Health inspection·December 7, 2022

F 0553 It is the facility's policy that each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 1. The resident and his/her family, and/or the Authorized representative, are invited to attend and participate in the resident's assessment and care planning conference. 2. The resident may exercise his/her right to participate in the care planning process including, but not limited to: a. Development and implementation of his or her person-centered care plan b. Participation in the planning process c. Participation in establishing goals and determining effectiveness of the plan of care d. Participation in changes to the plan of care 3. Resident assessments are begun on the first day of admission and completed no later than the fourteenth {14th ) day after admission. 4. A baseline care plan is completed within 48 hours of admission. A summary of the baseline care plan will be provided to the resident and/or resident representative 5. A comprehensive care plan is developed within seven (7) days of completing the resident assessment by the Interdisciplinary Team that includes the physician, Registered Nurse, Nurse aide that provides care to the resident and dietary staff. 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 2 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Advance notice of the care planning conference is provided to the resident and authorized representative. Such notice will be provided in writing. 7. The Social Service Director or designee is responsible for contacting the resident's family and for maintaining records or such notices. Notices include: a. The date of the conference b. The time of the conference c. The location of the conference d. The name of the resident and authorized representative. Documentation may include but not limited to: a. The date and time the resident and the authorized representative were provided notification of the conference b. The method of contacting the resident and the authorized representative. c. Reason the resident and/or authorized representative were unable to attend d. The date and signature of the individual providing notification of the conference to the resident and the authorized representative 8. Administrative policies governing the development and use of care plans have been established by this facility. Copies of such policies are available from the Assessment Coordinator, the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 3 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0553 Nursing Services, and/or the business office. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of cerebral infarction, muscle weakness, type two diabetes, and major depressive disorder. Residents Affected - Few Review of Resident #32's annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Review of Resident #32's medical record revealed his most recent care plan conference was dated 03/17/22. On 12/06/22 at 10:14 A.M. an interview with the DON verified the care plan conference dated 03/17/22 was the most recent care conference for Resident #32 and he had not been offered care conferences quarterly since then. She reported this was due to the facility did not have a social work or designee working in the facility to complete the care conferences. Review of the facility policy titled, (Facility Name) Bedside Care Plan Procedure, updated 10/14, revealed the facility should prepare a plan of care meeting schedule at least three weeks in advance for the following types of care plan meetings: initial, quarterly, with a significant change, and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 4 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and facility document review the facility failed to ensure resident privacy curtains were clean. This affected two Residents (#37 and #41) of 47 residents reviewed for environment. The facility census was 47. Findings included: Observation on 12/04/22 at 9:51 A.M. of Resident #37's privacy curtain revealed multiple dark soiled areas noted on the edge of the curtain used to pull it closed for privacy and approximately 24 inches from the bottom of the curtain. The soiled areas were easily noted when the privacy curtain was open. Resident #41 was Resident #37's roommate. Observation on 12/05/22 at 9:10 A.M. of Resident #37's privacy curtain with the same multiple dark soiled areas as noted on 12/04/22. Observation on 12/05/22 at 9:55 A.M. of Resident #37's privacy curtain with the same multiple dark soiled areas as noted on 12/04/22 with Licensed Practical Nurse (LPN) #338. She verified the privacy curtain was soiled and unsanitary. On 12/05/22 at 10:07 A.M. an interview with Maintenance Coordinator (MC) #332 revealed privacy curtains were only washed for a deep clean and when they are dirty. He verified a deep clean was when a resident was discharged , and the room was cleaned for the next resident. MC #332 verified the privacy curtains are not laundered regularly, but the housekeeping staff are to look at them when they are in cleaning and wash them if they are dirty. On 12/05/22 at 11:03 A.M. review of the document titled, Housekeeping Check List', undated revealed housekeeping staff are to assess privacy curtains for cleanliness and proper hanging. An interview at the time with MC #332 revealed even though there is a location for housekeeping staff to sign and date the form, he does not make the housekeeping staff do this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 5 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0641 Ensure each resident receives an accurate assessment. 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 facility staff interview the facility failed to accurately code minimum data set (MDS) 3.0 assessments for one (#2) of one resident reviewed for insulin. The total facility census was 47. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses that include but are not limited to end stage renal disease, weakness, unsteadiness on feet, congestive heart failure and pain in right knee. Review of the quarterly MDS dated [DATE] revealed the resident is cognitively intact had delusions and verbal behaviors one to three days of the review period. Resident #2 had the following medications coded as administered during the review period, seven days of injections, zero days of insulin injections, seven days of antidepressant and diuretic medications. Review of the 10/12/22 quarterly MDS revealed the resident had seven days of injections coded and zero days of insulin provided to the resident. Review of the 09/30/22 quarterly MDS revealed the resident had seven days of injections coded and zero days of insulin provided to the resident. Review of Resident #2's physician orders revealed the resident had: Lantus solostar U-100 insulin pen (long acting insulin) 100 units/ml give 60 units twice daily dated 08/11/22. Novolog Flex pen U-100 100 U/ML (short acting insulin) give 35 units with meals, dated 08/11/22. Review of the medication administration records (MAR) for November, October and September 2022 the resident received Lantus (long acting insulin) 60 mg twice daily and Novolog (short acting insulin)35 units insulin during the look back periods. Interview with Licensed Practical Nurse (LPN) #316 on 12/06/22 at 2:22 P.M. it was confirmed Resident #2 does take insulin daily and the MDS's dated 11/14/22, 10/12/22 and 09/30/22 were coded incorrectly as the resident was receiving insulin daily during the look back period. LPN #316 stated she looks at the MAR report when she is coding her MDS's and stated she must have not seen the insulin Resident #2 received during those MDS look back periods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 6 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review the facility failed to develop care plans completely and timely upon admission. This affected two residents (#39 and #42) of three residents reviewed for urinary catheter/urinary tract infection and two residents reviewed for behavior and emotional needs. The facility census was 47. Findings included: 1. Review of Resident #39's record revealed she was admitted on [DATE] with the diagnoses of muscle weakness, type two diabetes mellitus without complications, major depression disorder, and urinary tract infection. Review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and entered the facility with a urinary/Foley catheter (a flexible tube that drains urine from the bladder to a urine bag). Review of Resident #39's care plan, dated 10/28/22, revealed a care plan for her having an alternation in elimination related to a Foley catheter. This care plan was developed 27 days after admission. On 12/06/22 at 11:34 A.M. an interview with Licensed Practical Nurse (LPN) #316 revealed she did not develop Resident #39's care plan regarding her catheter timely on admission. She reported she was behind with care plans due to a lot of admissions. 2. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of dehiscence of amputation of stump, acquired absence of left leg below the knee, muscle weakness, infection following a procedure, major depressive disorder, schizoaffective disorder, Post-Traumatic Stress Disorder (PTSD), and suicidal ideations. Review of Resident #42's admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively independent and had the following mood symptoms for the previous 12 to 14 days: little interest or pleasure doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite or overeating, feeling bad about himself or that he was a failure or has let his family down, trouble concentrating and thoughts that he would be better off dead. Review of Resident #42's current care plan revealed no care plan for care of symptoms for PTSD. On 12/06/22 at 3:38 P.M. an interview with LPN #316 revealed she did not develop a PTSD care plan for Resident #42 and she should have done so to guide care. Review of the facility policy titled, Care Plan - Use of, updated 11/16, revealed a resident centered care plan shall be used to identify resident care needs and goals including interventions to meet those identified goals. A comprehensive person-centered care plan will be completed within seven days of the completion of the resident assessment (MDS) and will become part of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 7 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to update care plans timely. This affected one resident (#37) of one resident reviewed for anticoagulant use. The facility census was 47. Findings included: Review of Resident #37's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of type two diabetes mellitus without complications, pressure ulcer of sacral region (Stage 4), muscle weakness, major depressive disorder, and generalized anxiety. Review Resident #37's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and had received an anticoagulant (medication used to prevent blood clots) for the seven lookback days. Review of Resident #37's physician order dated 09/27/22 revealed an order for Enoxaparin (an anticoagulant medication) 40 milligram/0.4 milliliters subcutaneous once every morning which was discontinued on 11/04/22. After 11/04/22 Resident #37 no longer had an order for an anticoagulant. Review of Resident #37's current care plan revealed a risk for bruising/bleeding related to use of an anticoagulant. On 12/04/22 at 10:29 A.M. Resident #37 reported she was not on a blood thinner (anticoagulant). On 12/05/22 at 11:09 A.M. an interview with Licensed Practical Nurse (LPN) #316 revealed Resident #37's care plan was not accurate and up to date since she had been off the anticoagulant for one month. On 12/05/22 at 3:34 P.M. an interview with LPN #316 revealed she does not look at discontinued medications and update care plans for these changes. She reported she has not been trained to do this. Review of the facility policy titled, Care Plan - Use of, updated 11/16, revealed all staff members are expected to report changes in resident care needs to their supervisor to enable the resident centered care plan to be updated accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 8 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review the facility failed to ensure a care planned nutritional intervention for weight loss was followed. This affected one resident (#39) of four residents reviewed for nutrition. The facility census was 47. Residents Affected - Few Findings included: Review of Resident #39's record revealed she was admitted on [DATE] with the diagnoses of muscle weakness, type two diabetes mellitus without complications, major depression disorder, and urinary tract infection. Review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent, needed supervision and setup only for eating and no dental concerns, oral concerns, or swallowing difficulties. Review of Resident #39's weights revealed on 10/03/2022, the resident weighed 143.0 pounds and on 11/29/2022, the resident weighed 136.6 pounds which was a -4.48% weight loss. Review of Resident #39's care plan dated 10/04/22 revealed she was at risk for altered nutrition and the goal was Resident #39 will receive adequate nutrition to meet estimated nutrition needs as evidence by no significant weight change. One of the interventions was staff were to offer/provide substitutes of equal nutritive value if intake was less the 50% of the meal. Review of Resident #39's dietary intake dated 10/01/22 to 12/06/22 revealed Resident #39 has had 135 meals (out of a total of 195 meals) with less than 50% intake. Observation on 12/05/22 at 12:15 P.M. of Resident #39 revealed the resident was not eating lunch and an interview at the time with Resident #39 revealed she was not offered anything else for lunch. Observation on 12/06/22 at 9:58 A.M. revealed Resident #39 not eating breakfast. State Tested Nurse Assistant (STNA) #305 removed the tray, did not offer any substitute of equal nutritive value per care plan. On 12/06/22 at 10:20 AM an interview with STNA #305 verified she did not offer other food items to Resident #39 when her meal intakes was less than 50%. Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, undated, revealed the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. Review of the facility policy titled, Care Plan - Use of, updated 11/16, revealed a resident centered care plan shall be used to identify resident care needs and goals including interventions to meet those identified goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 9 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident #13's oxygen was in place and being administered as ordered. This affected one (Resident #13) of two residents reviewed for respiratory care. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease and emphysema. Resident #13 had a physician order for continuous oxygen at three liters per nasal cannula. An observation on 12/06/22 at 8:17 A.M. revealed Resident #13 was sitting in a wheelchair in the dining room on the secure unit. The resident had her head down and eyes closed. The resident's oxygen tubing was observed hanging over the handle on the back of the wheelchair. At the time of the observation, Licensed Practical Nurse (LPN) #307 verified Resident #13's oxygen tubing was not in place and was located where the the resident could not have placed it. LPN #307 also verified Resident #13 was ordered oxygen at all times. Resident #13's oxygen saturation was 89 to 90 percent on room air. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 10 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review the facility failed to proper assess residents for trauma-informed care. This affected one resident (#42) of two residents reviewed for behavioral/emotional services. The facility census was 47. Residents Affected - Few Findings included: Review of Resident #42's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dehiscence of amputation stump, acquired absence of left leg below the knee, muscle weakness, infection following a procedure, major depressive disorder, schizoaffective disorder and post-traumatic stress disorder (PTSD), and suicidal ideations. Review of Resident #42's admission minimum data set (MDS) assessment dated [DATE] revealed he was cognitively independent and had an active diagnosis of PTSD. Review of Resident #42's care plans revealed no care plan for his PTSD. Review of Resident #42's Clinical admission Documentation dated 09/28/22 revealed Resident #42 was admitted with no psychiatric diagnosis. Observation on 12/06/22 at 3:21 P.M. of Resident #42 sitting calmly in his chair watching television. An interview at the time with Resident #42 revealed he was asked last week by someone in the facility about psychotherapy therapy and he told them it may help him. He reported he has not had any psychotherapy while in the facility. On 12/07/22 at 12:01 P.M. an interview with Resident #42 revealed his trigger for PTSD is yelling. He reported none of the staff have asked him what his PTSD trigger was. On 12/07/22 at 12:04 P.M. interviews with State Tested Nurse Assistant (STNA) #305 and STNA #336 both revealed they were not aware of what Resident #42's PTSD trigger was. On 12/07/22 at 12:05 P.M. an interview with Licensed Practical Nurse (LPN) #331 revealed he was not aware of what Resident #42's PTSD trigger was. On 12/07/22 at 12:06 P.M. an interview with Registered Nurse (RN) #306 revealed she was not aware of what the PTSD trigger was for Resident #42. She revealed it is important for staff to know if a Resident has a PTSD diagnoses and what the triggers are. She reported PTSD triggers were something usually discussed in team meetings, but she doesn't remember Resident #42's being discussed. On 12/07/22 at 12:51 P.M. an interview with RN #306 verified the Clinical admission Document dated 09/28/22 was not accurate for Resident #42. Review of the facility policy titled, Trauma-Informed Care, dated 10/19, revealed it is the facility's policy to ensure all residents are assessed for a history of trauma and receive trauma-informed care, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 11 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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. 2. Observation on 12/04/22 at 10:49 A.M. revealed outdated food items in the refrigerator on the secure unit. A container with an unknown food item was labeled with Resident #20's name and was dated 10/02/22. There was also an unopened and unlabeled store bought Cobb salad with expiration date of 11/27/22. Interview on 12/04/22 at 11:01 A.M. Licensed Practical Nurse (LPN) #307 verified Resident #20's food and the Cobb salad were outdated and should have been discarded. LPN #307 also verified Resident #20 did not reside on the secure unit. Based on observation, facility staff interview, and policy review the facility failed to store food in a sanitary manner. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility also failed to store food items correctly in the secured unit which had the potential to affect all residents who lived on the secured unit. The total facility census was 47. Findings Include: 1. Observation of the reach in refrigerator in the main kitchen on 12/04/22 at 8:55 A.M. revealed there was a large plastic container labeled vegetable soup dated 11/26, one 112 ounce open can of vanilla pudding covered with plastic wrap dated 11/17/22 -11/21/11. In the refrigerator were also two pitchers of milk, one pitcher of sweet tea, and one pitcher of orange cool aid that were undated and unlabeled. Interview with Dietary Worker (DW) #309 on 12/04/22 at 9:00 A.M. it was confirmed the reach in refrigerator had a large plastic container labeled vegetable soup dated 11/26, an open can of vanilla pudding covered with plastic wrap dated 11/17/22 -11/21/11 and two pitchers of milk, one pitcher of sweet tea, and one pitcher of orange cool aide that were undated and unlabeled. Observation of the main kitchen walk in refrigerator on 12/04/22 at 9:03 A.M. revealed the refrigerator had the following items stored incorrectly: large plastic container of potato salad was opened and undated, a 32 ounce carton of liquid whole eggs was opened and undated, a small rectangle metal steam tray container that had a green soft mixture in the container was unlabeled and undated, Swiss cheese slices in the plastic manufacture package that was opened and placed in another plastic zippered bag undated, provolone cheese slices in the plastic manufacture package that was opened and placed in another plastic zippered bag undated, a large hard plastic container of shredded orange colored cheese covered in plastic wrap unlabeled and undated, a plastic zipper bag of pale beige lunch meat unlabeled and undated, one gallon containers of mayonnaise, Italian dressing, ranch dressing, teriyaki sauce, Sweet Baby Ray's Barbecue sauce, La Choy sweet and sour sauce, and sweet relish were opened and undated, and a 32 ounce jar of Dijon mustard was opened and undated. The refrigerator also had a brown plastic tub which had the following unlabeled and undated items in the tub: 4 croissant sandwiches, 11 personal sized plastic bowls with unknown food item in the bowls. Interview with DW # 309 on 12/04/22 at 9:10 A.M. it was verified the following food items were in the walk in refrigerator and not stored correctly: potato salad was opened and undated, a 32 ounce carton of liquid whole eggs was opened and undated, a small rectangle metal steam tray container had pureed peas in it and was stored unlabeled and undated, Swiss cheese and provolone cheese slices were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 12 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 opened and undated, a large hard plastic container of shredded cheddar cheese covered in plastic wrap unlabeled and undated, a plastic zipper bag of turkey lunch meat unlabeled and undated, one gallon containers of mayonnaise, Italian dressing, ranch dressing, teriyaki sauce, Sweet Baby Ray's Barbecue sauce, La Choy sweet and sour sauce, and sweet relish were opened and undated and a 32 ounce jar of Dijon mustard was opened and undated. DW #309 identified the items in the brown tub as the following: 4 croissant chicken salad sandwiches, 10 personal sized containers of pasta salad and one personal container of potato salad. DW #309 verified the items in the brown tub were not labeled or dated. Observation of the dry storage area on 12/04/22 at 9:12 A.M. revealed the floor had multiple black marks on the tiles, and there were 13 condiment packets on the floor and one ketchup packet had opened and sprayed ketchup which was dried to the floor. There was observed a 25 pound bag of white sugar which had the corner of the bag torn opened and was sitting on the shelf and not in a storage container to prevent contamination and undated, a 25 pound bag of flour was opened undated and not in a storage container to prevent contamination, two 7.5 pound bags of bread crumbs were opened, undated and not in a storage container to prevent contamination, 36 apple oatmeal bars dated best by 11/30/22, 216 apple oatmeal bars dated best by 11/29/22, and 111 apple oatmeal bars dated best by 11/02/22, a box labeled keep frozen pretzel sticks, which had 76 individual sized bags of pretzel sticks which were in dry storage and not frozen. During an observation of the dry storage area and interview on 12/04/22 at 9:30 A.M. with the DW #309 it was confirmed the dry storage area revealed the floor had multiple black marks on the tiles, and there were 13 condiment packets on the floor and one ketchup packet had opened and sprayed ketchup which was dried to the floor. There was observed a 25 pound bag of white sugar which had the corner of the bag torn opened and was sitting on the shelf and not in a storage container to prevent contamination and undated, a 25 pound bag of flour was opened undated and not in a storage container to prevent contamination, two 7.5 pound bags of bread crumbs were opened, undated and not in a storage container to prevent contamination, 36 apple oatmeal bars dated best by 11/30/22, 216 apple oatmeal bars dated best by 11/29/22, and 111 apple oatmeal bars dated best by 11/02/22, a box labeled keep frozen pretzel sticks, which had 76 individual sized bags of pretzel sticks which were in dry storage and not frozen. Interview with the Dietary Manager (DM) on 12/04/22 at 10:41 A.M. confirmed the apple oatmeal bars had a best by date on them, the DM stated he would call the company to see when the food item should be used by, there was no follow up from the DM. Review of Policy titled Refrigerator storage undated revealed: POLICY: Refrigerated food shall be stored in a manner that optimizes food safety and quality. NOTE: This policy is specific to refrigerated storage for the nursing facility food and does not apply to residents' personal refrigerators. (See Safe Handling of Food Brought in by Outside Sources for Resident Consumption Policy and Procedure in this section of this manual.) PROCEDURE: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 13 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 Perishable food shall be refrigerated or frozen immediately upon delivery. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Many Refrigerators shall be maintained at temperatures 41° F or below. A thermometer shall be present inside the refrigerator. Temperatures shall be documented twice daily at minimum. 4. Walk-in refrigerators shall have food stored on shelving at least 6 inches above the refrigerator floor and 18 inches beneath the refrigerator ceiling. If the refrigerator has a sprinkler system, items shall be stored 18 inches below the level of the sprinkler head. 5. Food storage- containers shall be: o Shallow to facilitate cooling o Impervious o Dishwasher safe Stockpots, used jars or one time use plastic containers shall not be used for purposes of food storage. 6. Refrigerated items shall bear a label indicating product name and date (month, day and year) product was received, used or first opened. Discard date may be included on labels per facility preference. 7. Stock in refrigerator shall be rotated such that all new deliveries are placed behind existing stock (First In-First Out). 8. Medication, employee lunches or any non-food items shall not be stored in dietary refrigerators. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 14 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 All pre-dished items shall be covered to prevent off-flavoring, drying or cross contamination while refrigerated. 10. Hot food shall be arranged in the refrigerator to provide maximum heat transfer through the container walls and allow circulation of air to cool. 11. Meat shall be stored on bottom shelf. Cooked meat shall not be stored along with frozen meat items that are being thawed (e.g., cooked ham in tray with raw ground beef). 12. Food container covers shall be impervious and non-absorbent. Clean linens or napkins shall only be used for moisture retention in raising dough or lining or covering bread/roll containers. 13. Food shall not be stored under exposed or unprotected sewer lines or water lines. 14. Cross-contamination of food shall be prevented by: o Storing raw meat on shelves below fruits, vegetables or other ready-to-eat food o Separating raw animal food during storage, preparation, holding and display from other raw or ready-to-eat food o Separating different types of raw animal food from each other, except when combined as ingredients o Cleaning and sanitizing storage containers, equipment, surfaces and utensils 15. Eggs shall be stored away from strong odors. Raw eggs shall be stored on the bottom shelf of the refrigerator and kept in their original container. 16. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 15 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 All refrigerator units shall be clean, free of rust and in proper working order, including gaskets and condensers. Level of Harm - Minimal harm or potential for actual harm Review of Policy titled Dry Storage and Supplies undated revealed: Residents Affected - Many POLICY: All non-perishable food shall be stored in a manner that optimizes food safety and quality. PROCEDURE: 1. Product shall be stored on storeroom shelving which is no less than 6 inches from the floor and 18 inches from the ceiling. If the storeroom has a sprinkler system, items shall be stored 18 inches below the level of the sprinkler heads. 2. Stock in dry storage shall be rotated such that new deliveries are placed behind existing stock (_First In-First Out). 3. The storeroom shall be maintained free from dirt, dust, water, debris, pests or any potential source of contamination. The walls, ceiling and floor shall be maintained in good repair and regularly cleaned. 4. The storeroom shall be ventilated and maintained as close to optimal temperature (50-70°F) and humidity as possible. 5. Opened food shall be stored in resealed containers/food bags that are labeled/dated. 6. Dry goods shall be stored for a period not to exceed one (1) year or the manufacturer's recommended use by date. 7. Food container covers shall be impervious and nonabsorbent. Clean linens or napkins shall only be used for moisture retention in raising dough or lining or covering bread/roll containers. 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 16 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 Food and containers of food shall not be stored under exposed or unprotected sewer lines or water lines. Level of Harm - Minimal harm or potential for actual harm 9. Residents Affected - Many Dented cans shall be stored separately or immediately returned to the food vendor. If dented cans are stored in the storeroom, they shall be marked clearly to prevent usage. 10. Shelving in the storeroom shall be sturdy, free from rust and have a surface which is smooth and easily cleaned. , 11. Cross-contamination by poisonous or toxic material shall prevented by: o Separating the poisonous or toxic material from food and supplies by spacing or partitioning o Storing the poisonous or toxic material in an area that is not above food, equipment, utensils, linens or single-serve, single-use articles o Storing the poisonous or toxic material off of the floor 12. Working containers used for storing poisonous or toxic material such as cleaners and sanitizers, shall be clearly and individually identified with the common name of the material. 13. Working containers holding food/ingredients that are removed from their original package for use (e.g., cooking oils, flour, herbs, potato flakes, salt, spices and sugar) shall be identified with the common name of the food and dated per facility date marking policy. Ingredients that can be unmistakably recognized such as dry pasta need not be identified. 14. The Storage of Food Guidelines may be utilized as an additional resource FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 17 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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, interview and facility policy review the facility failed to implement appropriate infection and control practices. This had the potential to affect one (Unit One) of three units. Unit One housed 21 of 47 residents residing in the facility. Residents Affected - Some Findings included: Observation on 12/06/22 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #331 washing his hands and donning (putting on) gloves for finger stick blood sugar check of Resident #42. He then collected his equipment of a glucometer (a device to measure blood glucose level), a lancet, a, test strip, alcohol wipes and Novolog pen for the Resident #42. LPN #331 laid the glucometer on Resident #42's bed and then cleaned Resident #42's finger, punctured the finger for a drop of blood and obtained a finger stick blood sugar of 99. No insulin was needed for this blood glucose reading. LPN #331 then put the lancet and the test strip he had just used on Resident #42 in one of his gloved hands, removed his glove over the lancet and test strip, put the first glove removed with lancet and test strip in his other hand and removed the second glove over the first glove, lancet and test strip then discarded it in Resident #42's trash can. LPN #331 then picked the glucometer up off of Resident #42's bed, walked to the medication cart and laid the used glucometer on the cart without a barrier. He then wrapped the glucometer in a cleaning wipe and placed it in a cup. He reported it would stay in the cup for two minutes. LPN #331 revealed he had completed the blood sugar assessment procedure and there was no additional steps. On 12/06/22 at 8:18 A.M. an interview with LPN #331 verified he discarded the used lancet and test strip in Resident #42's trash can and laid the glucometer which had been on Resident #42's bed on the medication cart without a barrier. He verified he did not clean the cart once he cleaned the glucometer and placed it in a cup. He verified both of these actions broke infection control guidelines and the lancet and test strip should have been placed in the sharps container for safety. Review of the facility policy titled Sharps Disposal, updated 11/19, revealed it is the facility's policy that this facility shall discard contaminated sharps into designated container. Whoever, uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. Contaminated sharps will be discarded into containers that are closable, puncture resistant, leakproof on sides and bottoms, labeled or color-coded in accordance with our established labeling system and impermeable and capable of maintaining impermeability through final waste disposal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 18 of 19 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility policy review the facility failed to ensure a resident room and bathroom was free of pests. This affected two residents (#9 and #32) of 47 residents residing in the facility. Residents Affected - Few Findings included: Observation on 12/04/22 at 10:58 A.M. of Resident #9 sitting in his room with a back scratcher which he was using as a fly swatter. There were several small flying insects observed to be flying around the room. An interview at the time with Resident #9 revealed flies had been in his room and bathroom for about two months. He reported that he has informed the facility of the problem, and nothing is getting done. Observation on 12/04/22 at 11:00 A.M. of Resident #9's bathroom, which he shared with Resident #32, of approximately 20 to 30 small flying insects on the walls, sink, toilet and floor. There was also a small red fruit fly trap on the bathroom counter. Observation on 12/05/22 at 9:00 A.M. of Resident #9's bathroom with an increase from the day before of flying insects, approximately 30 to 40 insects. Observation on 12/05/22 at 9:50 A.M. of Resident #9's bathroom with Licensed Practical Nurse (LPN) #338. An interview at the time with LPN #338 verified it was infested with flying insects and not a sanitary place to live. On 12/05/22 at 9:57 A.M. an interview with Maintenance Coordinator (MC) #332 revealed he was not aware of any flying insect problem. He reported there had been fly issues in the facility in the past but not recently. MC #332 observed Resident #9's room and bathroom during the interview and verified the flying insects and it was an unsanitary place to live. Review of the facility policy for pest control (untitled and undated) revealed the aim of the policy is to ensure that, as far as possible, pests within the facility are kept to an absolute minimum with the ideal being eradication but due to the resilience of persistence of some species the ideal is impossible to achieve. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365481 If continuation sheet Page 19 of 19