Signature Healthcare Of Galion

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

record at the time nursing staff entered it into the electronic medical record, that she was notified about it.

Dietitian #200 confirmed she would do a full nutritional assessment every six months, annually, and when there was a significant change. She confirmed there had not been a full nutritional assessment completed since February 2025 for Resident #28.Review of the facility weight assessment and intervention policy, dated September 2021, revealed the nursing staff will measure resident weights on admission, and at least monthly unless otherwise ordered by the physician. The dietitian will review the weights to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the resident's target weight range, approximate calorie, protein, and other nutrient needs compared with the resident's current intake, the relationship between current medical condition or clinical situation and recent fluctuations in weight, and whether and to what extent weight stabilization or improvement can be anticipated. Care planning for weight loss or impairment will be a multidisciplinary effort and will include the interdisciplinary team (IDT).

The dietitian will discuss undesired weight gain with the resident and/or family. Interventions for undesired weight gain should consider resident preferences and rights. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes, and those wishes will be respected. This deficiency represents non-compliance investigated under Complaint Number 2643992.

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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

10/27/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and resident and staff interview, the facility failed to obtain ordered medications to administer to residents. This affected one (#28) of three residents reviewed for medication administration.

The facility census was 48.Findings include:Review of the medical record revealed Resident #28 was admitted on [DATE REDACTED] with diagnoses that included chronic kidney disease, unspecified convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema.Review of a plan of care dated 03/24/25 revealed Resident #28 had the potential for pain. Interventions included to administer medications per physician orders, encourage the resident to request pain medication before the pain becomes too intense, and to monitor for changes in usual activities.Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #28 was cognitively intact and did not receive opioid medication.Review of a nursing progress note dated 10/09/25 at 4:40 P.M. revealed Resident #28 was admitted to the hospital for hyperkalemia. Review of an admission progress note dated 10/13/25 at 4:45 P.M. revealed Resident #28 returned to the facility on [DATE REDACTED] at 4:45 P.M.Review of a physician order dated 10/13/25 at 4:20 P.M., created by Regional Director of Nursing #300, revealed Resident #28 was ordered pregabalin (an anticonvulsant medication commonly used to treat nerve pain and certain types of seizures) 75 milligrams (mg) twice a day for neuropathy.Review of the medication administration record (MAR) revealed Resident #28 did not receive pregabalin 75 mg on 10/13/25 at 8:00 P.M. through 10/20/25 at 8:00 A.M. Resident #28 received pregabalin 75 mg on 10/20/25 at 8:00 P.M. through 10/22/25 at 8:00 A.M.

Resident #28 did not receive pregabalin 75 from 10/22/25 at 8:00 P.M. through 10/27/25 at 8:00 A.M.

Review of the resident's progress notes revealed pregabalin was not available on 10/13/25 through 10/20/25 and 10/22/25 through 10/27/25. Review of a nursing progress note dated 10/19/25 at 4:16 P.M. revealed the pharmacy requested a new prescription for pregabalin 75 mg twice a day. The pharmacy indicated pregabalin could not be filled without a new prescription. The on-call certified nurse practitioner (CNP) was contacted, and a three-day supply prescription was sent to pharmacy. Nursing staff were to follow up with the primary care physician or CNP for the need of a new prescription. Review of a triage note dated 10/20/25 at 12:59 A.M. revealed Resident #28 was readmitted to the facility. The resident's pregabalin was changed from 100 mg twice a day to 75 mg twice a day. The pharmacy had not filled this particular script yet. The pharmacy indicated they have not received a new prescription to indicate the change in dosage. The CNP was notified about the dosage change and the need for the new prescription. An

interview on 10/27/25 at 1:30 P.M. with Resident #28 stated she did not know why her pain medication was stopped. Resident #28 stated the medication was stopped when she returned from the hospital. An

interview on 10/27/25 at 3:16 P.M. with Regional Director of Nursing #300 stated the pharmacy would not send Resident #28's pregabalin without a prescription. Regional Director of Nursing #300 stated the facility CNP indicated the prescription had been sent but the pharmacy responded they never received the prescription. Regional Director of Nursing #300 verified Resident #28 received pregabalin on 10/20/25 through 10/22/25 because an on-call CNP ordered the pregabalin. The on-call doctors/CNPs would only order medications for three days so the facility doctor/CNP could make the decision whether to continue the medication. Regional Director of Nursing #300 verified Resident #28 did not received pregabalin 75 mg from 10/13/25 at 8:00 P.M. through 10/20/25 at 8:00 A.M. and from 10/22/25 at 8:00 P.M. through 10/27/25 at 8:00 A.M. as ordered.This deficiency represents non-compliance investigated under Complaint Number

1. 2643992. Event ID:

Facility ID:

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