsy. Review of Resident #55's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician orders revealed an order dated 05/15/25 for Resident #55 to be a Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) code status, indicating the resident would receive comfort care, but no resuscitation efforts in the event of cardiac or pulmonary arrest. Review of Resident #55's signed DNR form dated 04/15/25 revealed the resident was a DNR-CCA code status. Review of Resident #55's plan of care dated 12/04/24 revealed the resident was a full code status, indicating life saving measures would be completed in the event of cardiac or pulmonary arrest. Interview on 06/17/25 at 3:30 P.M., the Director of Nursing (DON) verified Resident #55's care plan did not match his code status orders. 2. Review of the medical record of Resident #4 revealed an admission date of 01/25/16. Diagnoses included epilepsy, schizophrenia, anxiety, and depression. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with all activities of daily living with the exception of bathing, which required supervision. Review of Resident #4's medical record revealed an order dated 02/12/25 for the resident to be a Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) code status, indicating the resident would receive comfort care, but no resuscitation efforts in the event of cardiac or pulmonary arrest. Review of Resident #4's signed DNR form dated 06/02/21 revealed the resident was to be a DNR-CCA. Review of Resident #4's care plan dated 01/02/25 revealed the resident was a full code status, indicating life saving measures would be completed in the event of cardiac or pulmonary arrest. Interview on 06/17/25 at 3:30 P.M., the Director of Nursing (DON) verified the plan of care did not match Resident #4's code status order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 14 of 62 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 07/09/2025 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 - Some 3. Review of the medical record of Resident #50 revealed an admission date of 08/04/22. Diagnoses included chronic obstructive pulmonary disease, anxiety, depression, type two diabetes mellitus with diabetic neuropathy, malingerer, and antisocial personality disorder. Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] reveled the resident had intact cognition. Interview on 06/16/25 at 3:26 P.M., Resident #50 stated it had been a while since she had a care conference and she did not believe care conferences were being held on a quarterly basis. Review of the medical record revealed one care conference for the Resident #50 dated 12/17/24. Further review of the medical record revealed no evidence of any additional care conferences being completed during the prior year. Interview on 06/17/25 at 3:03 P.M., the Director of Nursing (DON) confirmed the last care conference for Resident #50 was held 12/17/24. The DON confirmed care conferences should be completed quarterly and Resident #50 only had one care conference in the past year. Review of the facility policy titled, Care Conference, dated 09/01/21, revealed the facility would hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care. 5. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's care conferences revealed on 02/16/25 Resident #10 and her son were present along with Director of Nursing (DON) and nurse for a care conference. The facility was unable to provide documented evidence of additional care conferences from the past 12 months. Interview on 06/18/25 at 8:56 A.M. with Social Services (SS) #89 revealed the care conference dated 02/16/25 was the only care conference for Resident #10 that they could locate. SS #89 reported it was difficult to schedule due to Resident #10's family request for Sunday meetings. SS #89 reported the facility did not hold meetings if residents or family were not in attendance. Review of the facility policy titled Care conferences dated 09/01/21 revealed the facility shall hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care. It stated meetings shall be held as needed. 6. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's weights revealed on 03/01/24 the resident weighed 318 pounds (lbs.) upon admission, on 08/03/24 the resident weighed 269.6 lbs., on 10/04/24 the resident weighed 255.8 lbs., on 11/06/24 the resident weighed 252.0 lbs., and on 12/07/24 the resident weighed 244.0 lbs. Review of the dietitian progress notes dated 01/08/25 revealed Resident #10's weight was trending down from 275 lbs. to 239 lbs. for a 13.1 percent (%) loss in 180 days with gradual weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 15 of 62 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 07/09/2025 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 - Some Double protein portions were recommended although the resident voiced displeasure with the quality of the food. Intakes were variable at 25 to 100%. House shakes had also been added and ordered on 12/20/24 for lunch and dinner trays. The order was discontinued on 02/03/25 when the resident was hospitalized . The physician and nursing staff were notified of the weight loss. Review of the dietitian's progress notes dated 01/29/25 revealed Resident #10 had a weight loss of 12.9% over 180 days. Intakes were variable at 25 to 75% of meals. Weekly weights were to be added due to the need for close monitoring and follow-up. The most recent weight to this dietitian's note, was on 01/07/25 when the resident weighed 239 lbs. Review of the plan of care dated 01/29/25 revealed Resident #10 had a nutritional problem or potential nutrition problem related to significant weight loss, feeding assistance, therapeutic diet, and meal refusals with interventions including to monitor, document and report signs and symptoms of dysphagia including pocketing, choking, coughing, drooling etc., monitor signs and symptoms of malnutrition including weight loss of over three pounds in one week, over five percent in one month, over seven and a half percent in three months, and over 10 percent in six months, to provide and serve diets as ordered, and dietitian to evaluate and make recommendations as needed. There was no documentation of a nutrition care plan prior to 01/29/25 and the care plan was not updated after the resident's weight loss, pureed diet order change or her hospitalization. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with pureed texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with pureed texture. Review of Resident #10's weights revealed on 02/03/25 and 02/04/25, the resident weighed 241.3 lbs. Review of Resident #10's physician orders dated 02/04/25 through 03/04/25 revealed an order for weekly weights. Review of Resident #10's weights revealed on 03/09/25 the resident weighed 217.4 lbs. Review of Resident #10's physician orders dated 03/11/25 through 05/21/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 03/12/25 revealed Resident #10 had a weight loss of 241 lbs. to 217.4 lbs. for a weight loss of 10% over 30 days. Resident #10 did not like the pureed texture, and intakes were low at 25 to 75% of meals. Med pass (supplement) was added three times daily as well as an appetite stimulant to improve intakes. The plan was to continue weekly weights for close monitoring and follow up. Interview on 06/18/25 at 4:30 P.M. with Regional Nurse #160 confirmed the care plan had not been updated since resident was switched to a pureed diet and no new interventions had been added after significant weight loss was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 16 of 62 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 07/09/2025 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 - Some 7. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's, dysphagia, muscle wasting, diabetes and malnutrition. Review of Resident #21's care plan dated 12/17/24 revealed the resident was at risk for falls with interventions to monitor for changes in mobility added on 12/17/24, food and fluids within reach added on 12/17/24, education on transfer and ambulation techniques added on 12/17/24, implement preventative fall interventions added on 12/17/24, resident and staff education on safety interventions added on 01/09/25, non-skid strips added on 01/23/25, non-skid footwear added on 01/23/25, remove recliner from the room and provide bed added on 02/18/25, toileting schedule added on 02/20/25, perimeter mattress/scoop mattress added on 02/25/25, medication review dated 03/04/25, maintain needed items within reach added on 03/05/25, mat to floor added on 03/05/25, room change closer to nurses station added on 03/07/25, low bed added on 03/13/25, bed against the wall added on 03/16/25, apply side rails added on 03/18/25, and increased lighting added on 03/18/25. Review of the medical record revealed Resident #21 had falls on 02/17/25, 02/20/25, 02/26/25, 02/28/25, 03/03/25, 03/05/25 in the morning and in the evening, 03/06/25, 03/13/25, 03/16/25 and 03/17/25. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a BIMS of 09. Review of fall investigation dated 02/28/25 and progress note dated 03/03/25 revealed Resident #21 had a fall trying to get out of her room during a fire drill. The new intervention was to offer resident to come to common areas during fire drills. The care plan was not updated with this intervention. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed the care plan was not revised with new interventions for Resident #21. 4. Review of the medical record for Resident #162 revealed an admission date of 11/14/24 with diagnoses that included chronic obstructive pulmonary disease (COPD), type one diabetes, and hypothyroidism. Review of Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. An interview conducted on 06/16/25 at 11:15 A.M. with Resident #162 revealed he had not been asked by facility staff to participate in an initial care conference upon admission. Review of the care conferences for Resident #162 revealed that care conferences took place on 03/19/25 and 06/09/25; however, there was no documented evidence of an initial care conference from Resident #162's admission. An interview conducted on 06/23/25 at 9:27 A.M. with the Social Worker #89 confirmed that Resident #162 did not have an initial care conference. Review of the facility policy titled Care Conference, dated 09/01/21, revealed the facility would hold regular interdisciplinary care conferences to provide residents and families the opportunity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 17 of 62 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 07/09/2025 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 participate in the plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 18 of 62 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 07/09/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review, resident interview, staff interview, and review of policy and procedure, the facility failed to ensure a resident received showers/bed baths as scheduled. This affected one (Resident #24) out of two residents reviewed for activities of daily living (ADLs). The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/26/23 and diagnoses including cerebral palsy (unspecified), generalized muscle weakness, unsteadiness on feet, and major depressive disorder (recurrent, mild). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Additionally, the resident required maximum assistance with bathing. Review of the care plan for Resident #24 revealed a self-care deficit related to factors including chronic fatigue, generalized weakness, impaired mobility, poor balance, poor coordination, and shortness of breath, which necessitated staff assistance with personal hygiene, including bathing. The care plan included goals to maintain the resident's current level of function while ensuring timely and adequate support with activities of daily living. Interventions specifically called for assistance with personal hygiene and bathing as needed, encouragement for the resident to use the call light to request help, and ensuring staff promptly responded to these needs. Review of the shower records for Resident #24 revealed multiple instances where showers were not provided as scheduled, with gaps exceeding seven days. Specifically, there was an 18-day gap between showers from 03/07/25 to 03/25/25, an 11-day gap from 03/28/25 to 04/08/25, another 11-day gap from 04/18/25 to 04/29/25, and an 8-day gap between 05/23/25 and 05/31/25, during which no showers were recorded. After 06/07/25, no further showers were documented. There was no documented evidence that the resident refused showers during these periods. Interview on 06/16/25 at 12:15 P.M. with Resident #24 revealed she would at times go more than a week without a bath and reported that facility staff would document a refusal even when she had not refused. She also stated she preferred bed baths over taking showers. Interview on 06/17/25 at 11:52 A.M. with Certified Nursing Assistant (CNA) #115 revealed that if residents refused showers, staff would ask the resident three times and then have them sign the shower sheet. She added that if the resident still refused, staff would ask again the next day. CNA #115 noted that Resident #24 received bed baths on Tuesdays and Fridays and typically did not refuse her bed baths. Interview on 06/17/25 at 11:56 A.M. with the Director of Nursing (DON), revealed that refusals for showers were only documented on the shower sheets and not in the progress notes. She also confirmed Resident #24 had multiple gaps in bathing. Interview on 06/18/25 at 9:44 A.M. with Resident #24 revealed that she had not been to the hospital recently and had remained in the facility the entire time. She reported refusing showers only a couple of times and that when she refused, she signed a refusal form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 19 of 62 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 07/09/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Activities of Daily Living (ADLs) revealed appropriate care and services were to be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 20 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interview, and review of facility policy and procedure, the facility failed to ensure fall investigations were completed thoroughly, included a root cause analysis, and appropriate fall interventions were initiated and in place. This affected four residents (#21, #25, #38, and #162) of five reviewed for falls. The facility census was 64. Findings include 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. Review of the care plan dated 12/17/24 revealed Resident #21 was at risk for falls with interventions including to monitor for changes in mobility added on 12/17/24, food and fluids within reach added on 12/17/24, education on transfer and ambulation techniques added on 12/17/24, implement preventative fall interventions added on 12/17/24, resident and staff education on safety interventions added on 01/09/25, non-skid strips added on 01/23/25, non-skid footwear added 01/23/25, remove recliner from the room and provide bed added 02/18/25, toileting schedule added on 02/20/25, perimeter mattress/scoop mattress added on 02/25/25, medication review dated 03/04/25, maintain needed items within reach added on 03/05/25, mat to floor added on 03/05/25, room change closer to nurses station added on 03/07/25, low bed added 03/13/25, bed against the wall added on 03/16/25, apply side rails added on 03/18/25, and increased lighting added on 03/18/25. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #21 had falls on 12/15/24, 02/28/25, 03/05/25, 03/06/25, 03/13/25, and 03/17/25. Review of the progress note dated 02/17/25 revealed while staff were in the room assisting Resident #21 with a bed bath, and the resident was scooting forward in her reclining chair and slid to the floor. No evidence of an investigation/report was provided. A later note on 02/17/25 revealed the new intervention included removing the recliner and having the bed return to the room. This fall was not included on the incident accident log. Review of the progress note dated 02/20/25 revealed Resident #21 had a fall with interventions to toilet every two hours. This fall was not included on the incident accident log. Review of the fall investigation dated 02/20/25 revealed Resident #21 had an unwitnessed fall at 8:15 A.M. when staff entered the room and found the resident sitting on her buttocks on the floor next to her bed. Resident #21 stated she was trying to have a bowel movement. A new intervention was created to toilet every two hours. At the time of the fall bed was found in low position and room was uncluttered. This fall was not included on the incident accident log. Review of the progress note dated 02/25/25 revealed while staff were answering a call light they found Resident #21 sitting on her buttocks. Resident #21 stated she was trying to go to the bathroom and tried to stand and walk to the commode. The resident stated she forgot she could not walk. This fall was not included on the incident accident log. Review of the progress note dated 02/26/25 revealed Resident #21 had a fall in her room after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 21 of 62 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 07/09/2025 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 0689 sliding out of bed. Level of Harm - Minimal harm or potential for actual harm Review of the fall investigation dated 02/26/25 revealed Resident #21 had a witnessed fall at 9:00 A.M. when the resident was found beside her bed in a sitting position. Resident #21 slid out of bed onto the floor. The bed was in a low position and the resident declined to go to the common area to sit. Resident #21 stated she kept forgetting she could not walk and when trying to get out of bed, she slid to the floor. Resident #21 was noted to be alert and oriented to self and a new intervention to apply non-skid strips to the floor beside the bed was initiated. This intervention was already in place per the care plan added 01/23/25. This fall was not included on the incident accident log. Residents Affected - Some Review of the progress note dated 02/28/25 revealed Resident #21 had a fall by her door. Resident #21's wrist was swollen and an x-ray was ordered. Review of the fall investigation dated 02/28/25 revealed Resident #21 had an unwitnessed fall at 4:30 P.M. when the resident was found lying across the floor in the room with the door closed due to a recent fire drill. Resident #21 was concerned the fire alarm was not a test and attempted to exit her room. Resident #21 was assisted back to bed. Her left wrist was swollen and an x-ray was ordered. No new interventions were mentioned in the report and the x-ray results came back with no findings of fracture. Review of the progress note dated 03/03/25 revealed Resident #21 had a fall after hearing the fire alarm on 02/28/25. The new intervention per note was to offer Resident to come to common areas during fire drills. Review of the progress note dated 03/03/25 revealed Resident #21 slid out of bed onto her buttocks. Resident #25 was noted with increased paranoia and confusion. Review of the fall investigation dated 03/03/25 revealed Resident #21 had an unwitnessed fall at 6:40 P.M. when the resident was found on her buttocks with no injury noted. Resident #21 had increasing periods of hallucinations and paranoia. Resident #21 stated they told me to leave or they were going to call the cops, staff reassured her safety. No new interventions were mentioned in the report. This fall was not included on the incident accident log. Review of the progress note dated 03/04/25 revealed Resident #21's new intervention was for a medication review to be completed. Review of the fall investigation dated 03/05/25 revealed Resident #21 had an unwitnessed fall at 3:00 A.M. when the resident was found on the floor after sliding off the bed. The bed was in a low position. Resident #21 stated she did not know why she was trying to get out of bed. No new interventions were mentioned in the report. This fall was not included on the incident accident log. Review of the progress notes dated 03/05/25 revealed Resident #21 had a fall after sliding from the bed. A second fall occurred where Resident #21 was found on the ground leaning up against the bathroom door. Resident #21 had a hematoma to the right eye brow. Review of the fall investigation dated 03/05/25 revealed Resident #21 had an unwitnessed fall at 4:15 P.M. when the resident was found on her buttocks leaning up against the bathroom door. Resident #21 had a noted injury (hematoma to right eyebrow). Resident #21 told staff she was trying to urinate. The bed was in a low position and the floor mat was in place. The fall investigation did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 22 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some include staff interviews of the last time the resident was assisted to the toilet. No new interventions were mentioned in the report. Review of the progress note dated 03/06/25 revealed Resident #21 had a fall and was found laying next to her floor mat. Resident #21 reported she tried to get a glass of water and the water was found on the floor mat. Resident #21 had been offered a drink about 45 minutes prior. Review of the fall investigation dated 03/06/25 revealed Resident #21 had an unwitnessed fall at 5:15 P.M. when the resident was found lying on the floor besides the floor mat. Resident #21 was assisted in a tilt back wheelchair and brought to the nurses station. Resident #21 stated she was trying to get a drink of water and the water was found on the floor mat. The nurse had reported she last saw Resident #21, 45 minutes prior and offered her water. No new interventions were mentioned in the report. Review of the internal fall investigation dated 03/06/25 revealed the new immediate intervention for Resident #21's fall included placing a water pitcher within reach when in bed. Resident #21 was also moved to a room closer to the nurses station. Review of the progress note dated 03/07/25 revealed new intervention recommendations from Resident #21's fall on 03/06/25 included to ensure water was within reach and move the residents room closer to the nursing station. Review of the fall investigation dated 03/13/25 revealed Resident #21 had an unwitnessed fall at 2:00 A.M. when the resident was found crawling across the floor in the room on her elbows facing the doorway by the sink. Resident #21's bed was in the low position and the floor mat was in place. Resident #21 was noted with continued confusion and agitation, and having conversations with people who were not in the room. Resident #21 was alert to herself only. No new interventions were mentioned in the report. Review of the progress note dated 03/13/25 revealed Resident #21 was found crawling on the floor on her elbows on the floor. Review of the progress note dated 03/16/25 revealed a fall occurred and Resident #21 slid out of bed. The facility had no investigation/incident report. The fall was not included on the incident accident log. Review of the progress note dated 03/17/25 revealed Resident #21 slid out of bed. Review of the fall investigation dated 03/17/25 revealed Resident #21 had an unwitnessed fall at 3:30 P.M. when the resident was attempting to go to the bathroom and slid out of the bed to the floor due to a recent fire drill. Resident #21 was concerned the fire alarm was not a test and attempted to exit her room. Resident #21 was assisted back to bed. Her left wrist was swollen and an x-ray was ordered. No new interventions were mentioned in the report and x-ray results came back with no findings of fracture. Review of the internal fall investigation dated 03/17/25 revealed Resident #21 was toileted and educated on utilizing the call light for assistance and transfers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 23 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impairment with a Brief Interview of Mental Status (BIMS) of 09. The answer to question J1800 revealed the staff marked no for no prior falls. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #21's falls dated 02/17/25, 02/20/25, 02/25/25, 02/26/25, 03/03/25, 03/05/25 (first fall), and 03/16/25 were not documented on the incident accident log. They confirmed the residents falls were missing a root cause analysis and many did not have any new interventions documented. They confirmed interventions were not specific to the cause of the fall and confirmed it would not be appropriate to have a new fall intervention, be something that was already in place at the time of the fall. They were unable to provide additional information if current interventions were in place and also failed to provide evidence of additional investigation information such as staff statements about the last time the resident was toileted, after several falls were related to the need to go to the bathroom. Regional Nurse #160 acknowledged fall procedures were lacking and staff were unaware of all falls. Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications. 2. Review of the medical record for Resident #25 revealed an admission date of 12/30/16. Diagnoses included chronic obstructive pulmonary disease, diabetes, kidney disease and muscle weakness. Review of Resident #25's care plan dated 02/18/24 revealed the resident was at risk for falls with interventions of monitor for changes in mobility added 02/18/25, walker within reach added on 02/21/25, implement preventative fall interventions added on 02/21/25, resident and family education to call for assistance before transferring added on 03/18/25, education on transfers and ambulation techniques added on 03/18/25, resident education on safety interventions added on 03/18/25, clear pathways added on 04/29/25, maintain needed items in reach added on 05/05/25, and remind resident to ask for assistance added on 05/20/25. Review of the incident accident log dated 12/01/24 to 06/16/25 revealed Resident #25 had falls on 02/20/25, 03/18/25, 04/14/25, 04/19/25, 05/04/25 and 05/19/25. Review of the fall investigation dated 02/20/25 revealed Resident #25 had an unwitnessed fall at 10:00 P.M. when staff found the resident sitting on her buttocks on the floor with her back against the bed and leaning on the left side with her elbow and palm against the floor. Resident #25 stated she was attempting to stand at the end of the bed and slid down the side of the bed. No new interventions were noted in the investigation. Review of the fall investigation dated 03/18/25 revealed Resident #25 had a witnessed fall at 3:15 P.M. after the resident had ambulated to the bathroom, became dizzy, lost her balance, and landed on her buttocks. No new interventions were noted in the investigation. Review of internal fall investigation document dated 03/18/25 revealed Resident #25 was educated on the importance of utilizing the call light for assistance with ambulating if feeling dizzy. Review of the fall investigation dated 03/24/25 revealed Resident #25 had an unwitnessed fall at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 24 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7:00 P.M. when the resident was ambulating back from the bathroom and her knee gave out and resident eased herself to the floor. Resident #25 reported she was not using her walker. No new interventions were noted in the investigation and this fall was not included on the incident accident log. Review of the fall investigation dated 04/14/25 revealed Resident #25 had an unwitnessed fall at 4:55 P.M. when the resident was trying to get into her wardrobe she leaned on the bed, lost her balance, and fell on her right side. Resident #25 reported new pain to her upper right arm and an injury was documented. No new interventions were noted in the investigation. Review of the fall investigation dated 04/19/25 revealed Resident #25 had an unwitnessed fall at 7:20 A.M. when the resident slid out of bed trying to get up to go to the bathroom. Resident #25 landed on the right side and complained of right arm pain. Resident #25 was noted to have a new skin tear 3 centimeters (cm) by 3 cm on the right elbow. No new interventions were noted in the investigation. Review of internal fall investigation document dated 04/19/25 revealed Resident #25 had injury to the right upper arm, pain, and a skin tear to the right elbow. Review of the fall investigation dated 05/04/25 revealed Resident #25 had an unwitnessed fall at 7:15 P.M. when the resident slid to the floor when trying to transfer herself without assistance. No new interventions were noted in the investigation. Review of Resident #25's internal fall investigation document dated 05/04/25 revealed the resident was reminded to call for assistance. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 6:45 P.M. when the resident was found on the ground/floor with her back on the bottom bar of the overbed table. Resident #25 stated she was going to the bathroom. Abrasions were noted to the back of the resident's head. Staff reminded her to call for staff assistance before getting out of bed. Review of internal fall investigation document dated 05/19/25 revealed Resident #25 had an injury/abrasion to the back of the head. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 8:00 P.M. when the resident fell while ambulating without assistance to go to the bathroom. Resident #25's room was noted to be clear of clutter. No new interventions were noted in the investigation and this fall was not included on the incident accident log. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25's assessment for question J1800 revealed the staff marked no for no prior falls and no falls with injury were documented. Interview on 06/18/25 at 4:54 P.M. and on 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed the falls dated 03/24/25 and the second fall on 05/19/25 were not documented on the incident accident log. They confirmed the fall investigations were generic and many did not have any interventions documented. They confirmed interventions were not specific to the cause of the fall. Regional Nurse #160 acknowledged that fall procedures were lacking and staff were unaware of all falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 25 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications. Residents Affected - Some 4. Review of record revealed that Resident #38 was admitted on [DATE]. Diagnoses included myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the facility fall document dated 04/27/25 revealed that Resident #38 slid off of his bed as he was noted to be sitting on the floor next to his bed. The physician and family were notified. Review of the progress note dated 04/27/25 revealed Licensed Practical Nurse (LPN) #79 stated she walked into Resident #38's room this morning to give him medication and the resident was noticed to be sitting on the floor in front of his bed. Resident #38 reported he was sitting on the side of the bed eating breakfast and just slid off, to the floor. The aides reported he was last seen sitting on his bed two minutes before. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had a Brief Interview of Mental Status (BIMS) of a 02 indicating the resident was severely cognitively impaired. Resident #38 was independent with eating, oral care, and personal hygiene. Resident #38 required partial to moderate assistance for toileting and substantial maximum assistance for dressing the lower body and baths. Review of the plan of care dated 05/20/25 revealed that Resident #38 was a fall risk related to decreased strength and endurance, functional problems, generalized weakness, history of falls, history of self-transfers, medications, and the need for assistance with activities of daily living. Interventions included implementing preventative fall interventions and devices and the resident was to be encouraged to sit in the wheelchair for meals. Observation on 06/16/25 at 4:50 P.M. with Resident #38 revealed he was sitting on the side of his bed eating at his bedside table. Resident #38 was sitting with regular socks on with his feet touching the floor. An unoccupied wheelchair was sitting in front of the window. Review of the facility daily schedule dated 06/17/25 and 06/18/25 revealed that Certified Nursing Assistant (CNA) #90 had worked Resident #38's hall for day shift. Observation on 06/17/25 at 5:00 P.M. Resident #38 sitting on his the side of his bed eating with the bedside table in front of him. Resident #38's feet were touching the floor and he had regular socks on his feet and no shoes. Interview on 06/23/25 at 9:15 A.M. with the Director of Nursing (DON) revealed the staff were supposed to be asking if Resident #38 would sit in his wheelchair for meals due to his fall from two months ago. The DON stated she was not aware of staff not asking Resident #38 to sit in his wheelchair during all meals in his room, but that staff should be asking Resident #38 to sit in his wheelchair for meals. The DON stated she was not notified by staff that Resident #38 was not using the wheelchair during meals. Interview on 06/23/25 at 10:29 A.M. with CNA #90 confirmed that last week she did not offer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 26 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 38 to sit in his wheelchair for both days, specifically on 06/17/25, when she worked at the facility. CNA #90 stated she did not know that Resident #38 was supposed to be asked to sit in a wheelchair during meals in his room. CNA #90 stated she was going to ask Resident #38 if he would sit in his wheelchair today. Review of the facility policy titled Falls dated September 2021 revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 3. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type one diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of Resident #162's initial fall risk assessment dated [DATE] revealed a score of 11, indicating moderate fall risk. Interventions included educating the resident on room orientation and call light use and ensuring the call light was within reach. Review of Resident #162's fall event dated 02/03/25 revealed the resident became dizzy and fell to his knees while returning to bed. A Certified nursing assistant (CNA) witnessed the fall but could not prevent it. Neurological checks were completed, and the walker was noted to be within reach. However, no new interventions were added, and this fall was not documented on the facility's incident and accident log. Review of Resident #162's fall event dated 05/03/25 revealed the resident was found lying in the hallway with his walker tipped over. He stated he became dizzy and saw black spots before falling. Neurological checks were completed. No injuries were noted. The only intervention added was resident education. The plan of care and interventions were not revised or expanded. Review of Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. The resident required moderate assistance with showering, transfers, and ambulation, and used a wheelchair for locomotion. Review of Resident #162's fall event dated 06/09/25 revealed the resident was found on his buttocks near the bed and reported falling after attempting to respond to someone calling his name. He stated he must have been asleep. Neurological checks were completed. No injuries were noted. There was no investigation documented whether existing interventions were in place and effective and no new interventions were implemented. Review of the plan of care dated 06/09/25 revealed Resident #162 was at risk for falls due to impaired mobility, weakness, and history of falls. Interventions included education to call for assistance before transferring, preventative fall interventions/devices, maintaining call light within reach, use of non-skid footwear, and safety education. Review of the updated fall risk assessment dated [DATE] revealed the resident remained at moderate risk for falls with a score of 40. Despite this, the care plan and existing interventions remained unchanged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 27 of 62 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 07/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/23/25 at 11:30 A.M. with Director of Nursing (DON) confirmed Resident #162 had a moderate fall risk and stated that education was the facility's primary fall prevention strategy. She confirmed new interventions also were not initiated for the 06/09/25 fall. Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications. Event ID: Facility ID: 365679 If continuation sheet Page 28 of 62 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 07/09/2025 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** Based on observations, medical record review, staff interview, family interviews, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of nutritional problems and malnutrition, maintained acceptable parameters of nutritional status, and failed to follow nutritional interventions, complete weekly weights as ordered, provide appropriate assistance with meals, and provide appropriate oversight and monitoring to address significant and severe weight loss for Resident #10. This affected one (#10) of five residents (#10, #21, #26, #34, and #35) reviewed for nutrition. The facility identified a total of eight residents (#10, #11, #21, #27, #33, #35, #46 and #58) as being at nutritional risk. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphagia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's medical record revealed no documented evidence of an admission nutritional assessment or admission risk assessment. Review of Resident #10's weights revealed on 03/01/24 the resident weighed 318 pounds (lbs.) upon admission, on 08/03/24 the resident weighed 269.6 lbs., on 10/04/24 the resident weighed 255.8 lbs., on 11/06/24 the resident weighed 252.0 lbs., and on 12/07/24 the resident weighed 244.0 lbs. Review of Resident #10's dietitian progress notes dated 12/18/24 revealed the resident's weight was trending down from 273 lbs. to 244 lbs. for a 10.6% weight loss in 180 days with 25 to 100% of intakes. Ice cream and pudding supplements were in place and weight loss was beneficial due to the residents' high Body Mass Index (BMI). The physician and nursing staff were notified of the weight loss. Review of Resident #10's physician order dated 12/20/24 revealed a diet order for regular diet at regular consistency with double protein portions. Review of Resident #10's physician orders revealed an order dated 12/23/24 for the resident to be assisted with meals due to pocketing food. Review of Resident #10's weights revealed on 01/07/25 the resident weighed 239 lbs. Review of the dietitian progress notes dated 01/08/25 revealed Resident #10's weight was trending down from 275 lbs. to 239 lbs. for a 13.1% loss in 180 days with gradual weight loss. Double protein portions were recommended although the resident voiced displeasure with the quality of the food. Intakes were variable at 25 to 100%. House shakes had also been added and ordered on 12/20/24 for lunch and dinner trays. The order was discontinued on 02/03/25 when the resident was hospitalized . The physician and nursing staff were notified of the weight loss. Review of progress note dated 01/28/25 revealed upon assessment, Resident #10 had increased confusion and frequent involuntary movements. Vital signs included blood pressure 143/90 millimeters of mercury (mmHg) [normal ranges around 120/80 mmHg], respirations 19 breaths per minute (normal ranges from around 12 to 18) and pulse 87 beats per minute (bpm) [normal ranges from around 60 to 100]. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 29 of 62 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 07/09/2025 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 Residents Affected - Few resident was maintaining oxygen saturation levels at 94 % on 3 liters of oxygen. After informing the nurse practitioner of findings, an order was received to send Resident #10 to the hospital for evaluation. Review of the dietitian's progress notes dated 01/29/25 revealed Resident #10 had a weight loss of 12.9% over 180 days. Intakes were variable at 25 to 75% of meals. Weekly weights were to be added due to the need for close monitoring and follow-up. The most recent weight to this dietitian's note, was on 01/07/25 when the resident weighed 239 lbs. Review of the plan of care dated 01/29/25 revealed Resident #10 had a nutritional problem or potential nutrition problem related to significant weight loss, feeding assistance, therapeutic diet, and meal refusals with interventions including to monitor, document and report signs and symptoms of dysphagia including pocketing, choking, coughing, drooling etc., monitor signs and symptoms of malnutrition including weight loss of over three pounds in one week, over five percent in one month, over seven and a half percent in three months, and over 10 percent in six months, to provide and serve diets as ordered, and dietitian to evaluate and make recommendations as needed. There was no documentation of a nutrition care plan prior to 01/29/25 and the care plan was not updated after the resident's weight loss, pureed diet order change or her hospitalization. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with pureed texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with pureed texture. Review of Resident #10's weights revealed on 02/03/25 and 02/04/25, the resident weighed 241.3 lbs. Review of Resident #10's physician orders dated 02/04/25 through 03/04/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 02/12/25 revealed Resident #10's weight loss was trending down from 270 lbs. to 241.3 lbs. with a weight loss of 10.7% over 180 days. Resident #10 had returned from the hospital with a diet downgrade to pureed texture. Intakes were poor at less than 25 to 75% of meals consumed. It noted that Resident #10 needed assistance for feeding at times and weekly weights were to be continued for close monitoring and follow-up. There was no documented evidence in the medical record of the resident having a weight of exactly 270 lbs. per this dietitian's note. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had significant cognitive impairment with a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. The resident was noted as independent with eating and had previous significant weight loss and was not on a weight loss program. Review of the physician note dated 03/03/25 revealed Resident #10 continued to require full assistance with activities of daily living including supervision during meals due to pocketing. She had chronic weight loss with a current weight of 239 lbs. It noted that Resident #10 had a history of poor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 30 of 62 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 07/09/2025 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 oral intake due to food dissatisfaction but agreed to house shakes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #10's weights revealed on 03/09/25 the resident weighed 217.4 lbs. Residents Affected - Few Review of Resident #10's physician orders dated 03/11/25 through 05/21/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 03/12/25 revealed Resident #10 had a weight loss of 241 lbs. to 217.4 lbs. for a weight loss of 10% over 30 days. Resident #10 did not like the pureed texture, and intakes were low at 25 to 75% of meals. Med pass (supplement) was added three times daily as well as an appetite stimulant to improve intakes. The plan was to continue weekly weights for close monitoring and follow up. Review of Resident #10's progress notes dated 03/12/25 revealed the physician was notified of the resident's significant weight loss. A new order was received for Mirtazapine (an appetite stimulant). Review of Resident #10's physician orders revealed on 03/12/25 the resident was ordered Med Plus 2.0 three times daily for a supplement and Mirtazapine due to increased weight loss. Review of Resident #10's Medication Administration Record (MAR) from March 2025 through June 2025 revealed the supplements and appetite stimulant were completed and offered as ordered. The Med Plus supplement was frequently refused or very little was consumed. Review of Resident #10's weights revealed on 03/18/25 the resident weighed 216.6 lbs. and on 04/06/25 the resident weighed 217.8 lbs. Review of the dietitian's progress notes dated 04/09/25 revealed Resident #10 had a weight loss of 14.8% over 180 days. Resident #10 required assistance at times with meals. The plan was to continue weekly weights for close monitoring and follow up. Review of the dietitian's progress notes dated 04/29/25 revealed Resident #10 had a weight loss of 14.9% over 180 days. Resident #10 required assistance at times with meals. The plan was to continue weekly weights for close monitoring and follow up. The most recent weight to this dietitian's note, was on 04/06/25 when the resident weighed 217.8 lbs. Review of Resident #10's weights revealed on 05/04/25 the resident weighed 216.6 lbs. Review of the quarterly Minimum Data Set (MDS) assessment, with a target date of 05/16/25, revealed Resident #10 had significant cognitive impairment with a BIMS of 04. The activities of daily living section of the assessment, dated 05/29/25 within the MDS, noted that Resident #10 was independent for eating. Review of facility tasks from 05/01/25 to 05/31/25 revealed Resident #10 was independent with eating seven meals out of 93. The remaining days the resident required supervision assistance for 42 meals, limited assistance for five meals, extensive assistance for three meals, and total dependence for three meals. Thirty-three meals were either not documented or marked as refused and NA for not applicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 31 of 62 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 07/09/2025 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 Residents Affected - Few Review of facility tasks from 06/01/25 to 06/15/25 revealed Resident #10 was independent with eating two meals out of 45. The remaining days the resident required supervision assistance for 26 meals, limited assistance for zero meals, extensive assistance for one meal, and total dependence for three meals. Thirteen meals were either not documented or marked as refused and NA for not applicable. Review of the dietitian's progress notes dated 05/21/25 revealed Resident #10's weekly weights were discontinued due to stabilization of weights over 90 days. Review of Resident #10's Treatment Administration Record (TAR) from February 2025 to May 2025 revealed Licensed Practical Nurse (LPN) #138 had signed off the weekly weight for all of the residents ordered weekly weights, but there was no documentation on the TAR for what the weights actually were. Review of Resident #10's medical record related to the weekly weights order for February 2025 through May 2025 revealed weekly weights were not completed as ordered. The resident had monthly weights completed with only two additional weights completed on 03/09/25 and 03/18/25. Review of Resident #10's weights revealed on 06/04/25 the resident weighed 212.4 lbs. Review of the dietitian's progress notes dated 06/04/25 revealed Resident #10 triggered for significant weight loss for a weight loss of 13.1% over 180 days. It noted that her intake improved from 25 to 100% and the resident required assistance at times with meals. Review of a speech therapy note dated 06/07/25 revealed an assessment occurred of Resident #10 eating a cookie. She required excessive time for chewing and moderate pocketing and food left in the cheek. Resident #10 was unable to fully clear food and was given maximum verbal cues. Review of speech therapy notes dated 06/11/25 revealed Resident #10 was trialed on a more liberalized (mechanical) diet and had a choking episode during the trial. Review of the menu ticket dated 06/16/25 revealed Resident #10 had a pureed diet order and was to receive pureed honey glazed turkey, pureed sweet potatoes, pureed green beans, and pureed strawberries. A note at the bottom stated vanilla house shake and ice cream with lunch and dinner trays only [indicating the shake and ice cream were to be given in addition to the meal]. Observation on 06/16/25 at 11:50 A.M. revealed Resident #10 was served a lunch tray. Resident #10 was not assisted to a sitting position in her bed and was not supervised or assisted while eating. Resident #10 told Certified Nurse Aide (CNA) #80 she did not want her food as it looked gross. CNA left the tray at the bedside and did not offer any alternatives. Observation and interview on 06/16/25 at 12:20 P.M. revealed Resident #10 had eaten less than 25% of the meal. CNA #80 confirmed Resident #10 had eaten less than 25% of the meal tray and confirmed no assistance was provided. Review of facility tasks for meal assistance revealed on 06/16/25 it indicated Resident #10 received supervision assistance for the lunch meal. Interview on 06/16/25 at 3:19 P.M. with Resident #10's family revealed the resident had not been eating the pureed food and confirmed she had lost weight. He was concerned and wanted her moved back to a mechanical soft diet so she wouldn't refuse her meals as often. He also reported concerns about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 32 of 62 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 07/09/2025 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 quality of life versus quantity of life, especially if she was just starving herself due to not liking the food. Level of Harm - Minimal harm or potential for actual harm Observation on 06/17/25 at 12:08 P.M. revealed Resident #10 had a lunch tray at bedside. Resident #10 was not assisted to a sitting position in her bed and was not supervised or assisted while eating. Residents Affected - Few Review of facility tasks for meal assistance revealed on 06/17/25 it stated Resident #10 required total dependance upon staff assistance for the lunch meal. Interview on 06/17/25 at 12:13 P.M. with CNA #118 revealed they picked up Resident #10's food tray and the resident had eaten about 10% of her food. CNA #118 confirmed she did not offer an alternative and did not assist the resident with eating. CNA #118 was unable to answer if Resident #10 required assistance with eating and was unable to answer when asked how staff should find out/determine if a resident required assistance with eating. CNA #118 was shown the orders in Resident #10's record and she then confirmed Resident #10 had an order to assist with eating due to pocketing food and confirmed staff should be observing and offering assistance per the physician order. Interview on 06/17/25 at 12:13 P.M. with the Director of Nursing (DON) confirmed Resident #10 had an order to assist with meals due to pocketing and was unable to state what the order meant for the resident or what her expectations were related to staff responding to or following the order. She further stated she would need to review the facility policy regarding what the order meant. Interview on 06/17/25 at 1:51 P.M. with Regional Nurse #160 confirmed Resident #10 had an order for assistance with meals due to pocketing and the facility had no policy specific to and could not explain what the order of assistance due to pocketing meant. Interview on 06/18/25 at 9:35 A.M. with Dietitian #162 revealed Resident #10 had been steadily losing weight since her admission in March 2024. She confirmed Resident #10 was obese and some weight loss was not concerning to her, but she did not want the resident to have significant drops in weight or be listed as excessive weight loss. Dietitian #162 confirmed the resident was hospitalized for an aspiration event and returned on a pureed diet. Resident #10 was accepting of the shakes and ice cream and ate very little of her meals. Dietitian #162 confirmed she recommended weekly weights to try and catch any big drops or changes in her weights and staff informed her they were assisting residents [including Resident #10] with eating. Dietitian #162 confirmed facility staff were not completing weekly weights as recommended and it was a struggle to get staff to obtain weights. She stated she spoke to the floor staff and management staff about getting the weights completed. She also reported corporate staff told her to discontinue weekly weights so they would not get a citation for not obtaining weights. She stated she would expect staff to offer assistance with eating when required and alternatives should have been offered if residents declined the meal or ate very little of it. Interview on 06/18/25 at 10:29 A.M. with Speech Therapist (ST) #155 revealed Resident #10 had not passed the food trial for the mechanical soft food texture due to coughing during the trial. She revealed Resident #10 did pocket pureed food, especially pureed eggs, but that she continued to recommend pureed texture and continued to work with the resident. She acknowledged while many days Resident #10 could feed herself, pocketing food was not safe and monitoring/assisting during meals was appropriate. Interview on 06/18/25 at 11:00 A.M. with the DON confirmed weekly weights were not obtained as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 33 of 62 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 07/09/2025 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 Residents Affected - Few ordered for Resident #10 and she also confirmed the resident was not being assisted during meals as ordered/required. Interviews on 06/16/25 around 11:00 A.M. and on 06/18/25 around 4:00 P.M. with Regional Nurse #160 revealed the facility had been purchased by a new entity with a change over in December 2024. Regional Nurse #160 stated the previous company had walked in and took many boxes of records without current staff's knowledge of exactly what was taken. He also revealed the previous company had Matrix electronic charting system and now this new company had Point Click Care (PCC) charting system, and not everything had been transferred over to PCC. He revealed they only had access to a limited version of the old Matrix charting system, leading to missing medical record documentation including information pertaining to Resident #10's nutrition. Interview on 06/26/25 at 10:54 A.M. with LPN #138 revealed that weekly weights and other vital signs were to be completed over the weekends, so when she worked on Tuesday's she would just sign off it got completed. LPN #138 verified she did not obtain any weights for Resident #10 but signed them off. She reported all weights would be documented in the weights and vital signs section of the medical record. Review of the facility policy titled, Weights, dated 09/01/21 revealed weights must be obtained routinely in order to monitor parameters of nutrition over time. Weekly weight should be obtained by the same day each week when possible. The dietitian or physician may order specific nutritional interventions as indicated. Review of the facility policy titled Assistance with meals dated September 2021 revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff shall serve resident trays and help residents who require assistance with eating. Review of the undated facility policy titled Activities of Daily Living revealed residents shall be provided with care, treatment and services to maintain or improve abilities. The types of assistance included: Independent, where the resident shall complete the activity with no help or staff oversight at any time in the last seven days; Supervision, where the resident required oversite, encouragement or cueing to complete the activity three or more times in the previous seven days; Limited assistance, where the resident was highly involved in the activity and received physical help in guided maneuvering of limbs(s) or other non-weight bearing assistance three or more times in the previous seven days; Extensive assistance, where the resident preformed part of the activity over the past seven days or staff provided weight bearing support; And total dependance, where staff performed an activity with no participation by resident for any aspect of the ADL activity during the entire seven day look back. This deficiency represents non-compliance investigated under Complaint Number OH00165179. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 34 of 62 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 07/09/2025 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 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 record review, observation, interview, and facility policy review, the facility failed to provide oxygen to one resident (#58) out of two reviewed for respiratory care. The facility census was 64. Residents Affected - Few Findings Include: Review of the medical record for Resident #58 revealed an admission date 04/28/25. Diagnoses included chronic systolic heart failure, paroxysmal atrial fibrillation, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #58 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #58 was dependent on turning, personal hygiene, toileting, dressing upper and lower body. Review of the plan of care dated 06/10/25 revealed that Resident #58 had impaired respiratory status related to anxiety, congestive heart failure, history of smoking, obesity, pulmonary edema, and respiratory failure. Interventions included activity level as tolerated, administer medication as ordered, monitor for increased anxiety associated with shortness of breath, monitor for signs and symptoms of increased shortness of breath, monitor for lung sounds, provide oxygen as ordered, and monitor lung sounds for wheezing or crackles as needed. Review of Resident #58's medical record from 05/01/25 through 06/16/25 revealed no documented evidence of a physician order to administer oxygen by nasal cannula. Observation on 06/16/25 at 11:25 A.M. revealed Resident #58 was trying to get out of bed and had both feet and legs coming off of the bed. The resident had oxygen on via nasal cannula and the oxygen concentrator was set at five liters per minute. Resident #58 was alert with confusion. Interview on 06/16/25 at 11:29 A.M. with Licensed Practical Nurse (LPN) #122 verified that Resident #58 had oxygen on at five liters via nasal cannula. LPN #122 verified that there was no active order for oxygen in Resident #58's medical chart. Review of the facility policy titled Oxygen Administration dated September 2021 revealed that oxygen therapy was the administration of oxygen at concentration greater than room air with the intent of treating or preventing the symptoms and manifestations of hypoxia. Initial need was determined by documenting hypoxia or having a physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 35 of 62 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 07/09/2025 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, staff interview, and review of facility policy and procedure, the facility failed to ensure Certified Nurse Aides (CNA) had annual performance evaluations. This had the potential to affect all facility residents. The facility census was 64. Residents Affected - Many Findings include 1. Review of the employee file for CNA #120 revealed she began employment on 04/09/24 The employee file revealed no documented evidence of a completed annual performance evaluation. 2. Review of the employee file for CNA #81 revealed she began employment on 07/05/23. The employee file revealed no documented evidence of completed annual performance evaluations. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified no evaluations were in the employee files for CNA #81 and #120. Interview on 06/24/25 at 4:20 P.M. with the Administrator verified evaluations were electronic and disappeared and facility was unable to provide any evidence of them being completed. Review of facility policy titled Performance Evaluations dated September 2021 revealed the job performance of employees shall be reviewed at least annually. A copy shall be provided to the Human Resource (HR) Director and maintained in the employee file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 36 of 62 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 07/09/2025 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 record review, staff interview, and review of facility policy, the facility failed to ensure pharmacy reviews were followed up on in a timely manner and documentation of the pharmacy recommendations were maintained for one resident (#21) out of five reviewed for pharmacy recommendations. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. a. Review of monthly pharmacy reviews dated 08/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 09/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 10/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 11/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 04/2025 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Further review of the medical record for Resident #21 revealed no documented evidence of the pharmacy recommendation forms for 08/2024, 09/2024, 10/2024, 11/2024, and 04/2025. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the facility was missing pharmacy recommendations for 08/2024, 09/2024, 10/2024, 11/2024 and 04/2025. b. Review of Resident #21's pharmacy recommendation dated 12/30/24 revealed the resident was ordered Gabapentin 200 three times daily and the medication had life threatening respiratory risk and recommended a risk verse benefit analysis to be completed or taper the medication. The medical provider signed on 01/05/25 and check marked the need for a risk versus benefit analysis. Review of Resident #21's medical record found no evidence of documentation of the risk versus benefit analysis and what risks and benefits were identified for Resident #21. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the facility did not have a documented risk versus benefit analysis for Resident #21. c. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated please evaluate risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 37 of 62 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 07/09/2025 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 versus benefit of the following medication in a hospital patient. Listed medications included vitamin D, B-12, Iron, multivitamin, and potassium. The provider signed and marked agree with a note to discontinue all five supplements. The provider did not date the form. Review of facility orders for June 2025 revealed a continued order initially ordered on 02/25/25 for potassium oral tablet with instructions give 20 milliequivalents (mEq) once daily. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the form was not dated by the provider and also acknowledged the potassium medication was still an active medication and was never discontinued per the Pharmacist and Physician decision. d. Review of Resident #21's physician order dated 02/01/25 to 04/25/25 revealed orders for Bupropion HCl extended release (SR) oral tablet 12 hour 150 mg with instructions to give one tablet daily. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated Wellbutrin SR (12 hour) 150 milligrams (mg) once daily was to be twice daily and it asks if the medication should be the XL (24 hr) medication instead. The provider marked other and stated updated in Point Click Care (PCC) (the electronic charting system). The provider signed and dated the form on 04/01/25. Review of Resident #21's physician order dated 04/26/25 revealed and order for Wellbutrin XL oral tablet extended release 24 hour with instructions to give 150 mg one tablet daily. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing (DON) confirmed the medication was changed according to pharmacy recommendation on 04/26/25. The DON acknowledged a delay from a recommendation given 03/17/25 that was addressed by the provider on 04/01/25, but the order was not changed until 04/25/25. e. Review of Resident #21's physician orders dated 03/07/25 revealed an order for Lorazepam 0.5 ml by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's physician order dated 03/13/25 through 04/23/25 revealed orders for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tablet every four hours as needed. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated the resident was receiving the following as needed (PRN) psychoactive medication Lorazepam 0.5 milligrams (mg) every four hours as needed. The form had the information circled with a note to clarify with pharmacy. The provider wrote disagree and documented the reason as hospice. The provider did not sign or date when they reviewed the pharmacy recommendations. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing (DON) reported she was unaware of what clarification occurred with the pharmacy, but stated the doctor wrote disagree and hospice. The DON acknowledged all PRN psychotropic medications should be limited to 14 days and have a stop date and reevaluation for appropriateness. The DON also confirmed no provider signed or dated the form. Review of facility policy titled Medication Regimen Review, dated September 2021 revealed a consultant pharmacist shall review medications at least monthly and evaluate for drug or food interactions, accuracy, timing, dosage, and form, and be aware for adverse side effects. The Pharmacist will provide a written report of irregularities. Documentation shall be maintained as part of the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 38 of 62 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 07/09/2025 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 medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 39 of 62 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 07/09/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and facility policy review, the facility failed to ensure a medication error rate less than five percent (%). Two errors were observed out of twenty-six opportunities, equaling an error rate of 7.69%. This affected two residents (#59 and #217) out of three residents reviewed for medication administration. The facility census was 64. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #59 revealed an admission date of 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Review of the physicians order dated 12/09/24 revealed that Resident #59 had an order for Calcium Carbonate 500 milligrams (mg) with instructions to take one tablet by mouth every six hours as needed for indigestion. Review of the physician order dated 01/07/25 revealed that Resident #59 had an order for Calcium Carbonate 500 mg with instructions to take two at bedtime for indigestion. Review of the plan of care dated 04/03/25 revealed that Resident #59 had an impaired metabolic status related to diabetes. Interventions included administering medications as ordered, monitoring labs, monitoring vital signs, and reporting adverse side effects to the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #59 had Brief Interview of Mental Status (BIMS) of 15 that indicated she was cognitively intact. Observation and interview on 06/17/25 at 8:15 A.M. with LPN #135 revealed eight of Resident #59's medications were to be administered by the nurse including Januvia 100 mg one tablet, Lasix 20 mg one tablet, Metformin 500 mg extended release one tablet, Magnesium Oxide 400 mg one tablet, one daily vitamin one tablet, Omeprazole 20 mg delayed release one tablet, and Acetaminophen 325 mg two tablets. Observation and interview on 06/17/25 at 8:20 A.M. with LPN #135, revealed Resident #59 stated she had heart burn. The resident followed the nurse to the medication cart and LPN #135 was observed to administer two Calcium Carbonate 500 mg tablets. Interview on 06/17/25 at 4:40 P.M. with LPN #135 confirmed she gave Resident #59 two Calcium Carbonate 500 mg. LPN #135 stated that Resident #59 had two different orders for Calcium Carbonate 500 mg. LPN #135 verified she should have given Resident #59 one Calcium Carbonate 500 mg tablet per the as needed order. 2. Review of record for Resident #217 revealed an admission date 05/08/25. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, gastroesophageal reflux disease, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #217 had a Brief Interview of Mental Status (BIMS) of 15 that indicated she was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 40 of 62 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 07/09/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care dated 06/19/25 revealed that Resident #217 was receiving psychotropic medication related to anxiety and antidepressant use. Interventions were to administer medications per physicians order, consult with pharmacy, and monitor and report adverse side effects to the physician. Review of the physician orders for Resident #217 revealed an order for Vitamin B12 sublingual 2,500 micrograms (mcg) sublingually one time a day for vitamin deficiency due at 9:00 A.M. Observation and interview on 06/17/25 at 8:33 A.M. with LPN #135 revealed 14 of Resident #217's medications were to be administered including Benzonatate 200 mg one tablet, Gabapentin 600 mg one tablet, Hydroxyzine Hydrochloride (HCL) 25 mg one tablet, Cetirizine 10 mg one tablet, Docusate sodium 100 mg one tablet, Duloxetine HCL delayed release (DR) 30 mg two tablets, Januvia 50 mg one tablet, Risperidone 1 mg one tablet, Triamterene Hydrochlorothiazide 37/5-25 mg one tablet, Lisinopril 5 mg one tablet, Oxybutynin 10 mg extended release one tablet, Pantoprazole sodium DR 40 mg one tablet, Vitamin D3 125 mcg one tablet. Vitamin B12 sublingual 2,500 mcg was not included. Interview on 06/17/25 at 4:40 P.M. with LPN #135 verified that Resident #217 did not receive Vitamin B12 sublingual 2,500 mcg. Review of the facility policy titled Administering Medications dated unknown revealed that medication shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician and care plan team, had determined that the resident had the decision capacity to take medication safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 41 of 62 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 07/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and facility policy review, the facility failed to appropriately and safely store medications and biologicals. This affected two residents (#2 and #217) out of 30 residents in the survey sample. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #217 revealed an admission date 05/08/25. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, gastroesophageal reflux disease, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #217 had a Brief Interview of Mental Status (BIMS) of 15 that indicated she was cognitively intact. Review of Resident #217's physician orders revealed the resident did not have an order for Calcium Carbonate (TUMS) or an order to have medications unattended at bedside. Observation on 06/16/25 at 10:15 A.M. revealed Resident #217 had a medication cup that contained three round tablets, resembling TUMS, in the med cup on the bedside table next to her bed. Interview on 06/16/25 at 10:17 A.M. with Licensed Practical Nurse (LPN) #122 verified that Resident #217 had three TUMS tablets on her bedside table. LPN #122 also verified with an electronic chart that Resident #217 did not have an order for TUMS or an order to have medication at bedside. 2. Review of the medical record for Resident #2 revealed an admission date 09/14/23. Diagnoses included type two diabetes, morbid obesity, pain in right shoulder, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 had Brief Interview of Mental Status (BIMS) of 07 that indicated she was cognitively impaired. Review of the plan of care dated 04/29/25 revealed that Resident #2 had the potential for pain related to osteoarthritis, weakness, and advanced disease process. Interventions included administering medication as ordered, determining what the residents' pain level was for the day, and monitoring any changes in usual activities of daily living. Review of Resident #2's physician orders revealed the resident did not have an order for Bio Freeze or an order to have medications/treatments unattended at bedside. Observation on 06/16/25 at 10:22 A.M. with Resident #2 revealed she used the green medication gel that was in the pill cup on her bedside table. The medication cup was sitting on the bedside table in the medication cup, half full of an unknown green gel. Interview on 06/16/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) #122 verified that Resident #2 had Bio freeze medicated gel at bedside. LPN #122 confirmed in the electronic chart that Resident #2 did not have an order for Bio freeze or to keep medications/treatments at bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 42 of 62 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 07/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the undated facility policy titled Administering Medications revealed that medication shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician and care plan team, had determined that the resident had the decision capacity to take medication safely. Review of the facility policy titled Storage of Medications dated 09/01/21 revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Event ID: Facility ID: 365679 If continuation sheet Page 43 of 62 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 07/09/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dental services were arranged in a timely manner. This affected three residents (#10, #21, and #50) of four residents reviewed for dental services. The facility census was 64. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #50 revealed an admission date of 08/04/22. Diagnoses included chronic obstructive pulmonary disease, anxiety, depression, type two diabetes mellitus with diabetic neuropathy, malingerer, and antisocial personality disorder. Review of Resident #50's plan of care dated 03/11/25 revealed the resident had the potential for pain due to dental pain. Interventions included to refer to ancillary services as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. The resident was assessed as having no dental issues. Review of a progress note dated 05/19/25, authored by Nurse Practitioner (NP) #400, revealed Resident #50 was seen for dental pain. Resident #50 broke a tooth the day prior and inflammation was noted in the area. Antibiotic therapy was initiated to address a potential infection and a consult for dental evaluation and treatment was ordered. Review of Resident #50's physician orders revealed an order dated 05/19/25 to refer to dental related to a broken tooth. Review of Resident #50's medical record revealed no evidence of a dental appointment being completed or scheduled on or after 05/19/25. Interview on 06/16/25 at 3:20 P.M., Resident #50 stated she had a broken tooth and dental services were supposed to be arranged. Resident #50 stated she had asked staff about it and nothing had been done. Resident #50 stated she was experiencing some pain related to her broken tooth. Interview on 06/17/25 at 3:02 P.M., the Director of Nursing (DON) verified there was no evidence of a dental consult being arranged since 05/19/25. The DON stated there was no information available on the status of the order. Interview on 06/20/25 at 8:56 A.M., Social Services Director (SSD) #89 stated she was not made aware of the order for a dental consult for Resident #50 when the order was written. SSD #89 confirmed she documented attempts to arrange such consults in the medical record at the time of the attempt. Review of the undated facility policy titled, Availability of Dental Services, revealed dental services would be available to all residents requiring routine and emergency dental care and all requests for routine and emergency dental services would be directed to Social Services to assure appointments are made in a timely manner. 2. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphagia, atrial fibrillation, diabetes, muscle weakness, metabolic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 44 of 62 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 07/09/2025 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 0791 encephalopathy, and muscle wasting atrophy. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 01/29/25 revealed Resident #10 had a nutritional problem or potential nutrition problem related to significant weight loss, feeding assistance, therapeutic diet, and meal refusals with interventions including to monitor, document, and report signs and symptoms of dysphagia including pocketing, choking, coughing, and drooling, and monitor signs and symptoms of malnutrition including weight loss of over three pounds in one week, over five percent in one month, over seven and a half percent in three months, and over 10 percent in six months, provide and serve diets as ordered, and dietician to evaluate and make recommendations as needed. Residents Affected - Few Review of the ancillary services consent dated 03/04/25 revealed Resident #10 signed up to receive dental services. Review of the dental note dated 04/16/25 revealed Resident #10 was seen by the dentist. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had significant cognitive impairment with a Brief Interview of Mental Status (BIMS) of 04. It stated the resident had no broken teeth and no mouth pain or discomfort. Interview on 06/16/25 at 3:21 P.M. with Resident #10's son revealed the facility recently got consent for dental services and the resident had not received dental care during the first year of admission. Interview on 06/17/25 at 5:46 P.M. with Social Services #89 revealed she found resident had been approved for Medicaid in July 2024, but was not informed of the the change, to get a timely consent signed to begin services. She revealed once she realized it, a consent was signed and services were initiated. 3. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphagia, muscle wasting, diabetes, and malnutrition. Review of the social services documentation revealed Resident #21 was approved for Medicaid on 07/17/24. Review of Resident #21's dental consent dated 07/31/24 revealed the resident signed a consent to receive dental services. Review of the dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. The note further stated Medicaid resident-resources were sent to the facility and the appointment should be scheduled with a Medicaid provider, location determined by the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. It stated the resident had no broken teeth and no mouth pain or discomfort. Review of the plan of care on 06/23/25 revealed Resident #21 did not have any care plan related to dental needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 45 of 62 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 07/09/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/16/25 at 11:56 A.M. with Resident #21 revealed she had several broken teeth that needed pulled and she had not heard any update on getting extractions scheduled. Interview on 06/17/25 at 5:46 P.M. with Social Services #89 revealed Resident #21 was seen by the dentist 04/16/25, but confirmed a follow up was not scheduled and she was unaware of any recommendations for needs for a follow up. Review of the undated facility policy titled Availability of Dental Services, revealed oral health and dental services shall be provided to each resident. All requests for routine and emergency services should be directed to social service staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 46 of 62 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 07/09/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of dietary production spreadsheets, review of resident meal tickets, and review of the facility's always available menu, the facility failed to ensure portion sizes were served as planned, which had the potential to affect all residents. The facility also failed to ensure items on the always available menu were available for Resident #17 and Resident #37. This affected two residents (#17 and #37) out of 64 residents observed during dining. The facility also failed to ensure the meal served matched the meal ticket. This affected two Residents (#10 and #21) of three observed for meal tickets. The facility census was 64. Findings include: 1. Observations on 06/17/25 from 11:05 A.M. to 11:35 A.M. revealed four ounce scoops were utilized for the pureed and regular broccoli. When [NAME] #125 was serving the meal and scooped the pureed and regular broccoli, she was not filling the entire scoop. Interview on 06/17/25 at 11:35 A.M., [NAME] #125 verified she was not consistently filling the entire scoop with the pureed and regular broccoli when serving. When queried as to how much broccoli was actually being served, [NAME] #125 replied, that's a good question. 2. Observations on 06/17/25 from 11:05 A.M. to 12:09 P.M. revealed three ounce scoops were utilized for the pureed and ground pork loin. Review of the Production Sheet, dated 2025, revealed the serving size for the ground pork and pureed pork was a #8 scoop (4 ounces). Interview on 06/17/25 at 12:09 P.M., Dietary Director (DD) #101 verified three ounce scoops were utilized for the pureed and ground pork and the serving size on the production sheet was four ounces. DD # 101 stated the cook was responsible for ensuring the appropriate scoop size was used. 3. Observation on 06/17/25 at 11:52 A.M. revealed an unidentified staff member opened the door to the kitchen and asked the dietary staff for a grilled cheese for Resident #17. [NAME] #135 stated there were no grilled cheese's available. The unidentified staff member then exited the kitchen without any food. Review of the undated facility document titled, Always Available at Mealtimes, revealed grilled cheese, hot dogs, peanut butter and jelly sandwiches, deli sandwiches, and salads were available. Observation on 06/17/25 at 12:50 P.M. revealed the always available menu was posted throughout the building. Interview on 06/17/25 at 12:50 P.M., Dietary Director (DD) #101 confirmed grilled cheese was on the always available menu, posted throughout the building and was not available for the lunch meal. DD #101 stated she had ran out of cheese. DD #101 stated she was going to go to a local grocery store earlier in the day, however the Administrator told her not to go. DD #101 confirmed items on the always available menu should always be available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 47 of 62 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 07/09/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 06/18/25 at 2:56 P.M., Resident #17 stated she did not like what she was served for lunch on 06/17/25 and stated she did not recall receiving a grilled cheese at lunch instead of the original menu items. 4. Review of Resident #37's lunch meal ticket, dated 06/17/25, revealed a note to add a grilled cheese to the meal. Review of the undated facility document titled, Always Available at Mealtimes, revealed grilled cheese, hot dogs, peanut butter and jelly sandwiches, deli sandwiches, and salads were available. Observation on 06/17/25 at approximately 12:15 P.M. revealed Resident #37's meal tray contained pork loin, a baked potato, broccoli, and a lemon bar. There was no grilled cheese provided on the lunch tray. Interview on 06/17/25 at approximately 12:15 P.M., Dietary Director (DD) #101 verified Resident #37 was not provided with a grilled cheese because the kitchen was out of cheese. Interview on 06/18/25 at 2:54 P.M., Resident #37 verified she did not receive the grilled cheese at lunch on 06/17/25 as was printed on her meal ticket. Resident #37 stated what was served on her tray did not match what was printed on her meal ticket and that happened all the time. 5. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's dietician progress notes dated 12/18/24, 01/08/25, and 01/29/25 revealed the resident did not like the quality of the food provided. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with puree texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with puree texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had significant cognitive impairment with a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. The resident was noted as independent with eating and had previous significant weight loss and was not on a weight loss program. Review of the menu ticket dated 06/16/25 revealed Resident #10 had a puree diet order and was to receive pureed honey glazed turkey, pureed sweet potatoes, pureed green beans, and pureed strawberries. Observation on 06/16/25 at 11:50 A.M. revealed Resident #10 was served a lunch tray which included mashed potatoes and gravy, with no mashed sweet potatoes provided. Resident #10 told Certified Nurse Aide (CNA) #80 she did not want her food as it looked gross and also stated, those don't look like sweet potatoes. The CNA left the tray at bedside and did not offer any alternatives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 48 of 62 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 07/09/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation and interview on 06/16/25 at 12:20 P.M. revealed Resident #10 had eaten less than 25% of the meal. CNA #80 confirmed Resident #10 had eaten less than 25% of the meal tray. The CNA also confirmed the resident was not provided the meal that was on the menu, as she was given mashed potatoes and not pureed sweet potatoes. Interview on 06/18/25 at 9:35 A.M. with Dietician #162 revealed the facility should be following the meal tickets and menu. 6. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphasia, muscle wasting, diabetes and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. Review of Resident #21's physician order dated 02/11/25 revealed a diet order for a no added salt diet with mechanical soft texture. Review of the meal ticket dated 06/16/25 revealed Resident #21 was to receive ground honey glazed turkey, soft roasted sweet potatoes, green beans, and bananas. Review of the substitution log dated June 2025 revealed no evidence of the facility being out an any items on 06/16/25. Observation and interview on 06/16/25 at 12:03 P.M. with Resident #21 and Licensed Practical Nurse (LPN) #122 revealed the LPN brought in the food tray for the lunch meal which did not include green beans. LPN #122 confirmed the meal ticket stated green beans yet no green beans were provided. Resident #21 reported that the kitchen rarely served the menu as posted and items frequently did not match the tickets. This deficiency represents non-compliance investigated under Complaint Number OH00165179. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 49 of 62 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 07/09/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to place Resident #26 on the appropriate diet. This affected one resident (#26) out of 30 residents reviewed for the sample. The facility had a census of 64. Findings include: Review of the medical record for Resident #26 revealed an original admission date of 01/30/25 and the most recent re-entry on 05/28/25. Diagnoses included acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #26 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Additionally, Section K of the MDS stated Resident #26 had no swallowing disorders, was on a therapeutic diet, but it did not state that the resident was receiving a mechanically altered diet. Review of Resident #26's hospital Discharge summary dated [DATE] revealed the resident was to continue a regular diet. Review of Resident #26's physician orders revealed the facility initiated a mechanically soft texture diet on 06/03/25. The order was changed to a regular texture diet on 06/17/25 following surveyor intervention. Review of the amount eaten task for the past 30 days revealed Resident #26 consumed less than 50% of meals on multiple dates, including 05/31/25, 06/06/25, 06/07/25, 06/08/25, 06/10/25, 06/12/25, 06/14/25, and 06/15/25. Interview on 06/16/25 at 4:00 P.M. with Resident #26 revealed he was placed on a mechanically soft diet upon admission on [DATE] and did not know why. He stated he did not like the mechanically soft diet and most of the time would not eat the meals provided, so his family would bring in food. On 06/18/25 at 10:08 A.M., Resident #26 further stated he was not eating the food because of the mechanical soft texture. Interview on 06/17/25 at 12:57 P.M. with Rehabilitation Director #144 revealed the speech therapist mistakenly placed Resident #26 on a mechanically altered diet based on his previous admission. The Rehabilitation Director stated there were no speech therapy progress notes from the current admission, and the therapist based the order on Section K of the MDS, which incorrectly reflected that the resident was on a mechanically altered diet. Interview on 06/18/25 at 11:49 A.M. with the Registered Dietitian (RD) #162 revealed that placing Resident #26 on a mechanical soft diet was an error. The RD stated that during the initial screening, the resident did not demonstrate any issues with chewing or swallowing and had not failed any feeding or pocketing tests. She confirmed the diet was mistakenly continued from the prior stay, during which the resident had been on a mechanical soft renal diet due to broken teeth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 50 of 62 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 07/09/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure staff wore hair nets in the kitchen as appropriate. This had the potential to affect all 64 residents in the facility. Residents Affected - Many Findings include: Observation on 06/16/25 at 8:25 A.M. revealed [NAME] #135 preparing food in the kitchen. [NAME] #135 had long hair, pulled back, and was not observed to be wearing a hairnet. Observation on 06/16/25 at 8:37 A.M. revealed Dietary Aid (DA) #134 pouring juice into individual glasses. DA #134 had long hair, pulled back, and was not observed to be wearing a hairnet. Interview on 06/16/25 at 8:38 A.M., [NAME] #135 verified herself and DA #134 were not wearing hair nets. [NAME] #35 stated staff ran out of hair nets over the weekend and they were unable to get more as they were locked in the manager's office. Interview on 06/16/25 at 8:45 A.M., Dietary Director (DD) #101 verified the staff did not have access to the hair nets as they were locked up, because when she leaves them out, they go missing. DD #101 verified staff should wear hair nets upon entering the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 51 of 62 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 07/09/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. a. Review of the record for Resident #59 revealed an admission date 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Residents Affected - Some Review of Resident #59's physician order dated 12/09/24 revealed that Resident #59 had an order for Insulin Lispro injection solution 100 unit per milliliter subcutaneously before meals and at bedtime for diabetes. Review of the plan of care dated 04/03/25 revealed that Resident #59 had impaired metabolic status related to diabetes. Interventions included administering medication as ordered, monitoring laboratory results, monitoring vital signs, and reporting adverse side effects to the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #59 had Brief Interview for Mental Status (BIMS) of 15 that indicated she was cognitively intact. b. Review of the record for Resident #30 revealed an admission date 01/05/24. Diagnoses included type two diabetes mellitus and chronic systolic heart failure. Review of the physicians order dated 04/04/25 revealed that Resident #30 had an order for insulin Glargine-yfgn subcutaneous solution 100 units per milliliter one time a day with blood glucose check in the morning. Observation on 06/17/25 at 8:00 A.M. with Licensed Practical Nurse (LPN) #135 revealed she came out of Resident #30's room with a glucometer in her hand. LPN #135 took a Sani disinfectant wipe disinfectant (a germicidal, tuberculocidal, and viricidal disinfectant) and wrapped it around the glucometer and sat it on top of the medication cart where it stayed wrapped in the Sani wipe for six minutes. LPN #135 prepared medication for Resident #59 and after the medications were prepared, LPN #135 took the wrapped glucometer with the Sani wipe to Resident #59 room to perform a blood glucose check. LPN #135 laid a brown paper towel on top of a bedside table then placed the wrapped glucometer on top of it. LPN #135 washed her hands, then placed gloves on her hands, then unwrapped the Sani wipe from the glucometer, then picked it up to obtain Resident #59's blood glucose check. LPN #135 took the blood glucose from Resident #59's finger, then disposed of her gloves in the trash can. LPN #135 washed her hands, then wrapped the Sani wipe back around the glucometer (the same wipe that was used to disinfect the glucometer after Resident #30's blood glucose check), then exited Resident #59 room. LPN #135 laid the glucometer with the Sani wipe on top of her medication cart. Interview on 06/17/25 at 8:05 A.M. with LPN #135 verified that she did not maintain infection control by utilizing the same Sani disinfectant wipe from Resident #30's room after her blood glucose was taken and took it into Resident #59's room for her blood glucose check. Interview on 06/17/25 at 5:00 P.M. with LPN #135 stated that she also did not follow the Sani wipe directions that stated to clean, and then leave the item to dry for two minutes after the cleaning to work properly. Review of the facility document titled Safety Data Sheet dated 02/18/19 revealed that product Super Sani-Cloth Germicidal wipes directions were to use it as a disinfectant on hard, non-porous surfaces. It stated to not reuse the towelette and to pick up the wipe and place it in appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 52 of 62 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 07/09/2025 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 container for infectious waste disposal. Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled Super Sani-Cloth dated unknown revealed that the bactericidal, tuberculocidal and viricidal had a dwell time to dry in two minutes. Residents Affected - Some 4. Review of the medical record revealed that Resident #19 had admission date 05/17/25. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, depression disorder, and dependence on wheelchair. Review of the physician order dated 12/20/24 revealed Resident #19 had an order for enhanced barrier precautions every day and night. Review of the physician order dated 12/22/24 revealed Resident #19 had a suprapubic catheter, 24 french with a 10 milliliter (ml) bulb. The orders also revealed an order for suprapubic catheter care every shift. Review of physician order dated 03/21/25 revealed that Resident #19 had wound care for right hip and left ischial with instructions to apply Dakins solution to moisten gauze, squeezing out excess moisture to lightly pack gauze inside the wound, ensuring it did not pass the edge of the wound, cover with abdominal dressing, then apply a thin layer of thick barrier paste to satellite macerated ulcerations twice a day or as needed every shift for wounds. Review of plan of care dated 04/21/25 Resident #19 had a suprapubic catheter related to having neurogenic bladder. Interventions included monitor and document intake and output as per facility policy, monitor for pain and discomfort, and report to the physician for signs and symptoms of urinary tract infection. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #19 was independent with all care though he did have a wound and a suprapubic catheter. Observation and interview on 06/16/25 at 4:51 P.M. with Certified Nurse Aid (CNA) #501 verified there was no enhanced barrier precaution sign for Resident #19's room even though the resident had an indwelling urinary catheter. Interview on 06/17/25 at 11:40 A.M. with Wound Nurse Practitioner #600 confirmed Resident #19 had a wound and it was being debrided in an outpatient clinic because it was too deep to treat at the facility. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated January 2024 revealed that enhanced barrier precautions are an infection control method used in the facility to reduce transmission of drug-resistant organisms. Review of the facility policy titled Infection Prevention and Control Program dated September 2022 revealed the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. Prevention of infection was to implement appropriate isolation precautions when necessary and educating staff and ensuring that they adhere to the proper techniques and procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 53 of 62 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 07/09/2025 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 Level of Harm - Minimal harm or potential for actual harm 5. Review of the medical record revealed that Resident #38 was admitted on [DATE]. Diagnoses included myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the physician order dated 03/03/25 revealed that Resident #38 was to be on enhanced barrier precautions every shift. Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had a Brief Interview for Mental Status (BIMS) of 02 that indicated severely cognitively impaired. Resident #38 was independent for eating, oral care, and personal hygiene. Resident #38 required partial to moderate assistance for toileting and required substantial maximum assistance for dressing the lower body and baths. The assessment indicated the resident had an indwelling suprapubic catheter. Review of the plan of care dated 05/20/25 revealed that Resident #38 had suprapubic catheter related to obstructive uropathy. Interventions included monitor of signs and symptoms of urinary tract infection, document output, securement device to be applied to securely anchor catheter tubing, change catheter and drainage system as ordered, keep tubing free of kinks, and privacy cover to the drainage bag. Review of the physician order dated 05/22/25 revealed that Resident #38 had an order for a suprapubic catheter and an order to re-insert Foley catheter as needed for malfunction or dislodgement. Observation on 06/16/25 at 4:51 P.M. with Resident #38 revealed an enhanced barrier precaution sign was not posted outside or in the room. Interview on 06/16/25 at 4:51 P.M. with Certified Nurse Aid (CNA) #501 verified there was no enhanced barrier precaution sign for Resident #38's room even though the resident had an indwelling urinary catheter. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated January 2024 revealed that enhanced barrier precautions are an infection control method used in the facility to reduce transmission of drug-resistant organisms. Review of the facility policy titled Infection Prevention and Control Program dated September 2022 revealed the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. Prevention of infection was to implement appropriate isolation precautions when necessary and educating staff and ensuring that they adhere to the proper techniques and procedures. 6. Review of record revealed that Resident #60 had admission date 01/09/25. Diagnoses included injury at C4 level of cervical spinal cord, quadriplegia, acute and chronic respiratory failure with hypoxia, disorder of autonomic nervous system, and morbid (severe) obesity. Review of the plan of care dated 03/21/25 revealed that Resident #60 had episodes of bladder and bowel incontinence. Interventions included administering medications, assisting residents with toileting needs, monitoring rectal area for redness, irritation, and skin excoriation or breakdown, provide peri care after each incontinent episode, then apply house barrier after incontinence care. Review of plan of care dated 03/21/25 revealed that Resident #60 had impaired skin integrity as evidenced by a pressure ulcer related to the resident being confined to a bed at all times, or most of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 54 of 62 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 07/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the times with intervention to assist the resident with turning and repositioning, encourage the resident to reposition, laboratory services as ordered, medication per physicians ordered, complete Braden scale as needed, if resident refuses interventions and treatments encourage compliance to minimize further skin impairment, and complete wound evaluation to monitor the progress of the resident's skin condition. Review of the physician order dated 05/04/25 revealed that Resident #60 had an order to cleanse the coccyx wound with 0.125% Dakins solution, then rinse with saline, apply zinc oxide topically to the peri wound and apply silver alginate rope to wound bed, leaving a one-inch tail and cover with abdominal daily and may change as needed if it becomes soiled or displaced. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #60 was dependent on staff for assistance with meals, oral care, incontinence care, dressing lower and upper body, personal hygiene, and bathing. Review of the skin evaluation dated 06/11/25 revealed that Resident #60's coccyx pressure wound was a stage four and measured 2.5 centimeters (cm) by 2.5 cm by 5.5 cm depth. Observation on 06/18/25 from 10:39 A.M. through 10:55 A.M. with Resident #60 who was provided incontinence care before wound care. CNA #90 provided the incontinence care. She used a washcloth to wipe away feces, but instead pushed a large amount of feces into the wound bed. LPN #94 then performed the wound treatment by using Dakins to the wound bed that was 0.0125 strength (quarter strength) then utilized four normal saline syringes to cleanse the wound bed. Then calcium alginate rope was applied with a sterile Q-Tip, then an abdominal dressing with tape was applied. Interview on 06/18/25 at 10:49 A.M. with CNA #90 confirmed that during incontinence care for Resident #60, she had wiped the feces into the wound bed when providing incontinence care. CNA #90 stated that was not normal practice and stated it could cause an infection in the wound. Interview on 06/18/25 at 10:52 A.M. with LPN #94 revealed that it looked like a problem having feces in the wound bed. LPN #94 stated it had happened before and that she would have to wash the wound out some more to cleanse the feces out of the wound bed. Review of the facility policy titled Wound Care dated September 2021 revealed part of the procedure was to wash and dry hands thoroughly, put on gloves, cleanse the wound and then apply treatments as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00165179. Based on observation, record review, interview, and review of facility policy and procedure, the facility failed to ensure implementation of the appropriate isolation status for Resident #19, #26, and #38. This affected three residents (#19, #26, and #38) out of five residents reviewed for infections. The facility failed to ensure proper hand hygiene was followed during a tube feed administration for Resident #162. This affected one resident (#162) out of one residents reviewed for tube feeding. The faciltiy failed to ensure appropriate glucometer sanitation for Resident #59. This affected one resident (#59) out of three residents observed for medication administration. And the facility failed to maintain infection control during wound care for Resident #60. This affected one resident (#60) out of one resident reviewed for pressure ulcers. The facility census was 64. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 55 of 62 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 07/09/2025 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 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #26 revealed an original admission date of 01/30/25 and the most recent re-entry was on 05/28/25. Diagnoses included acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Residents Affected - Some Review of the 5-day minimum data set (MDS) 3.0 assessment dated [DATE] for Resident #26 revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of Resident #26's physician orders revealed ongoing enhanced barrier precautions (EBP) starting on 05/29/25 related to an indwelling urinary catheter and an order for contact precautions specifically for Clostridioides difficile (C. diff) from 06/16/25 to 06/17/25. Review of the laboratory results confirmed a positive test for C. diff on 06/06/25. No subsequent testing was completed to determine a resolution; however, on 06/18/25, the Assistant Director of Nursing stated that the resident had completed antibiotic treatment and had formed stool for 48 hours, so retesting was not performed. Observation on 06/16/25 at 11:45 A.M. revealed only the enhanced barrier precaution sign posted on the resident's door, but no contact precaution signage was present. Further observation and interview on 06/17/25 at 11:30 A.M. revealed multiple family members present in the resident's room without the use of any personal protective equipment (PPE). The resident's son reported that staff had not educated the family on the risks of entering the room without PPE. Interview on 06/16/25 at 11:45 A.M. with Licensed Nurse Practitioner (LPN) #93 confirmed the resident had an active C. diff infection, but contact precautions were not implemented in practice, despite new orders for contact precautions being placed on the same date. Review of the facility policy titled, Infection prevention and control program dated September 2022 revealed to prevent infection the facility will implement appropriate isolation precautions when necessary. 2. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included type one diabetes mellitus without complications, chronic obstructive pulmonary disease, muscle wasting and atrophy, and presence of a gastrostomy feeding tube. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #162 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident required moderate assistance with most transfers and lower body dressing, used a wheelchair, and was occasionally incontinent of bladder and bowel. Review of physician orders revealed Resident #162 received TwoCal 240 milliliters via gastrostomy tube five times per day as bolus feeds, with water flushes of 150 milliliters every six hours and 60 milliliters every four hours. The resident also had orders to flush the tube before and after medications, maintain the head of bed at 30 to 45 degrees during and after feedings, and monitor the site for signs of infection or complications. The care plan identified maintaining adequate nutritional and hydration status as a goal, with interventions including infection monitoring, respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 56 of 62 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 07/09/2025 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 assessment, and monitoring for gastrointestinal symptoms. Level of Harm - Minimal harm or potential for actual harm Observation on 06/23/25 at 9:59 A.M. revealed Licensed Practical Nurse (LPN) #138 performed hand hygiene and donned personal protective equipment (PPE) prior to administering the resident's tube feeding. During the process, the nurse dropped an item on the floor and touched the floor while wearing gloves. The nurse did not change gloves or perform hand hygiene before proceeding with the procedure. The nurse then attempted to pull residual fluid, then flushed the tube with 30 milliliters of water, administered the full TwoCal bolus feeding via syringe, and flushed again with 30 milliliters of water. Residents Affected - Some Interview on 06/23/25 at 9:59 A.M. confirmed that she had touched the ground with her gloved hands and did not remove or change gloves or wash her hands prior to completing the resident's tube feeding. Review of the facility policy titled, Infection prevention and control program dated 09/22 revealed to prevent infection the facility will educate staff and ensure that they adhere to proper techniques and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 57 of 62 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 07/09/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure an effective antibiotic stewardship program was being followed/implemented regarding McGeers criteria for one resident (#10) out of four residents reviewed for infections. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/01/24 with diagnoses including urinary tract infection site not specified, acute pyelonephritis, chronic respiratory failure with hypercapnia, and carcinoma in situ of unspecified bronchus and lung. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severely impaired cognition. Review of the nurses' notes revealed Resident #10 exhibited signs and symptoms consistent with a urinary tract infection on two occasions during June 2025. On 05/29/25 at 09:35 A.M., the resident was documented as having increased confusion and urinary discomfort. On 06/19/25 at 09:26 A.M., documentation indicated the resident again exhibited symptoms, and a second urinary tract infection was suspected. Review of Resident #10's urinalysis results revealed a positive urinalysis was reported on 06/03/25 following the initial symptoms noted on 05/29/25. However, no culture and sensitivity was completed for this episode. A second positive urinalysis was documented on 06/19/25, but again, no culture and sensitivity was completed. A review of the laboratory section confirmed that no culture and sensitivity reports were present for either infection. Review of the physician orders revealed that an order for Macrobid (Nitrofurantoin) 100 milligrams orally twice a day for seven days was initiated on 06/04/25 and completed on 06/10/25 for the first episode. For the second episode, Doxycycline 100 milligrams orally twice a day for five days was ordered on 06/19/25 and completed on 06/23/25. Neither treatment was supported by a completed culture and sensitivity to confirm the causative organism or antibiotic susceptibility. Interview on 06/24/25 at 01:14 P.M., Director of Nursing (DON) confirmed that Resident #10 did not have a culture and sensitivity (C&S) completed for the urinary tract infections and that the resident received antibiotics from 06/04/25 through 06/10/25 and from 06/19/25 through 06/24/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 58 of 62 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 07/09/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the influenza and pneumococcal vaccines for four residents (#19, #26, #38, and #162) out of five residents reviewed for vaccines. The facility had a census of 64. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type 1 diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Review of the immunization records revealed Resident #162 received the pneumococcal vaccine (Prevnar 20), intramuscular suspension, 0.5 mL, administered one time for pneumonia prophylaxis on 06/24/25. There was no evidence the resident received education on the risks and benefits prior to receiving the vaccine. 2. Review of the medical record for Resident #26 revealed an admission date of 05/28/25 with diagnoses including acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the immunization records revealed Resident #26 refused both the influenza and pneumococcal vaccines on 02/03/25. There was no evidence the facility provided education on the risks and benefits prior to the resident's refusal. 3. Review of the medical record for Resident #19 revealed an admission date of 05/17/25. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, depression disorder, and dependence on wheelchair. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 indicating he was cognitively intact. Resident #19 was independent with all care. Review of the immunization records revealed Resident #19 refused the influenza vaccine on 10/15/24. There was no evidence the facility provided education on the risks and benefits prior to the refusal. 4. Review of the medical record for Resident #38 revealed an admission date of 12/11/19 with diagnoses including myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 59 of 62 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 07/09/2025 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 0883 Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of the immunization records revealed Resident #38 received the influenza vaccine on 10/15/24 and the pneumococcal vaccine on 11/22/24. There was no evidence education on the risks and benefits was provided prior to administration. Residents Affected - Some Interview on 06/24/25 at 11:47 A.M. with Regional Nurse #160 confirmed that the above residents (#19, #26, #38, and #162) did not receive education prior to the administration or refusal of the vaccines. Review of the facility policy titled, Influenza Vaccine - Residents revealed prior to vaccination, the resident / family will be provided information and education regarding the benefits and potential side effects of the vaccines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 60 of 62 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 07/09/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the coronavirus (COVID) vaccine for two residents (#26 and #162) out of five residents reviewed for vaccines. The facility had a census of 64. Findings include: 1. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type one diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #162 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Review of the immunization records revealed Resident #162 received the COVID vaccine (Comirnaty) intramuscular suspension prefilled syringe, 30 micrograms (mcg)/0.3 milliliter (mL) messenger Ribonucleic Acid (mRNA) vaccine, administered one time on 06/24/25 for COVID prevention. There was no documented evidence the resident received education on the risks and benefits prior to receiving the vaccine. Interview on 06/24/25 at 11:47 A.M. with Regional Nurse #160 confirmed they could not provide evidence that the education regarding the risks and benefits of the COVID vaccine was provided to Resident #162 prior to administration. 2. Review of the medical record for Resident #26 revealed an admission date of 05/28/25 with diagnoses including acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the immunization records revealed Resident #26 refused the COVID vaccine on 02/03/25. There was no documented evidence the facility provided education on the risks and benefits prior to the resident's refusal. Interview on 06/24/25 at 11:47 A.M. with Regional Nurse #160 confirmed that education regarding the risks and benefits of the COVID vaccine was not being provided to residents, including Resident #26, unless they received the vaccine. Review of the facility policy titled, Influenza Vaccine - Residents revealed prior to a vaccination, the resident/family would be provided information and education regarding the benefits and potential side effects of the vaccines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 61 of 62 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 07/09/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on personnel record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of annual in-services. This had the potential to affect all facility residents. The facility census was 64. Residents Affected - Many Findings include: 1. Review of the employee file for Certified Nurse Aide (CNA) #120 revealed she began employment on 04/09/24. The employee file had no evidence of any continuing education. 2. Review of employee file for Certified Nurse Aide (CNA) #81 revealed she began employment on 07/05/23. The employee file had no evidence of any continuing education. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified there was no documented evidence of continuing education in the employee files for CNA #81 and CNA #120. Interview on 06/24/25 at 4:20 P.M. with the Administrator verified the continuing education was done on Relias (online education system) with the previous management company and he was unsure if the facility would have access to it. He further confirmed the facility was unable to provide any evidence of continuing education being completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365679 If continuation sheet Page 62 of 62

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Citations

26 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0567GeneralS&S Dpotential for harm
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0730GeneralS&S Fpotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0803GeneralS&S Fpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0887GeneralS&S Dpotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0947GeneralS&S Fpotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
0607GeneralS&S Cno actual harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0605GeneralS&S Dpotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0640GeneralS&S Epotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.

FAQ · About this visit

Common questions about this visit

What happened during the July 9, 2025 survey of SIGNATURE HEALTHCARE OF FAYETTE COUNTY?

This was a inspection survey of SIGNATURE HEALTHCARE OF FAYETTE COUNTY on July 9, 2025. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SIGNATURE HEALTHCARE OF FAYETTE COUNTY on July 9, 2025?

Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·July 9, 2025