Health inspection·December 28, 2023

F 0624 Hydroxyzine HCl (used to treat anxiety) 25 mg every six hours as needed both eyes once a day. Level of Harm - Minimal harm or potential for actual harm Lantanoprost drops (used to treat glaucoma) 0.005%; apply one drop to both eyes once daily. Levothyroxine (thyroid medication) 137 mcg once a day Residents Affected - Few Loratadine (antihistamine) 10 mg once a day Lumigan drops (used to treat glaucoma) 0.01% administer one drop once a day. Maxzide tablet (diuretic) 75-50 mg administer half a tablet once a day. Metformin (anti-diabetic medication) 500 mg twice a day Metoprolol tartrate 50 mg tablet twice a day Nystatin powder (antifungal) 100,000 unit/gram three times a day as needed topically. Pantoprazole delayed release tablet (used to treat gastric reflux) 40 mg twice a day. PreserVision AREDS-2 capsule 250-90-40-1 mg one tablet once daily. Refresh Optive drops 0.5-0.9% administer one drop to both eyes every 12 hours as needed. Saline Nasal Mist aerosol spray 0.65% one spray every 12 hours as needed. Systane gel drops 0.4-0.3% administer one strip once a day. Valsartan (used to treat high blood pressure) 320 mg once a day Phone interview on 12/27/23 at 11:46 A.M. with Registered Nurse (RN) #508 revealed he had completed the discharge assessment and discharge instructions with Resident #272 and was unaware any wrong medications had been sent home with her. Phone interview on 12/27/23 at 11:54 A.M. with Resident #272's son revealed his mother had contacted him related to other residents' medications being sent home with her at discharge. Resident #272's son stated he had photographic evidence of medications belonging to other residents that were sent home with Resident #272. Observation of the four photographs (jpeg numbers: #163932, #163942, #163947 and #163926) revealed medication punch cards containing a 30-day supply of medications which belonged to Residents #275, #276 and #277 which were sent home with Resident #272. These medications included Gabapentin (anticonvulsant and nerve medication) 100 mg, Gabapentin 300 mg, Gabapentin 600 mg and Methocarbamol (muscle relaxant) 500 mg. Review of the October 2016 facility policy called Discharge Planning revealed the facility would determine the resident's preferred pharmacy. Nursing was to review the medication and treatment list with the physician prior to discharge. Nursing was to arrange for resident medication or prescription to be provided upon discharge. The policy stated to refer to Medication Provided to Discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365287 If continuation sheet Page 2 of 3 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 365287 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221 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 0624 Resident in the Nursing Policies. Level of Harm - Minimal harm or potential for actual harm Interview on 12/27/23 at 12:40 P.M. with the Director of Nursing (DON) and Regional Nurse Consultant #502 confirmed the facility policy titled Discharge Planning indicated to refer to Medication Provided to Discharge Resident in Nursing Policies; however, the facility did not have a specific policy for medications at discharge. When a skilled resident was sent home, they were sent with their medications and could be in the original bubble medication card packaging obtained from the facility pharmacy. Residents Affected - Few Phone interview on 12/27/23 at 1:15 P.M. with former Resident #272 revealed she was alert to person, place, time, and situation. Further interview revealed Resident #272 received medications for three facility residents in addition to her own medications. Resident #272 said she did not take the medications and alerted the home health nurse of her concern. Three attempts to contact the home health nurse were unsuccessful. Interview on 12/28/23 at 10:07 A.M. with the DON revealed she was unsure how the additional medications were sent home with Resident #272 at discharge. Observation of the medication cart, at the time of the interview, revealed all drugs were stored in locked compartments and were labeled in accordance with professional standards including the resident's name, medication name, dosage, and directions. This deficiency represents non-compliance investigated under Complaint Number OH00148961. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365287 If continuation sheet Page 3 of 3