Inspection·January 29, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Ohio board of nursing licensure verification system, review of a personnel file, review of the facilities policies, resident and staff interviews, and review of the facility's Self-Reported Incidents (SRI), the facility failed to timely report allegations of misappropriation of resident's narcotic medications. This affected one (Resident #22) of 24 residents reviewed for abuse. The facility census was 69. Findings include: Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included post polio syndrome, arthritis, high blood pressure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Interview with Resident #22 on 01/23/24 at 10:29 A.M. confirmed he used to work in the medical field and had a concerning incident with Licensed Practical Nurse (LPN) #140. Resident #22 stated LPN #140 had attempted one evening to give him night time medications that included a Tylenol (treats mild pain, over the counter medication) instead of his ordered and scheduled Vicodin (narcotic pain medication to treat moderate to severe pain), in his cup of pills. Resident #22 stated he believed LPN #140 was trying to steal the Vicodin and put the Tylenol in his medications thinking he would not catch it. Resident #22 stated he took a picture on his cell phone, dated 11/24/23, of the Tylenol and shared this with the Director of Nursing (DON) at that time. Resident #22 stated requested for a written report regarding this incident however none was ever provided to him. Subsequent review of Resident #22's Controlled Drug Receipt, Proof of Use/Disposition Form, dated 11/24/23, revealed LPN #140 did sign out of the controlled records Vicodin 5/325 mg at 9:23 P.M. Interview with the DON on 01/23/24 at 4:17 P.M. confirmed Resident #22 had reported an incident of almost medication error. The DON confirmed Resident #22 had told her LPN #140 had attempted to give him Tylenol in place of Vicodin on 11/24/23 and that he made the nurse get the Vicodin to administer to him. The DON stated she did not think this was an attempt at narcotic drug diversion and therefore did not investigate the incident as such or report this to the Pharmacy Board, Board of Nursing, or to State Survey Agency, Ohio Department of Health. The DON stated LPN #140 was coached on 11/24/23 to ensure she was verifying medications prior to administration. The DON confirmed the facility has not reported any possible narcotic drug diversion to their pharmacy, board of nursing and/or law enforcement. Interview with Registered Nurse (RN) #102 on 01/23/24 at 11:22 A.M. confirmed she has been concerned that LPN #140 seems to sign out many more narcotics than anyone else and was suspicious she was diverting narcotics. RN #102 confirmed she has reported her concerns to management. Interview with Resident #22 and the Administrator on 01/25/23 at 3:18 P.M. confirmed Resident #22 was suspicious that LPN #140 was attempting to divert Vicodin and replace the pill with Tylenol. Review of the facility's SRI from 11/24/23 to 01/22/24 revealed there was no SRI reported involving Resident #22 and/or LPN #140. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 2 of 11 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 01/29/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of LPN #140's personal file revealed she was hired at the facility on 05/30/23, with the facility performing a check on her nursing license. LPN #140's licensed did not have any actions at the time of hire. LPN #140 had coaching on 11/24/23 to ensure verification of five rights for medication administration. LPN #140 received a personal action form dated 12/08/23 at which time multiple doses of Oxycodone (Narcotic) had been signed out on controlled log but not signed out on the Medication Administration record (MAR). The form did not list which resident/residents the 12/08/23 coaching had occurred from. Review of the Ohio Board of Nursing current licensure on 01/23/24 revealed LPN #140 had a nursing license. Under board action, it stated pending. Review of the facilities undated abuse policy revealed the facility will not tolerate Mistreatment, Abuse, Neglect of its residents or Misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of Abuse, Mistreatment, Neglect, Misappropriation of resident property, and injuries sustained by its residents. Facility staff should report all such allegations to the Administrator and the Ohio Department of Health (ODH) in accordance with the procedures in this policy. The policy defined misappropriation of resident property as; the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. All allegations Abuse, Neglect, Mistreatment, Injuries of Unknown Source, and Misappropriation of Resident Property must be reported immediately to both the Administrator and to the Ohio Department of Health. For the purposes of this policy, immediately means as soon as possible, but ought not to exceed twenty-four (24) hours after the incident or discovery of the injury. Review of the facility's Discrepancies, Loss and or Diversion of Medications policy, dated May 2020, revealed all discrepancies, suspected loss and/or diversion of medications. irrespective of drug type or class. are immediately investigated and reported. Immediately upon the discovery or suspicion of a discrepancy, suspected loss, or diversion, the Administrator. Director of Nursing (DON), and Pharmacy (i.e., Consultant Pharmacist) are notified and an investigation conducted. The DON or designee leads the investigation; The information is not to be discussed with other individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 3 of 11 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 01/29/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of the facility policy, and resident and staff interviews, the facility failed to ensure the residents who were dependent on staff for activities of daily living (ADL) received the assistance with shaving. This affected two (Residents #22 and #52) of three residents reviewed for ADL care. The facility census was 69. Residents Affected - Few Findings include: 1. Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included post polio syndrome, arthritis, high blood pressure, and diabetes mellitus. Review of Resident #22's plan of care, dated 03/23/22, revealed the staff were to provide assistance with all ADL care and mobility as needed/ anticipate resident needs as able and to assist with and/or shave facial hairs everyday or per resident preference. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22 was dependent on staff for ADLs, including shaving and bathing. Observation and interview with Resident #22 on 01/22/24 at 9:18 A.M. revealed it has been a week since he was shaven and preferred to be clean shaven everyday. Observation of Resident #22 on 01/24/23 at 7:59 A.M. revealed Resident #22 remained unshaven and again stated he preferred to be shaven daily. Resident #22 stated he moved rooms recently and was not getting shaved everyday. Interview with the Director of Nursing (DON) on 01/24/23 at 8:06 A.M. confirmed Resident #22 does need shaven and that it appeared to be several days of facial hair growth. The DON provided documentation on 01/24/24 at 1:20 P.M. stating Resident #22 refused to be shaved and bathed on 01/21/24. There was no other documentation to show Resident #22 refused to be shaven on a daily basis. 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with mood disturbance, rhabdomyolysis, metabolic encephalopathy, weakness, depression, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had short and long term memory problems, had physical, verbal and behaviors directed towards others one to three days of the review period, and the resident had rejection of care six days of the review period. Resident #52 was dependent n staff with showering, dressing, and personal hygiene. Review of Resident #52's shower documentation revealed Resident #52 was given a bed bath or shower on 01/04/24, 01/07/24, 01/10/24, 01/15/24, 01/18/24, and 01/23/24. The forms did not address if Resident #52 was shaven or had refused shaving. Review of the progress notes from 01/01/24 to 01/23/24 revealed there was no documentation of refusal of care by Resident #52. Review of the behavior documentation forms for Resident #52 for January 2024 revealed the resident was documented to refuse shaving on 01/05/24. The documentation indicated the goal was to have resident's daily care needs met within limitations of resistance to care with date of 01/06/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 4 of 11 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 01/29/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions attempted were documented as watching television, 15 minute checks, and approach in a calm manner. The interventions were documented as ineffective. There were no other behavior forms completed for Resident #52 from 01/01/24 to 01/23/24. Review of the behavior analysis report completed by the state tested nursing aides (STNAs) in the electronic medical record from 11/18/23 to 01/25/24 revealed the staff documented Resident #52 rejected care on 12/30/23 and 01/25/24. No other refusals of care were documented on the behavior analysis report. Observation of Resident #52 on 01/23/24 at 7:19 A.M. revealed the resident had several long hairs on her chin. Observation of Resident #52 on 01/24/24 at 7:22 A.M. revealed the resident was sitting in the lounge with a lidded cup in her hand watching television. The resident had several long hairs on her chin. Interview with STNAs #123 and #112 on 01/24/24 at 10:00 A.M. (who were observed to be providing incontinent care to Resident #52) revealed Resident #52 did not refuse care or have behaviors for them when they were providing care to her. STNAs #123 and #112 verified they document refusals of care in the electronic medical record, and they let the nurse know if the resident will not allow the staff to complete some part of daily care after re-approaching the resident at another time. Interview with the Director of Nursing (DON) on 01/24/24 at 1:20 P.M. confirmed shaving should be daily with morning care to residents. Interview with Registered Nurse (RN) #152 on 01/24/24 at 1:31 P.M. confirmed Resident #52 had several long hairs on her chain that had not just occurred in the past few days. RN #152 stated Resident #52 can be combative with care at times but not always. Review of the facility's undated policy titled Shaving the Resident revealed it is the facility's policy to promote cleanliness and to provide skin care. The following information should be recorded in the resident's medical record: the date and time that the procedure was performed.; The name and title of the individual{s) who performed the procedure; If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure.; and if the resident refused the treatment, the reason{s) why and the intervention taken. The staff were to report to the supervisor if the resident refuses the procedure and report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 5 of 11 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 01/29/2024 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 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 observations, medical record review, and staff interviews, the facility failed to ensure a resident received oxygen therapy as physician ordered. This affected one (Resident #22) of one resident reviewed for respiratory services. The facility census was 69. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included with post polio syndrome, high blood pressure, and pneumonia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of Resident #22's current physician orders for 01/2024 revealed an order for oxygen to be administered at two liters via nasal cannula, and have humidifier placed on oxygen. Observations of Resident #22 on 01/22/24 at 9:37 A.M. and 12:13 P.M. revealed Resident #22 was receiving oxygen from a concentrator that the tubing was plugged directly into. The observation identified there was no humidification bottle as ordered by the physician. The observation at 12:13 P.M. revealed an Oxygen Supply Person #900 had a cart and was going resident-to-resident changing their oxygen tubing, humidification bottles and breathing equipment. Interview with Oxygen Supply Person #900 stated he was just replacing what was current in each resident's room and had no idea what their physician's orders state. Subsequent observations of Resident #22 on 01/23/24 at 3:06 P.M. and on 01/24/23 at 7:59 A.M. revealed Resident #22 was receiving oxygen from a concentrator that the tubing was plugged directly into. The observation identified there was no humidification bottle as ordered by the physician. Observation and interview with the Director of Nursing (DON) on 01/24/24 at 8:06 A.M. confirmed Resident #22's physician order does state to administer oxygen with humidification. The DON confirmed Resident #22 does not have a humidification bottle on his oxygen concentrator. The DON confirmed the oxygen company changes the tubing and bottles on Monday and confirmed the person doing this does not have any nursing license. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 6 of 11 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 01/29/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #30's record revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Diagnoses included pyelonephritis,, type two diabetes mellitus, and obesity with a body mass index of 50-59. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was alert and oriented and had no behaviors. Resident #30 was coded as not receiving any scheduled or as needed pain medication and no non medication intervention was required for pain intervention the past five days. Resident #30's pain interview revealed the resident denied having any pain or hurting at any time in the past five days. Review of the physician orders dated 12/24/23 revealed Resident #30 had the following medications orders during her stay at the facility: Tylenol (antipyretic/analgesic) 650 milligrams (mg) every four hours as needed for pain and Oxycodone (Opioid) 5.0 mg every four hours as needed. On 01/10/24, an order for Hydrocodone/APAP (Opioid) 5/325 mg half tablet or whole tablet twice daily as needed for pain ordered. Review of the Controlled drug receipt log for Hydrocodone/APAP 5-325 for Resident #30 revealed the 28 doses that were documented as removed from the narcotic drawer were all removed by Licensed Practical Nurse (LPN) #140. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to the resident on the following four dates and times: 01/10/24 at 11:44 P.M.; 01/14/24 at 3:00 P.M.; 01/16/24 at 8:30 P.M.; and 01/18/24 at 2:50 P.M. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg for Resident #30 revealed following doses were signed as removed from the narcotic drawer but the time the medication was documented on the medication administration record as administered to the resident was drastically different on the following four dates and times: On 01/17/24, medication was documented on the controlled drug receipt as removed from the narcotic drawer at 1:40 A.M. and the MAR documented the medication was provided to the resident at 01/17/24 at 3:21 A.M. On 01/18/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 9:00 P.M. and the MAR documented the medication was provided to the resident on 01/18/24 at 10:35 P.M. On 01/19/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 11:15 P.M. and the MAR documented the medication was provided to the resident on 01/19/24 at 10:35 P.M. On 01/20/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 4:00 A.M. and the MAR documented the medication was provided to the resident on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 7 of 11 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 01/29/2024 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 0755 01/20/24 at 8:05 A.M. Level of Harm - Minimal harm or potential for actual harm Telephone interview with Resident #30 on 01/23/24 at 4:12 P.M. revealed the resident had no concerns with the nurses who provided care to her at the facility. Resident #30 denied having pain at the facility and stated she did not think she had any pain medication at the facility. Resident #30 was asked if she requested any medication for pain while a resident at the facility and she stated, I did not request any pain pills while at the facility. Resident #30 stated the facility provided her a prescription for Vicodin when she discharged home and stated, I am not going to fill it. Residents Affected - Few Interview with the Director of Nursing (DON) on 01/29/24 at 10:22 A.M. confirmed the controlled drug receipt log for Resident #30's Hydrocodone/APAP 5/325 mg and MAR did not match as documented above. The DON confirmed LPN #140 was the only nurse who had removed narcotic medication and documented narcotic medication as administered to Resident #30. Review of the facility's Medication Administration - General Guidelines policy, dated May 2020, revealed medications should be administered within 60 minutes of the scheduled time frame. The individual who administers the medications should record the administration on the MAR immediately after the medication is given. In no case should the individual who administered medications report off-duty without first recording the administration of any medications. Review of the facility's policy titled Discrepancies, loss and or Diversion of Medications, dated May 2020, revealed the policy identified all discrepancies, suspected loss and/or diversion of medications. irrespective of drug type or class. are immediately investigated and reported. Immediately upon the discovery or suspicion of a discrepancy, suspected loss, or diversion, the Administrator, Director of Nursing (DON), and Pharmacy (i.e., Consultant Pharmacist) are notified and an investigation conducted. The DON or designee leads the investigation; The information is not to be discussed with other individuals; During the process, the Consultant Pharmacist will verify suspected loss. This deficiency represents non-compliance investigated under Complaint Number OH00149667. Based on staff and resident interview, record review, and policy review, the facility failed to ensure controlled medications were accurately recorded as being received by Residents #30 and #66. This affected two (Resident #30 and #66) of nine residents reviewed for medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 12/16/23 and a discharge date of 01/05/24. Diagnoses included a trochanteric fracture of the left femur (hip fracture), a fracture of the lower end of the left radius (wrist), osteoarthritis, and anxiety. Review of the Minimum Data Set (MDS) 3.0 discharge return anticipated assessment, dated 01/05/24, revealed Resident #66 had intact cognition. Resident #66 experienced pain rating of an eight out of ten on a frequent basis, and the pain frequently made it difficult to sleep at night. Review of Resident #66's physician's orders revealed an order dated 12/27/23 for Hydrocodone-acetaminophen (APAP) 5-325 mg (a schedule II, controlled narcotic medication) give one tablet three times daily routine for five days (12/27/23 to 12/31/23) for pain. Resident #66 had an order dated 01/01/24 for Hydrocodone-APAP 5-325 mg, one tablet twice daily routine for five days (01/01/24 to 01/05/24) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 8 of 11 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 01/29/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for pain. Resident #66 had an order dated 12/16/23 for tramadol 50 mg (a schedule IV, controlled narcotic medication) one tablet every four hours as needed (PRN) for pain. On 12/27/23, Resident #66's tramadol order was changed to Tramadol 50 mg one tablet three times daily PRN for pain. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to the resident on the following eight dates and times: 12/29/23 at 3:15 A.M.; 12/29/23 at 5:30 P.M.; 12/30/23 at 5:30 A.M.; 12/31/23 at 2:25 A.M.; 12/31/23 at 6:00 P.M.; 01/01/24 at 2:55 A.M.; 01/03/24 at 3:50 A.M.; and on 01/15/24 at 2:00 A.M. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg for Resident #66 revealed following a dose was signed as removed from the narcotic drawer on 12/28/23 at 5:30 A.M. but the time the medication was documented on the MAR as administered to Resident #66 was between 7:00 A.M. and 11:00 A.M. Review of the controlled drug receipt log for Tramadol 50 mg revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to Resident #66 on the following 23 dates and times: 12/17/23 at 5:00 P.M. 12/18/23 at 5:00 P.M. 12/19/23 at 2:35 A.M. 12/19/23 at 6:00 P.M. 12/19/23 at 10:45 P.M. 12/20/23 at 4:30 P.M. 12/21/23 at 3:15 A.M. 12/21/23 at 4:00 P.M. 12/21/23 at 10:30 P.M. 12/22/23 at 3:00 A.M. 12/22/23 at 2:40 P.M. 12/22/23 at 6:20 P.M. 12/23/23 at 7:30 A.M. 12/23/23 at 11:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 9 of 11 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 01/29/2024 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 0755 12/24/23 at 3:25 A.M. Level of Harm - Minimal harm or potential for actual harm 12/24/23 at 4:30 P.M. 12/26/23 at 4:00 P.M. Residents Affected - Few 12/27/23 at 4:30 P.M. 12/27/23 at 10:40 P.M. 01/01/24 at 8:00 A.M. 01/01/24 at 7:00 P.M. 01/02/24 at 12 A.M. 01/03/24 at 11:30 P.M. Additionally, the MAR for Resident #66's Tramadol medication had doses signed as given, but with no corresponding entries on the controlled drug receipt log, on the following six dates and times: 12/23/23 at 4:03 A.M.; 12/28/23 at 6:33 A.M.; 12/28/23 at 5:41 P.M.; 12/29/23 at 4:49 P.M.; 12/30/23 at 5:45 A.M.; and 12/31/23 at 4:32 A.M. Telephone interview on 01/23/24 at 4:49 P.M. with Resident #66 revealed she did experience pain while a resident of the facility, and she recalled the nurses administering her pain medication, though she could not recall which medication she took at which times. An interview on 01/29/24 at 10:45 A.M. with the Director of Nursing (DON) verified the above discrepancies between the controlled drug receipt logs and the medication administration records. The DON confirmed that all PRN doses of the medication signed out from the controlled drug receipt logs should also be recorded on the MAR. The DON verified that after reviewing the medical record for Resident #66, two nurses, Licensed Practical Nurse (LPN) #140 and Registered Nurse (RN) #174, were suspended pending investigation into potential misappropriation of Resident #66's narcotic medications. The DON confirmed the investigation remained ongoing, but stated LPN #140 would not be returning to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 10 of 11 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 01/29/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to store refrigerated food properly. This had the potential to affect all 69 residents in the facility who received food from the kitchen. Residents Affected - Many Findings include: Observation of the walk-in refrigerator on 01/22/24 at 8:00 A.M. revealed there was a large metal tray labeled meat loaf that was uncooked on the top shelf over the drinks stored in carafes. There was also observed a small metal rectangle pan of brown liquid that was unlabeled and undated, a small metal rectangle pan of what appeared to be cooked meat with grease on top that was not dated or labeled, and a large metal tray of what appeared to be meatloaf that had been served but was not labeled or dated. Interview with Dietary Manager (DM) #177 on 01/22/24 at 8:15 A.M. confirmed there was meatloaf thawing that was on the top shelf and over drinks, DM #177 stated the meatloaf should be on the bottom shelf and not over other food/drink items. DM #177 also verified the three undated unlabeled metal containers not labeled or dated. DM #177 stated these three metal containers were gravy, cooked hamburger, and meatloaf that was previously served. DM #177 verified the the containers were not labeled or dated. Review of the facility's undated policy titled Refrigerated Storage revealed refrigerated food shall be stored in a manner that optimizes food safety and quality. The procedure included the 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. 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). Cross-contamination of food shall be prevented by: Storing raw meat on shelves below fruits, vegetables or other ready-to-eat food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 11 of 11