Inspection·May 17, 2021

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 medical record review, observation, resident and staff interviews and review of the facility policy, the facility failed to ensure oxygen tubing was labeled and dated. This affected three (#34, #41, #61) of three residents reviewed for oxygen therapy. Facility census was 67. Residents Affected - Few Findings included: 1. Review of Resident #34's medical record revealed an admission date of 05/10/18. Diagnoses included pneumonia, emphysema, chronic obstructive pulmonary disease (COPD), asthma, personal history of transient ischemic attack and chronic kidney disease. Review of Resident #34's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function. The resident also received oxygen therapy. Review of Resident #34's most recent care plan revealed the resident had the potential for alteration in respiratory function related to emphysema, COPD, and hypoxia. Interventions included to administer oxygen as ordered. Review of Resident #34's medical record revealed a physician's order dated 04/15/19 for continuous oxygen at two to three liters per minute. Observation on 05/11/21 at 10:42 A.M. of Resident #34 revealed the oxygen tubing and the humidifier attached to the oxygen concentrator were not dated or labeled. On 05/11/21 at 9:23 A.M. Licensed Practical Nurse (LPN) #250 verified Resident #34's oxygen tubing nor concentrator humidification were labeled nor dated. The nurse also verified that it was facility policy to date the tubing and humidification when replaced. Interview with Assistant Director of Nursing (ADON) #100 on 05/13/21 at 10:50 A.M. revealed a local company provided the oxygen tubing, humidification and concentrators for the facility residents. The company personnel was to change the tubing and humidification when making their weekly stops and were expected to label and date the equipment. ADON #100 verified the company and facility staff failed to label and date the oxygen tubing and concentrator humidification. 2. Review of Resident #41's medical record revealed an admission date of 12/24/20. Diagnoses included COPD, acute respiratory failure with hypoxia, tachycardia and paranoid schizophrenia. Review of Resident #41's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. The residents had shortness of breath on exertion and required oxygen therapy. Review of Resident #41's most recent care plan revealed the resident had a potential for alteration in respiratory function related to COPD, emphysema, respiratory failure and being a smoker. Interventions included to deliver oxygen as ordered. Review of Resident #41's medical record revealed a physician's order dated 02/13/21 for continuous oxygen at one to two liters per nasal cannula and to check placement and record oxygen saturation every shift. Special Instructions: every shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 2 of 4 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 365625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Bucyrus Center Fo 1929 Whetstone Street Bucyrus, OH 44820 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/11/21 at 10:43 A.M. of Resident #41 revealed the oxygen tubing and the humidifier attached to the oxygen concentrator were not dated or labeled. On 05/11/21 at 9:23 A.M. an interview with LPN #250 verified Resident #41's oxygen tubing nor concentrator humidification were labeled nor dated. The nurse also verified that it was facility policy to date the tubing and humidification when replaced. 3. Review of the Resident #61's medical record revealed an admission date of 04/07/21. Diagnoses included type 2 diabetes, chronic obstructive pulmonary disease, obstructive sleep apnea, and osteoarthritis. Review of the quarterly MDS assessment, dated 04/13/21, revealed the resident had impaired cognition. The resident also received oxygen therapy. Review of Resident #61's care plan dated 04/19/21 revealed the resident has potential for alteration in respiratory function related to chronic obstructive pulmonary disease. Administer oxygen as ordered and auscultate lung sounds as needed. Observation on 05/10/21 at 10:24 A.M., of Resident #61's revealed the oxygen tubing and humidifier attached to the oxygen concentrator were not labeled or dated. Interview on 05/11/21 at 3:10 P.M., with LPN #200 verified Resident #61's oxygen tubing and humidification were not labeled nor dated. Interview on 05/11/21 at 3:12 P.M. with Resident #61 reports does not know when the oxygen tubing was last changed. Resident #61 further stated the oxygen tubing is starting to have a weird smell. Interview with Assistant Director of Nursing (ADON) #100 on 05/13/21 at 10:50 A.M. revealed a local company provided the oxygen tubing, humidification and concentrators for the facility residents. The company personnel were to change the tubing and humidification when making their weekly stops and were expected to label and date the equipment. ADON #100 verified the company and facility staff failed to label and date the oxygen tubing and concentrator humidification. Review of facility policy titled Departmental Respiratory Therapy Prevention of Infection, dated 11/19, revealed it is the facility's policy to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Steps in procedure infection control in consideration related to oxygen therapy change the oxygen cannula and tubing every seven days, or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 3 of 4 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 365625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Bucyrus Center Fo 1929 Whetstone Street Bucyrus, OH 44820 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 medical record review, observation, staff interview and policy review, the facility failed to ensure soiled linens were properly placed in a bag or container and transferred to the laundry. This had the potential to affect one (#6) out of 32 residents sampled during the survey. Facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 10/09/18. Diagnoses included type two diabetes, chronic obstructive pulmonary disease and, polyneuropathy. Observation on 05/10/21 at 11:24 A.M., of Resident #6's bathroom floor with soiled towels, wash clothes and bed pad laying on the bathroom floor and not placed in a container or plastic bag. The soiled linens on the bathroom floor was verified with the Housekeeping Supervisor #505. Interview on 05/12/21 at 1:48 P.M. with the Assistant Director of Nursing (ADON) #100 revealed are not to be on the floor they are to be placed in a plastic bag and sent to the laundry. Review of the facility policy titled Laundry and Bedding, Soiled, undated, revealed it is the facility's policy that soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Soiled laundry and bedding (personal clothing, scrubs sits, gowns, bed sheets, blankets, towels, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 4 of 4