Inspection·January 26, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supplies for incontinence. STNA #196 stated about half a pack of wipes is used for episodes of bowel incontinence and a minimum of three to four wipes are used for urine incontinence. STNA #196 stated incontinence care is scheduled for every two hours, but due to the residents on her unit having impaired cognition, it is often provided more frequently. Interview on 01/26/24 at 3:40 P.M. with Resident #19 revealed the facility does not have enough wash cloths or towels to complete care. Resident #19 stated she contracted conjunctivitis due to the staff having to use the same wash cloth to clean her body and her face. Resident #19 did have one and half packs of wipes in her room. Interview on 01/26/24 at 3:46 P.M. with STNA #121 revealed the facility does not have enough incontinence pads, sheets, or washcloths. STNA #121 stated Resident #19 had pink eye from using the washcloths for incontinence care and showering. Interview on 01/26/24 at 3:49 P.M. with Resident #16 revealed the facility is out of washcloths and wipes. He stated he has been having family bring wipes from home and the staff use toilet paper for incontinence care. Resident #16 stated it takes about six wipes to get cleaned up. Interview on 01/26/24 at 4:47 P.M. with Director of Nursing (DON) revealed some residents with a specific insurance receive their own wipes and a list would be provided. Interview on 01/26/24 at 4:58 P.M. with Housekeeping Supervisor (HS) #111 revealed 50 washcloths come in each pack and an additional 25 packs were ordered at the time of the survey. HS #111 stated he plans to order more washcloths over the next few weeks. HS #111 stated aides were flushing wipes down the toilets and every toilet on the 100 hall had to be snaked so they decided to switch to washcloths for incontinence care. HS #111 stated 100 packages of washcloths were ordered but staff started throwing them away. HS #111 stated washcloths are washed with bleach with a water temperature of 160 degrees and the machines are hooked up to ozone which is a very high bacteria killer. Review of a list provided by the facility revealed 59 residents received incontinence care in the facility, and an additional list revealed 22 residents who are incontinent receive their own incontinence supplies from their insurance provider. An additional list provided from the facility revealed washcloths are used for showers, bathing, activities of daily living, and contractures. Interview on 01/26/24 at 5:15 P.M. with Administrator confirmed findings and stated the facility is ordering more washcloths and has started using wipes again. This deficiency represents non-compliance investigated under Complaint Number OH00150186. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 2 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident Matrix, policy review, and interviews the facility failed to ensure wound care was provided per orders. This affected one resident (#70) of three reviewed for skin alterations. Residents Affected - Few Findings included: Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of other part of right foot with fat layer exposed, abrasion, left lower leg, heart failure, kidney failure, unstageable pressure ulcer to left, deep tissue injury to the right heel, diabetes, and weakness. Review of the Matrix dated 01/26/24 revealed Resident #70 did not have pressure ulcers. Review of Resident #70's current orders and treatment administration records (TAR) dated 12/01/23 to 01/2026 revealed: All the following treatments were supposed to be administered from 7:00 A.M. to 3:00 P.M. A. On 12/06/23 a new order to cleanse the left heel and left lateral calf with wound cleanser, pat dry, apply Prisma, adaptic and silver alginate, and cover with abdominal (ABD) pad wrapped with kerlix daily and as needed. Review of the TAR for the left heel and left lateral calf revealed the treatment was not completed on 12/09/23 (Saturday) due to the resident refused, 12/16/23 (Saturday) to the nurse was not able to complete during her shift and Saturday 12/23/23 and 12/30/23 staff charted the resident was not available. On 01/06/24 (Saturday) the resident refused, on Saturday 01/13/24 the nurse was not able to complete her shift, and 01/20/24 (Saturday) not completed due to condition. There was no evidence the as needed treatment was administered in December 2023 or January 2024. B. On 12/18/23 a new order to cleanse bilateral legs with Hibiclens daily with dressing changes. Review of the TAR revealed on 12/02/23 (Saturday) the resident refused, 12/03/23 (Sunday) the resident was not available, and 12/09/23 (Saturday) he refused. On 12/16/23 (Saturday) the nurse was not able to complete, and Saturday 12/23/23 and 12/30/23 the resident was not available. On 01/06/24 (Saturday) the resident refused, and 01/20/24 (Saturday) was not completed due to conditions. C. On 12/30/23 there was a new order to cleanse the right shin with normal saline (NS) or wound cleanser (WC), apply ABD and wrap with kerlix daily and as needed. Review of the TAR revealed on 01/06/24 (Saturday) the resident refused, on 01/13/24 (Saturday) not able to complete during the nurse's shift, and 01/20/24 (Saturday) not able to complete due to condition. There was no documented evidence the as needed order was administered. D. On 01/02/24 a new order was received to clean the right shin with NS, pat dry, cover with border foam three times a week and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 3 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 Review of TAR revealed the treatment was not administered on 01/20/24 (Saturday) due to condition. Level of Harm - Minimal harm or potential for actual harm E. On 01/11/24 a new order was received to pad and protect bilateral dorsal feet with allevyn foam daily and to pad and protect bilateral heels and ABD and kerlix daily once daily. Residents Affected - Few Review of TAR revealed on 01/20/24 (Saturday) the treatments were not completed due to conditions. F. On 01/11/24 cleanse left lateral ankle with WC, pat dry, apply Prisma, adaptic and silver alginate, cover with ABD, and wrap with kerlix. Review of TAR revealed on 01/20/24 (Saturday) the treatments were not completed due to conditions. G. On 01/19/24 a new order was received to cleanse the left great toe plantar side with soap and water and change daily until healed. Review of TAR revealed on 01/20/24 (Saturday) the treatments were not completed due to conditions. Review of Resident #70's medication administration records (MAR) dated 12/01/23 to 01/26/24 revealed the resident had received medication all day on 12/23/23, 12/30/23, and 01/20/24 when the TAR indicated the resident was not available or due to condition. Review of Resident #70's nursing notes revealed no documentation related to wound care, condition, or resident not available on 12/02/23, 12/16/23, 12/23/23, 01/06/24, 01/13/24, or 01/20/24. Further review revealed on 12/30/23 the resident had asked for the leg wraps to be removed because they were too tight, and he would have the nurse reapply them later. Interview on 01/26/24 at 10:09 A.M., with Resident #70 and his wife Resident #71 revealed they had concerns with staff not administering Resident #70's treatments on the weekends. This past week the wound nurse was off Monday, so the residents' treatments were not done Saturday 01/20/24, Sunday 01/21/24, or Monday 01/22/24. The wife confirmed her husband has not refused any treatments and spends most of his time in his room sleeping or watching TV The Resident reported the only reason they have not blown up was the wounds were improving and the wound nurse that works during the week does her job. Interview on 01/26/24 at 3:34 P.M. and 5:28 P.M., with wound nurse Licensed Practical Nurse (LPN) #184 revealed she works Monday through Friday doing wound care. The LPN confirmed she was off Monday 01/22/24 and she was not sure when Resident #70's dressing was last changed due to it not being dated. LPN #184 confirmed Resident #70's and #71's concerns were because she had come in on Monday to change his dressing and the dressing, she had applied on Friday was still in-place. Resident #70 was not the only resident that this has happened to. The weekend staff don't always change residents wound dressings. The LPN confirmed she was not aware of the resident ever refusing treatment. The LPN reviewed the TARs with the surveyor and confirmed there was no evidence the resident was not available on the above dates, and she did not know why the nurse documented treatments were not done due to condition. The LPN reported Resident #70's wife (Resident #71) was very protective of her husband and has voiced concerns about the facility regarding the wound care and that is why she had never reported her concerns to management. Interview on 01/26/24 from 10:00 A.M. to 4:22 P.M., with an anonymous staff member revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 4 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 weekend staff were usually agency staff and there was one that will not change dressing on the weekends. Level of Harm - Minimal harm or potential for actual harm Interview on 01/26/24 at 5:45 P.M., with the Administrator revealed she was not aware of Resident #71's concerns regarding her husband's wound care not been completed on the weekends and she had started an investigation. Residents Affected - Few The facility had provided a policy undated titled Skin Abrasion/Skin Tears Care revealed to perform wound care per physician's orders and/or facility protocols. Document any problems or complaints made by the resident related to the procedure. If the resident refused the treatment, document the reason for refusal and the resident's response to the explanation of the risk of refusing the procedure, the benefits of accepting and available alternatives. This deficiency represents non-compliance investigated under Complaint Number OH00149967. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 5 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, review of the skill competency form for catheter care, observation, and interviews the facility failed to ensure infection control practices were maintained during urinary catheter care. This affected one resident (#24) of one resident observed for urinary catheter care. Findings included: Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including prostatic hyperplasia, urinary retention, sepsis, and metabolic encephalopathy. Review of Resident #24's plan of care for alteration in elimination related to Foley catheter (dated 01/22/24) revealed to perform catheter care every shift and/or per policy and to maintain dignity when checking/providing incontinence care for the resident. Review of Resident #24's current order revealed an order dated 01/22/24 for catheter care every shift. Review of Resident #24's indwelling catheter assessment dated [DATE] revealed the resident had a diagnosis of urinary retention. The resident required extensive assistance from two people with toilet use. Observation of catheter care on 01/26/24 at 2:03 P.M., with State Tested Nurse's Aide (STNA) #193 and the Assistant Director of Nursing (ADON) #201 revealed the STNA was not in Resident #24's room upon the surveyor's arrival. The STNA entered the room and did not perform hand hygiene and applied gloves. The STNA had a basin of water already drawn up and was sitting in the bathroom. The STNA gathered supplies and placed them on the resident's bedside table. The STNA raised the resident's bed and lowered the head of the bed. She removed the blankets from the resident, however, did not cover the resident with the bath blanket or towel she had sitting on the bedside table. The STNA unfastened the resident's incontinence brief/depends and pulled the depends down. There was a baseball size spot of bright red blood noted on the resident's depends and on the resident's penis/catheter. The STNA took a soapy washcloth and made five strokes from the tip of the penis down the catheter, two to three inches attempting to remove the blood from the penis/catheter. She threw the washcloth on the floor and retrieved a new soapy washcloth and finished cleansing the penis and peri area. The washcloth had blood noted on it. The STNA did not rinse or dry the penis, peri area, or catheter. She threw the washcloth in the basin of water as she had the resident turn to his left. She rinsed out the bloody washcloth in the basin and applied soap and cleansed the resident's rectal area with the same washcloth. There was a bowel smear noted on the washcloth. The STNA rinsed the rectal area with a clean washcloth and dried the area with a towel. The STNA had the resident turn back so he was lying on his back. She obtained a clean washcloth and rinsed the catheter tubing by holding the tubing at the tip of the penis about two to three inches down and wiping downward motion to the hub. The STNA rinsed the penis and peri area with the same washcloth and then dried the areas. At no time did the STNA obtain clean fresh water. The STNA replaced the resident's depends with a clean incontinence brief and placed sheet/cover over the resident. The resident reported the sheets felt good as he was not covered during the observation of catheter care. The STNA emptied the blood-tinged water in the toilet and rinsed the water basin. The STNA removed her gloves. The STNA picked the washcloth up from the floor. The STNA reported she used a glove to pick up the washcloth, however this was not observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 6 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 0690 Level of Harm - Minimal harm or potential for actual harm The ADON confirmed the STNA had a glove in her hand that she used to pick up the washcloth. The STNA then touched the resident's phone, bed controller, call light, and took the soap bottle back into the bathroom. The STNA had gathered the trash and linens and exited the room without performing hand hygiene or cleaning the bedside table. Residents Affected - Few Interview with the ADON and STNA after the observation confirmed the above findings. Review of the undated skilled competency form revealed to identify the resident and explain the procedure, position the resident in semi-Fowler's position, perform hand hygiene, apply clean gloves, wash perineum well with soap and warm water, ensure to wash from front to back. Cleanse the area well at catheter insertion and down the catheter tubing about three inches, ensure not to pull on catheter or advance further into urethra. All debris must be removed from the catheter at the insertion site. Rinse with warm water and pat dry gently with a clean towel. Position resident in a comfortable position with call light in reach. Remove gloves and perform hand hygiene. Review of the facility policy and procedure (undated) titled Catheter Care, Urinary revealed steps one to 11 were to place the clean equipment on the beside stand or overbed table. Wash and dry your hands thoroughly. Fill the wash basin one-half full of warm water and place on bedside stand. Position resident and put on gloves. Place a bed protector under the resident. Wash the resident's genital and perineum thoroughly with soap and water. Rinse the area well and towel dry. Pour wash water down the commode and flush. Place soiled linen into designated container. Put on clean gloves. Remove gloves and discard them into the designated container. Wash and dry hands. Then the next steps, 12-25, was to provide privacy by covering the resident with a sheet, exposing only the perineal area. With the non-dominant hand separate the labia of the female resident or retract the foreskin of uncircumcised male resident. Maintain the position of this hand throughout the procedure. Assess the urethra meatus. For the male resident use a washcloth with warm water and soap to cleanse around the meatus. Clean the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rise with warm water using the above technique. Return the foreskin to normal position. Use a clean washcloth with warm water and soap to cleans and rinse the catheter from the insertion site to approximately four inches outward. Secure the catheter, check the drainage tubing, and disposable items into designated container. Remove gloves and discard them into designated container. Wash and dry your hands thoroughly. Position the bed covers and make the resident comfortable. Place the call light with reach, cleans wash basin and return to designated storage area. Clean the bedside stand and return the overbed table to its proper position. Wash and dry your hands thoroughly. If the resident desires, return the door and curtains to the open position and if visitors are waiting tell them they may now enter the room. The policy did not address rectal area. Review of the facility undated policy titled Perineal Care revealed for a male resident wet a washcloth and apply soap or skin cleansing agent. Wash perineal area starting with urethra and working outward. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area. Retract foreskin of the uncircumcised male. Wash and rinse urethral area using a circular motion. Continue to wash the perineal area including the penis, scrotum, and inner thighs. Do not reuse the same washcloth or water to clean the urethra. Thoroughly rinse the perineal in the same order, using fresh water and a clean washcloth. Gently dry perineum following same sequence. Reposition foreskin of uncircumcised male resident. Turn resident, rinse washcloth, and apply soap or skin cleansing agent. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. Dry area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 7 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 0690 Level of Harm - Minimal harm or potential for actual harm thoroughly. Discard disposable items into designated container. Remove gloves and discard them into designated area. Wash and dry your hands thoroughly, reposition the bed cover, and make resident comfortable. Place call light in reach. Clean wash basin and return to the storage area. Clean beside stand, wash and dry hands thoroughly. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149967. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 8 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 medical record review, review of Center of Disease Control (CDC) information and guidance, review of infection control log, review of email, policy review, observation, and interviews the facility failed to ensure isolation protocols were discontinued timely. This affected three residents (#10, #63, and #70) of four residents reviewed for isolation. Residents Affected - Few Finding included: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including scabies, muscle weakness, urinary tract infection, aftercare following joint replacement, cellulitis, diabetes, respiratory and kidney failure, and heart disease. Review of Resident #10's order dated 01/15/24 revealed the resident was in contact isolation for scabies. Review of Resident #10's history and physical note dated 01/15/24 revealed staff reported the resident had a rash all over his back and they were concerned it was scabies. Assessment plan for the acute scabies was to treat him with permethrin 5% once now and repeat in seven days, wound team had already taken care of the hydrocortisone itching standpoint if this was not improving in seven days will need to consider an oral or ivermectin. Review of Resident #10's physician progress note dated 01/19/24 revealed the resident's treatment for scabies had been completed and to be repeated in seven days. The itching has subsided. Review of Resident #10's physician progress note dated 01/22/24 revealed staff was going to retreat the scabies with permethrin cream and the rash was showing 75% improvement. Review of Resident #10's medication/treatment administration records dated 01/2024 revealed the resident received the permethrin cream on 01/16/24 and 01/22/24. Further review of the treatment administration records indicated the resident was on contact isolation for scabies and was to be checked three times a day from 01/15/24 to 01/24/24, however there was X in the boxes except for 01/24/24 staff had signed off as administered. Review of the infection control log dated 01/2024 revealed the resident was on isolation precautions from 01/13/24 to 01/22/24 for scabies and was treated with permethrin cream. Review of Resident #10's plan of care revealed no evidence of a plan of care for scabies/isolation. Observation on 01/26/24 at 10:12 A.M., revealed outside Resident #10's room was an isolation cart and a sign was on the door indicating the resident was in contact isolation. Interview on 01/26/24 at 11:44 AM with the Director of Nursing (DON) revealed the resident should have been taken off isolation on 01/22/24 per the infection control log. Interview on 01/26/24 at 12:16 PM with the Administrator confirmed she had spoken to the DON, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 9 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 they had removed the isolation sign and cart from Resident #10's room today. Level of Harm - Minimal harm or potential for actual harm Interview on 01/26/24 at 4:33 PM, with Registered Nurse (RN) #200 confirmed Resident #10 did not have a plan of care for scabies/isolation but reported the facility had 21 days to develop a plan of care. Residents Affected - Few Review of the facility policy titled Scabies dated 11/2019 revealed it was the facility policy to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The procedure included obtaining or verifying the existence of the physician's order for this procedure. Review the resident's plan of care to assess any special needs of the resident. Affected residents should remain in contact isolation until 24 hours after the last treatment Resident #10's last treatment was 01/22/24 per the administration records. Isolation should have been discontinued on 01/23/24 per the policy. 2. Record review revealed Resident #63 was admitted to the facility 09/08/23 Methicillin resistant Staphylococcus aureus (MRSA), necrotizing fasciitis, sepsis, and need for assistance with personal care. Review of Resident #63's wound notes dated 01/15/24 revealed the resident wound culture was positive MRSA and initiated Bactrim twice a day for seven. Review of Resident #63's order dated 01/15/24 revealed contact isolation for MRSA. Review of Resident #63's infection plan of care dated 01/19/24 revealed no evidence of isolation. Review of Resident #63's medication/treatment administration records dated 01/2024 revealed the resident received 8.5 days (order was seven days) of Bactrim. The resident received one dose on 01/15/23 and two doses January 16th to 23rd, 2024. There was no evidence of isolation on the administration records. Review of the infection control log dated 01/2024 revealed Resident #63 was in isolation from 01/15/24 to 01/23/24 for MRSA in wound. Observation on 01/26/24 at 10:00 A.M., revealed Resident #63 had an isolation cart and sign on the door indicating the resident was in contact isolation. Interview on 01/26/24 at 1:37 P.M., with the Director of Nursing (DON) confirmed Resident #63 was diagnosed with MRSA and should have been off isolation precautions on 01/23/24. 3. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms and use of indwelling urinary catheter. Review of the CDC facility guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) dated 11/2015 revealed residents who are colonized or infected with CRE would be placed in contact isolation. Some facilities might choose to not place some non- CP-CRE that remain susceptible to other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 10 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antimicrobials on contact precautions. There was no recommendation for discontinuing contact precautions. Consider screening others who may have contact with residents. Review of an email dated 01/05/24 from the local health department revealed the facility was questioning if Resident #70 and his wife (Resident #71) had to be placed in isolation. The health department replied that Resident #70 would need to be in isolation, however his wife (Resident #71) doesn't need it and should still need treated as though she does not have it in terms of staff changing PPE in between caring for them. Resident #70 should probably have the culture and sensitivities done since there were only nine antibiotics on the report and all were resistant, and it looks like he may have a urinary tract infection. As for the wife (Resident #71), a urinalysis/culture likely doesn't need done unless she is exhibiting symptoms. The local health department contacted the state health department for more specific advice/recommendation. Review of Resident #70's orders and medication administration records revealed Resident #70 was ordered contact isolation/enhanced carrier precaution for CRE from 01/05/24 to 01/26/24. There was a note on 01/24/24 indicating the resident refused precautions on dayshift and on 01/25/24 at 3:00 P.M. to 11:00 P.M. shift the note indicated discontinued. Review of the infection control log dated 01/2024 revealed no evidence Resident #70 had CRE. Further review of the infection control log revealed the resident had a urinary tract infection from 01/12/24 to 01/21/24 and was on precautions due to the organism being positive for Enterobacterales (ESBL). Review of Resident #70's laboratory report dated 01/16/24 revealed on 01/09/24 a swab was collected from the axilla and groin and was negative for Carbapenem resistant Acinetobacter baumannii. Observation on 01/26/24 at 10:09 A.M., of Resident #70 and #71's room revealed no evidence the residents were in isolation. Interview on 01/26/24 at 10:09 A.M. with Resident #70 and his wife (Resident #71) reported they were placed in isolation longer than required. Resident #71 reported her husband was diagnosed with CRE on 01/05/24 and they both were placed in isolation because she refused to leave their shared room. The resident reported she had no laundry and was not able to wash her hair because they were not permitted to leave the room. Resident #71 reported they were not taken off isolation until 01/23/24 and was told he did not have CRE after he was rechecked. Interview on 01/26/24 at 4:33 P.M., with the Director of Nursing (DON) and Registered Nurse (RN) #200 revealed the resident was in the hospital in December 2023 and the facility received a call from the local health department on 01/05/24 notifying the facility Resident #70 had tested positive for CRE and needed to be retested and placed on contact isolation. The DON confirmed Resident #70's CRE was not on the antibiotic log, however they may have another log since the resident was not antibiotics related to the CRE. The facility retested the resident on 01/09/24 and on 01/26/24 the test came back negative for CRE. The resident remained in isolation because he had ESBL in his urine and isolation should have been discontinued on 01/21/24. The signs and cart have been removed; however, the order was not discontinued until today 01/26/24. Interview on 01/26/24 at 4:22 P.M., with State Tested Nurse's Aide (STNA) 196 revealed she was not aware Residents #10 and #63 were not in isolation due to there were still signs and isolation carts still outside the rooms. The STNA reported if signs and isolation carts were outside a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 11 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room, she would follow the precautions for the resident until the signs and isolation carts were removed from the room. Interview on 01/26/24 at 5:28 P.M. with wound nurse (Licensed Practical Nurse) #184 revealed she was not aware Resident #10's isolation was discontinued but she thought Resident #63's isolation was discontinued yesterday. The LPN reported she would continue to follow the precautions for the resident if there were signs posted and isolation carts outside the room. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions dated 11/2020 revealed for contact isolation signs would be used to alert staff of the implementations of airborne precautions, while respecting the residents' privacy. Place a sign on the door of the resident's room to instruct visitors of appropriate PPE to wear prior to entering the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00149967. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 12 of 13 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 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of pictures, observation, and interviews the facility failed to ensure a safe path of egress on the 300 hall. This had the potential to affect 27 residents (#8, #14, #15, #18, #19, #29, #34, #38, #39, #46, #50, #52, #55, #59, #60, #62, #70, #71, #74, #82, #85, #86, #87, #89, #91, #94, and #100) of 106 residents residing in-house during the time of the survey. Findings included: Observation on 01/26/24 at 10:07 A.M. of 300 hallway from room [ROOM NUMBER] to 321 revealed there was six wheelchairs sitting along the left side of the hall, five yellow caution signs randomly placed down the hallway, and one isolation cart blocking the path of egress. Review of two pictures provided from an anonymous source on 01/26/24 at 10:09 A.M., revealed two different pictures of wheelchairs lined down the left side of the hallway facing the egress doors from rooms 307 to 321. Interviews on 01/26/24 from 10:09 A.M. to 4:22 P.M., with a resident (who would like to remain anonymous) and an anonymous staff member revealed there had been issues with the path of egress on 300 hall being blocked with wheelchairs and was a safety hazard if there was an emergency. Interview on 01/26/24 at 10:51 A.M., with the Administrator revealed she would have staff move the wheelchairs and she would educate staff not to place wheelchairs in the hallways. This deficiency represents non-compliance investigated under Complaint Number OH00149967. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 13 of 13