Signature Healthcare Of Galion

F 0552 Level of Harm - Minimal harm or potential for actual harm

dental visit. Review of Resident #44's dental form dated 03/17/25 revealed the dentist examined the resident. Interview on 09/16/25 at 12:40 P.M., with the Administrator verified an updated informed consent form had not been obtained after Resident #44 switched to private pay. She reported billing occurred through the ancillary services themselves and not the facility. This deficiency represents noncompliance investigated under Complaint Number 1314302.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Galion

935 Rosewood Dr Galion, OH 44833

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 7:12 P.M. revealed the Medical Assistant (MA) was notified Resident #1 had a fall with a bump and bruising to the back of the head, and neurological checks were at baseline for Resident #1. Review of the modification of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #1 had severe cognitive impairment, no behaviors, no impairment to upper or lower, used a wheelchair, and was dependent on staff for care. The MDS also revealed Resident #1 received anticoagulant medication.

Interview on [DATE REDACTED] at 12:22 A.M., with the Director of Nursing (DON) verified the neurological checks were not completed as indicated on the neurological form for Resident #1. DON verified Resident #1 was on Eliquis and it was concerning that vital signs were completed on [DATE REDACTED] at 2:25 P.M. but Resident #1 was not able to be aroused to complete the neurological assessment. DON verified the documentation revealed Resident #'1's family and MA were not notified until later in the day that Resident #1 had a fall with injury.

DON verified the MA no longer worked for the facility and was not available to be questioned about the time of the notification and if they were aware Resident #1 was ordered Eliquis. DON provided scheduling and clock in and out times to verify there were two nurses working during the time the neurological assessment was not completed for Resident #1. Interview on [DATE REDACTED] at 3:55 P.M., with Licensed Practical Nurse (LPN) #261 verified she was working on [DATE REDACTED]. LPN #261 verified she did not complete the neurological assessments on [DATE REDACTED] at 1:25 P.M. and 1:55 P.M. LPN #261 verified she also did not assess Resident #1's pupils, consciousness, speech, and responsiveness at 2:25 P.M. LPN #261 verified she wrote on the neurological assessment that she was passing medications on another hall when the assessments needed completed. This deficiency represents non-compliance investigated under Complaint Number 1314302 and

1. 1314300. Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Galion

935 Rosewood Dr Galion, OH 44833

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 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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 parameters for Resident #1's midodrine (to treat low blood pressure) were entered correctly into the medical record and midodrine was administered according to the parameters ordered. This affected one (#1) of three residents reviewed for medications being administered correctly. The facility census was 51.Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE REDACTED] and expired on [DATE REDACTED]. Resident #1 had diagnoses that included but not limited to Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes. schizoaffective disorder/bipolar type, and depressive disorder. Review of the modification of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #1 had severe cognitive impairment. Review of physician orders revealed on [DATE REDACTED] Resident #1 was ordered midodrine five milligram (mg) three times a day for hypotension. Midodrine was to be held for systolic blood pressure (SBP) greater than 120 millimeters of mercury (mmHg). Review of medication administration records (MAR) from [DATE REDACTED] through [DATE REDACTED] revealed Resident #1 received 47 doses of midodrine with SBP greater than 120 mmHg. The highest blood pressure recorded when midodrine was administered was 169/103 mmHg on [DATE REDACTED] at 11:00 A.M. Interview on [DATE REDACTED] at 1:31 P.M., with the Director of Nursing (DON) verified the instructions to hold midodrine for SBP greater than 120 mmHg was on the order but did not show up on the MAR. DON verified Resident #1 received midodrine multiple times with the SBP was greater than 120 mmHg.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Galion

935 Rosewood Dr Galion, OH 44833

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 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and staff interview, the faciltiy failed to obtain physician ordered laboratory tests for one resident. This affected one (#17) of three residents reviewed for physician orders.

the faciltiy census was 51. Findings include:Review of Resident #17's medical record revealed an admission date of 01/15/25 with diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had severely impaired cognition. Review of Resident #17's progress note dated 01/20/25 revealed she returned from a nephrology appointment with a follow up appointment to take place on 07/20/25. The physician requested laboratory tests be drawn on 07/14/25 prior to the appointment. Review of Resident #17's physician order dated 01/20/25 revealed on 07/14/25 laboratory test were to be completed. The laboratory test included a complete blood count (CBC), hepatic function panel, magnesium, microalbumin/create ratio, renal function panel, sodium, protein/creatinine ration, and an urinary analysis. Review of Resident #17's medical record from 07/14/25 to 07/21/25 revealed no evidence the laboratory test were completed. Interview on 09/11/25 at 1:20 P.M. and 09/16/25 at 11:44 A.M. with Resident #17's family revealed the facility had not completed ordered test prior to appointments resulting in rescheduled or missing appointments. Interview on 09/15/25 at 11:39 A.M. with

the Director of Nursing (DON) verified Resident #17's laboratory test were not completed as ordered.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Galion

935 Rosewood Dr Galion, OH 44833

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** Based on

observation, staff interview, record review, and review of wound care policy, the facility failed to follow the appropriate infection control guidelines when changing dressing for Resident #28's wound. This affected one (#28) of two residents observed for infection control practices. The facility census was 51.Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE REDACTED] with diagnoses that included Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease.

Review of the significant change Minimum Data Set, dated [DATE REDACTED] revealed Resident #28 had severe cognitive impairment. Review of a wound evaluation note dated 09/08/25 at 2:01 P.M. revealed Resident #28 had a skin tear to the right lower leg. The skin tear measured 2.5 centimeters (cm) long and 0.8 cm wide and was 0.1 cm deep. Review of the new order, received on 09/11/25 ,to cleanse the skin tear to Resident #28's right lower leg with normal saline or wound cleanser, apply Vitamin A and D ointment and cover with Dermaview II (a moisture-vapor permeable transparent dressing that aids in the prevention of bacterial contamination) island dressing every three days and as needed. Observation on 09/15/25 at 11:07 A.M., revealed the Assistant Director of Nursing (ADON) #260 applied gloves and removed the dressing to Resident #28's right lower leg. ADON #260 placed the soiled dressing on a paper towel on an over the bed table. ADON #260 then cleansed the wound, placed the A and D ointment on the tip of her index finger and applied the ointment to the wound, and then covered the wound with Dermaview II. Interview, at the time of

the observation, ADON #260 verified she did not remove her gloves after removing the soiled dressing, perform any hand hygiene, and used her finger, covered with the possibly contaminated glove, to apply the ointment. Review of the policy titled Wound Care dated September 2021, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Steps in the procedure included to wash and dry hands thoroughly and put on exam gloves. The tape to the dressing should be loosen and the dressing removed. Pull the glove over the dressing and discard into appropriate receptacle.

Wash and dry hands thoroughly and put on gloves. The wound should be cleaned and treatments applied as ordered by the physician.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet