Inspection·October 24, 2019

F 0641 services and had a life expectancy less than six months. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #56's medical record revealed diagnoses including generalized muscle weakness, difficulty walking, legal blindness, and chronic obstructive pulmonary disease. Residents Affected - Some A nursing note dated [DATE] at 6:03 A.M. indicated Resident #56 was observed on the floor in her room. An incident reassessment summary dated [DATE] indicated Resident #56 stated she going to the bathroom and slipped and fell. An annual MDS 3.0 assessment, dated [DATE] indicated Resident #56 was cognitively intact and required supervision for walking in her room and in the corridor. The MDS indicated Resident #56 had no falls since the prior assessment completed on [DATE]. On [DATE] at 2:05 P.M., RN #300 verified the [DATE] MDS 3.0 assessment for falls was coded incorrectly as Resident #56 did have a fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365402 If continuation sheet Page 2 of 5 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 365402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Alliance Ctr for Rehab & NC Inc 11750 Klinger Avenue NE Alliance, OH 44601 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 - Few 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 observation, medical record review, review of Material Safety Data sheets (MSDS) and interview the facility failed to supervise the whereabouts of a resident on the dementia unit resulting in Resident #29 being located in a storage room unsupervised. This affected one resident (#29) of 22 residents residing on the unit. Findings include: Review of Resident #29's medical record revealed an admission date of 08/01/17. Diagnoses included cognitive communication deficit, history of suicidal ideation, difficulty walking, depression, dementia, history of falling, and cerebrovascular disease. Resident #29 resided in a secured dementia unit. A quarterly Minimum Data Set (MDS)3.0 assessment dated [DATE] indicated Resident #29 was sometimes able to make himself understood and was sometimes able to understand others. Resident #29 was assessed with impaired vision (able to see large print). An assessment of his mental status revealed Resident #29 was severely cognitively impaired. The MDS indicated Resident #29 wandered 4-6 days of the assessment reference period. Resident #29 was assessed as requiring extensive assistance with transfers and locomotion on the unit. Resident #29 did not walk. Resident #29 used a wheelchair for mobility. Review of Resident #29's care plan revealed behaviors included wandering at times, jiggling random door handles, wandering in and out of other resident rooms, and using. other residents' restrooms. On 10/22/19 at 11:45 A.M., while a Safety and Health Consultant was touring the facility, Resident #29 was observed in a storage room (which locked from the corridor side) unattended on the secure dementia unit. The door had a key code which Maintenance Staff #302 had to enter to unlocked the door from the outside. The door also had a self-closing device. Resident #29 was sitting in his wheelchair with his leg positioned in front of the door making it difficult to open. The room contained shelves with multiple wash basins with personal care products in them including mouth wash, toothpaste, and body wash. Behind Resident #29's wheelchair was an unlocked cabinet with items including hand sanitizer, perineal cleaner, moisturizing cream, mouth wash, toothpaste, shave cream and body wash. Maintenance Staff #302 tested the door function three times after Resident #29 was removed from the room with no problems noted with its functioning. On 10/24/19 at 1:35 P.M., Maintenance Staff #302 stated he had worked at facility since April 2019 and had never been told there was a problem with the lock or closure of the storage room on the secure unit where Resident #29 was located unsupervised. Review of MSDS sheets for the products in the storage room were reviewed. The MSDS for Dawnmist [NAME] Gel fluoride toothpaste revealed if the product was ingested the material was to be removed from the mouth and the mouth rinsed. Call a physician or Poison Control Center immediately. The MSDS for DawnMist mouth rinse indicated if the product came into contact with eyes the eyes were to be rinsed immediately with plenty of water for at least 15 minutes. If the product was ingested, a physician or Poison Control Center were to be contacted. The MSDS for Dawnmist Brushless Shave Cream indicated if the product was ingested a physician or the Poison Control Center should be contacted immediately. The MSDS for Secura Personal Cleanser indicated if the product was ingested, the Poison Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365402 If continuation sheet Page 3 of 5 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 365402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Alliance Ctr for Rehab & NC Inc 11750 Klinger Avenue NE Alliance, OH 44601 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 Center or physician should be contacted immediately for instructions. The MSDS for the Secura Personal Cleanser revealed the product was harmful if swallowed, caused skin irritation, could cause an allergic skin reaction, and caused serious eye damage and eye irritation. The MSDS for Secura Protective Cream revealed if ingested, a Poison Control Center or physician should be contacted immediately if ingested. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365402 If continuation sheet Page 4 of 5 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 365402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Alliance Ctr for Rehab & NC Inc 11750 Klinger Avenue NE Alliance, OH 44601 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 Based on observation, policy review, manufacturer guidelines review and interview the facility failed to maintain adequate infection control practices related to the use of a shared glucometer to prevent the spread of infection. This had the potential to affect four residents (#34, #57, #58 and #89) of four residents identified to be diabetic and who could use glucometer testing on the 211-222 rooms medication cart. Residents Affected - Few Findings include: On 10/22/19 at 11:30 A.M. Licensed Practical Nurse (LPN) #301 was observed using a glucometer to obtain Resident #34's blood glucose level. The blood glucose level was obtained and LPN #301 returned to the medication cart in the hallway. At 11:33 A.M., LPN #301 used one Clorox wipe to clean the glucometer. LPN #301 wiped the glucometer for approximately three seconds and placed the glucometer back into the top drawer of the medication cart, failing to ensure the glucometer maintained an appropriate contact time with the Clorox wipe. At 11:37 A.M., review of the Clorox wipes with LPN #301 indicated proper disinfection of surfaces required a contact time of three minutes for Clostridium difficile (C-Diff), 30 seconds for bacteria, one minute for viruses and one minute for blood borne pathogens. On 10/22/19 at 11:38 A.M., interview with LPN #301 verified the glucometer was wiped for three seconds and did not maintain contact time with the Clorox wipe as per the manufacturer's recommendations. Review of the undated facility policy and procedure titled Fingerstick Glucose Level revealed to follow bleach germicidal wipe contact time list. Review of the Clorox Healthcare Bleach Germicidal Wipes Manufacturer's Instructions revealed: To disinfect, all surfaces were to remain wet for contact time listed: bacteria 30 seconds, viruses 1 minute, C-Diff 3 minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365402 If continuation sheet Page 5 of 5