Health inspection·March 31, 2022

F 0676 Level of Harm - Minimal harm or potential for actual harm Review of the March 2022 tasks revealed Resident #14 was to ambulate 180 feet using a front wheeled walker with standby assist and wheelchair to follow six to seven days a week with a goal duration of 15 minutes as the resident tolerated. The documentation indicated Resident #14 had restorative ambulation on 03/01/22, 03/02/22, 03/03/22, 03/05/22, 03/06/22, 03/07/22, 03/08/22, 03/10/22, 03/13/22, 03/15/22, 03/20/22, 03/21/22, 03/23/22, 03/24/22, and 03/29/22. Residents Affected - Few Review of the nursing assistance [NAME] report dated 03/03/22 revealed the floor staff was to assist Resident #14 with ambulating 180 feet using a front wheeled walker with standby assist and wheelchair to follow six to seven days a week with a goal duration of 15 minutes as the resident tolerated. Interview on 03/30/22 at 10:30 A.M. with Certified Occupational Therapy Assistant (COTA) #88 indicated if therapy had any recommendation, they would write them on a Restorative Nursing Recommendation sheet and put them in the mailbox of Nurse #39. Interview on 03/30/22 at 1:03 P.M. Licensed Practical Nurse (LPN) #39 indicated therapy would place any recommendations in her mailbox, she would look at them to see if they needed any modifications or the staff needed educated. She stated the facility did not have restorative aides anymore and the nursing assistants were to pick up the restorative programs. She stated she would notify the nursing assistance if there were any new programs, and they were to document in point of care when completed. She stated she would take a task out of point of care if the resident start on therapy. Interview on 03/30/22 at 2:15 P.M. Registered Nurse (RN) #112 indicated he could not find documentation Resident #14 had refused restorative ambulation or was too ill to perform her restorative program. He verified Resident #14 had not received restorative ambulation six to seven times a week as recommended by therapy services in January, February, and March 2022. Review of the facility policy titled, Restorative Nursing Services, dated 07/2017 revealed the residents would receive restorative nursing care as needed to help promote optimal safety and independence. 2. Resident #33 was admitted on [DATE] with diagnoses including multiple sclerosis (MS), obesity, type II diabetes, quadriplegia, heart failure, contracture of left thigh, pain in both legs and left hip, and a fracture of right femur. Resident #33's Quarterly MDS 3.0 assessment of 03/04/22 revealed the resident was cognitively intact and required total dependence of two for ADLs. Resident #33's care plan of 01/18/22 revealed a care area for impaired functional range of motion related to MS with interventions for restorative services performed by floor staff of two sets of 15 repetition's of bilateral upper extremities through all planes six to seven days a week for a goal duration of 15 minutes a day. Review of Resident #33's 06/11/21 Restorative Nursing Recommendations revealed a recommendation for two sets of 15 repetitions of bilateral upper extremities through all planes six to seven days a week for a goal duration of 15 minutes a day Review of the the Documentation Survey Report v 2 for Resident #33 from 01/01/22 to 03/25/22 revealed the resident did not receive restorative services as recommended from 01/13/22 through 01/19/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 01/21/22 through 01/23/22, 02/01/22, 02/03/22, 02/04/22, 02/07/22, 02/19/22, 02/20/22, 03/01/22, 03/03/22, 03/04/22, 03/19/22, 03/20/22, 03/23/22 and 03/25/22. Interview on 03/30/22 10:26 A.M. with State Tested Nursing Assistant (STNA) #56 revealed she had not provided restorative services for Resident #33 as recommended. She said often times range of motion consisted of assisting residents with moving their limbs in the process of dressing/undressing. Interview on 03/30/22 at 10:30 A.M. with COTA #88 indicated if therapy had any recommendation for restorative services, they would write them on a Restorative Nursing Recommendation sheet and put it them in the mailbox of Nurse #39. Interview on 03/30/22 01:03 PM with LPN #39 revealed the facility used to have restorative aides but now the floor staff provided the restorative services. The STNAs were informed when there was a new restorative program and provided education on how to do the program if needed. The STNAs could see the program in [NAME] (care needs per resident) and the program was added to the care plan when active and canceled or placed on hold when the resident was in therapy. Resident #33 recently began therapy, so her programs were on hold as of 03/30/22. Interview on 03/30/22 at 1:50 P.M. with LPN #39 verified the 06/11/22 restorative nursing recommendation was added to Resident #33's care plan and per the Documentation Survey Reports for 01/10/22 to 03/25/22, the resident did not receive restorative services per the recommendation. Interview on 03/31/22 at 8:39 A.M. with Resident #31 revealed she was not receiving restorative services as recommended. She verified she was now receiving physical, occupational and speech therapy. Review of the facility policy titled, Restorative Nursing Services, dated 07/2017, revealed the residents would receive restorative nursing care as needed to help promote optimal safety and independence. 3. Review of the medical record for Resident #4 revealed an admission date of 09/18/20 with diagnoses that include hypertension, muscle weakness, and fibromyalgia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 had a cognitive impairment and required extensive assistance with two person physical assistance for bed mobility. Review of the Restorative Nursing Recommendations dated 02/04/22 revealed after Resident #4 discharged from therapy services it was recommended that she receive bilateral upper extremity active range of motion (AROM) including two sets of 10 reps. Review of Resident #4's medical record revealed no evidence Resident #4 received the recommended restorative nursing program. Observation on 03/28/22 at 4:55 P.M. of Resident #4 in bed revealed she was lying in her bed with her bed elevated and her hands on top of the covers. Interview on 03/28/22 at 4:55 P.M. with Resident #4 revealed she was no longer in therapy and does not receive restorative range of motion on her upper extremities. Resident #4 stated she sometimes gets pain in her arms, neck, shoulders, and would like to receive therapy services again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/29/22 at 10:33 A.M. with State Tested Nursing Assistant (STNA) #56 who stated she frequently works with Resident #4, revealed she does not complete an AROM program with Resident #4. Interview on 03/29/22 at 11:57 A.M. with Therapy Manager #88 revealed Resident #4 was discharged from Physical Therapy with a recommendation for AROM to the residents bilateral upper extremities including two sets of 10 reps. She continued the therapy department recommends a restorative program then they give the recommendations to the MDS nurse who then puts it into place. Interview on 03/29/22 at 12:20 P.M. with LPN #39 revealed Resident #4's recommendation for restorative programming was missed and it would be added to her plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure showers were provided a minimum of twice a week for Resident #31 and #33, and nails were cleaned and trimmed for Resident # 14. This affected three residents (Resident #14, Resident #31, and Resident #33) of three residents reviewed for activities of daily living (ADL). Residents Affected - Few Findings include: 1. Resident #31 was admitted on [DATE] with diagnoses including Parkinson's disease, major depressive disorder (MDD) and cognitive communication deficit. Resident #31's quarterly Minimum Data Summary (MDS) 3.0 of 03/01/22 revealed the resident was cognitively intact, totally dependent for bathing, and extensive assist of two for other ADLs. Review of the care plan for 11/23/21 revealed a care area for an ADL self-care performance deficit with an intervention for bathing/showering of total dependence of one staff for showering twice a week and as necessary. Review of the shower log from 01/01/22 to 03/26/22 for Resident #31 revealed the resident was scheduled for showers on Mondays and Wednesdays and received no showers for the periods from 01/22/22 through 02/07/22, and from 02/22/22 to 02/28/22, with no refusals documented during those periods. Interview on 03/31/22 at 8:39 A.M. with Resident #31 revealed she was not always getting her showers and was not given any reason by staff or the opportunity to shower during the next shift or next day. She would have to wait for her next scheduled day. Interview on 03/31/22 08:50 A.M. with State Tested Nursing Assistant (STNA) #76 verified Resident #31 did not always receive two showers a week, depending on how many staff were working, but she made sure all residents received at least one shower a week. Review of the February 2018 facility policy, titled Bath, Shower/Tub, revealed any refusals to bathe/shower should be documented and the supervisor notified. 2. Resident #33 was admitted on [DATE] with diagnoses including multiple sclerosis, MDD, obesity and quadriplegia. Resident #33's Quarterly MDS 3.0 assessment of 03/04/22 revealed the resident was cognitively intact and required total dependence of two for ADLs. Resident #33's care plan of 01/18/22 revealed a care area for self-care performance deficit with an intervention of total dependence of two for showering/bathing twice a week and as needed. Review of the shower log from 01/01/22 to 03/26/22 for Resident #33 revealed the resident was scheduled for showers on Tuesdays and Thursdays and received no showers for the periods of 01/28/22 to 02/07/22. There were no refusals documented for this period. Interview on 03/28/22 at 09:16 A.M. with Resident #33 revealed she does not always receive two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 showers a week, sometimes she only gets one. Level of Harm - Minimal harm or potential for actual harm Interview on 03/30/22 at 10:26 A.M. with STNA # 56 verified residents did not always receive two showers a week, depending on staff availability. Residents Affected - Few Review of the February 2018 facility policy, titled Bath, Shower/Tub, revealed any refusals to bathe/shower should be documented and the supervisor notified. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease major depressive disorder, dementia dysphagia, cognitive communication deficit, lack of coordination, muscle weakness, difficulty walking, unsteady on feet, hypertension, and need for assistance with care. Review of plan of care revised on 01/21/21 revealed Resident #14 was at risk for total dependence for self-care tasks due to Alzheimer's progression. Interventions included to provide equipment to aid activities of daily living (ADL) completion, turn and reposition routine rounds, anticipate and meet needs, encourage the resident to do as much for herself as able, set up for care tasks and cue, and one assist for transfers. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #14 had severely impaired cognition, required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Observation on 03/28/22 at 11:30 A.M. and 1:30 P.M., revealed Resident #14 had long, jagged dirty fingernails on both her hands. Interview on 03/29/22 at 4:38 P.M. Director of Nursing verified Resident #14's fingernails were long, jagged and dirty. She stated there was no documentation of having her nails trimmed or documentation of her refusing to have them trimmed. She also stated at 5:00 P.M. the activities department indicated Resident #14 did not get her nails trimmed in activities. Review of the facility policy titled, Care of Fingernails/ Toenails, dated 02/2018, revealed the purpose of the procedure was to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care included daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure the dishwasher was functioning in accordance with sanitation requirements. This had the potential to affected all 43 residents who consumed food or drink from the kitchen. Findings include: On 03/28/22 at 7:30 A.M., observation of the dishwasher revealed the temperature gauge was showing a final rinse temperature of 154 degrees Fahrenheit (F). The label on the dishwasher indicated the minimum final rinse temperature should have been 180 degrees F. Further observation of the kitchen revealed a three compartment sink with chemical sanitizer solution was available for use. Interview at the time of observation, Dietary Manager #68 verified the dishwasher temperature gauge was not functioning properly and a three compartment sink with chemical sanitizer solution was available in the kitchen. On 03/28/22 at 8:25 A.M., observation of the dishwasher revealed the temperature gauge was showing a final rinse temperature of 150 degrees F. Dietary Manager #68 verified the dishwasher temperature gauge reading at the time of the observation. Interview at the time of observation, Dietary Manager #68 stated temperature test strips were used several times each day to ensure the dishwasher was reaching a minimum temperature of 180 degrees F. On 03/29/22 at 4:31 P.M., observation of the dishwasher revealed the temperature gauge was showing a final rinse temperature of 170 degrees F. Dietary Manager #68 verified the dishwasher temperature gauge reading at the time of the observation. On 03/29/22 at 5:40 P.M., observation of the dishwasher revealed the temperature gauge was showing a final rinse temperature of 165 degrees F. Dietary Manager #68 verified the dishwasher temperature gauge reading at the time of the observation. On 03/30/22 at 1:21 P.M., interview with Dietary Manager #68 stated the dishwasher temperature gauge was still indicating the final rinse was less than 180 degrees F. On 03/31/22 at 11:25 A.M., interview with Dietary Manager #68 revealed the dishwasher temperature gauge was still indicating the final rinse was less than 180 degrees F and she was unsure when the replacement parts for the dishwasher would be available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility Self-Reported Incident (SRI) review, staff interview, and Ohio Revised Code review, the facility failed to ensure the admissions coordinator had not signed a cognitively impaired resident's signature and initials on her Durable Power of Attorney for Healthcare. This affected one resident (Resident #242) of one reviewed for falsification of records. Findings include: Review of the medical record revealed Resident #242 was admitted on [DATE] with the diagnoses of hemiplegia following cerebrovascular disease affecting the left side, dementia, major depressive disorder, anxiety disorder, encephalopathy, low back pain, left hand contracture, epilepsy, schizoaffective disorder, cerebral infarction, peripheral vascular disease, cognitive communication deficit, disorders of the brain, dysphagia, chronic pain syndrome, aneurysm, and vascular dementia. The resident expired on [DATE]. Review of the State of Ohio Health Care Power of Attorney form dated [DATE], revealed Admissions #101 had initialed and sign the name of Resident #242 on the document and spelled the resident's name incorrectly. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE], revealed Resident #242 had severely impaired cognition. Review of the facility Self-Reported Incident (SRI) dated [DATE], revealed the assistant administrator was researching pre-paid funeral arrangements for Resident #242. The assistant administrator noticed that the Durable Power of Attorney (DPOAHC) for Healthcare had incorrectly spelled the name of Resident #242 and used the incorrect initials. The assistant administrator looked further to see the initials were incorrect and, being familiar with Resident #242's signature noted the signature was dissimilar. The assistant administrator notified the Administrator. Administrator reviewed the document and it appeared admission #101 may have signed the name of Resident #242 then as Notary. The initial and signature resembled Admissions #101's handwriting. The Administrator met with admission #101 and asked her about the document. admission #101 stated she filled-out the form and signed it because the resident was unable to initial or sign. Administrator asked if Resident #242 was aware of the contents of the form and admission #101 stated the resident's son, Family Member #110, was aware because he was in the room and the other son and daughter were on the phone. Administrator read and pointed to the Durable Power of Attorney for Healthcare and the Notary section. admission #101 was silent. When Administrator asked about the initials, admission #101 stated that she took the hand of Resident #242 and guided her in writing the initials. Initials that were, in fact, incorrect. Administrator asked admission #101 if she understood it was falsification of a resident's record and legal document, she said no. admission #101 was relieved of her duties. admission #101 stated she disagreed and that she should not be separated from employment because of this action because she didn't know that she could not write someone's initials or sign their name. Administrator stated that she was a Notary, and admission #101 was silent. Administrator reached out to the son of Resident #242, the person listed as the DPOAHC, Family Member #110 on [DATE] to discuss the DPOAHC that his mother, Resident #242 had in her file. Family Member #110 stated that he remembered admission #101 had spoken with him about his mother and she was not able to make decisions due to her condition. He stated at the time, his mother had a severe kidney infection and was loopy beyond belief. He stated his mother (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not coherent. He had his brother and sister on the phone and was in his mother's room with admission #101. Family Member #110 stated him, and his siblings had agreed he should make the healthcare decisions for their mother. Family Member #110 was local, and his brother and sister live in the south. Family Member #110 stated the three of them were on the same page when it came to their mother's healthcare. He said his mother could not make decisions and the family was good with his decisions. Family Member #110 stated admission #101 told them if they did not have this document in place, his mom would become a ward of the state and someone else would make the decisions for her healthcare. Family Member #110 stated this concerned the family so they decided they should have the document and he should be the decision maker. Family Member #110 stated admission #101 took his mother's hand and initialed the document then admission #101 signed his mother's name. Family Member #110 asked if they get an attorney to have another document signed since their mom's health was failing and she was on hospice. Administrator stated the document was not necessary, and the facility would continue to contact him as the primary contact and his sister as the secondary contact. Review of the Notary Complaint form with an attached letter from the Administrator dated [DATE] revealed the facility had submitted a complaint against the former admissions coordinator (admission #101). Review of the email dated [DATE] from the Office of the Ohio Secretary of State revealed the facility's complaint had been assigned to the case from the Ohio Notary Advisory Board. Interview on [DATE] at 9:17 A.M. with Administrator indicated they were not able to get a statement from Admissions #101 because she was angry and did not believe she had done anything wrong. She verified the facility could not allow her to continue to work when she was signing the resident's names on documents, so the facility terminated her. Review of the Ohio Revised Code 147.141 revealed the notary public must not notarize a signature on a document if it appears the person was mentally incapable of understanding the nature and effect of the document at the time of notarization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 9 of 9