Health inspection·January 6, 2020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. 2. Review of Resident #5's medical record revealed she admitted to the facility 12/17/13. Diagnoses included bipolar disorder, personality disorder, anxiety disorder, and major depressive disorder. Review of Resident #5's Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact and independent with activities of daily living. Review of a form titled, Self Reported Incident Form, (SRI) tracking #183486, dated 11/08/19, revealed physical contact occurred between two residents and that there was no negative outcome to either resident. The SRI revealed Resident #46 had entered Resident #5's room and kicked her in her shins. Staff immediately intervened and re-directed Resident #46 out of Resident #5's room. The SRI stated Administrator attempted to interview Resident #46 following the incident, but he refused to participate. The SRI revealed Resident #46 had a history of traumatic brain injury and reduced mobility. Further review of the SRI revealed Administrator asked Resident #5 as to if she had any concerns related to Resident #46 or any other residents, to which Resident #5 replied, I think I will live. The SRI stated Resident #5 was laughing as she replied to Administrator. Under the heading, Facility Conclusion/Disposition, the SRI revealed the facility did not conclude that abuse occurred because the involved residents experienced no physical harm, pain, or mental anguish. The SRI stated Resident #46 could not provide a reason as to why he kicked Resident #5 and his anti-psychotic medication was increased. The SRI stated the facility followed their abuse policy. A witness statement stated 11/08/19 by Administrator revealed on 11/08/19 at 11:17 A.M., Licensed Practical Nurse (LPN) #36 heard Resident #5 calling out from her room. LPN #36 immediately responded and re-directed Resident #46 out of the room. Resident #5 reported to LPN #36 that Resident #46 had kicked her in the shins. The statement revealed, when interviewed, Resident #46 could not provide a reason as to why he had kicked Resident #5. Resident #5 was immediately interviewed who stated, I'm fine, I think I will live. Further review of the statement revealed as a result of the investigation, the facility did not conclude abuse occurred because no physical harm, pain, or mental anguish occurred nor could Resident #46 provide a reason why he kicked Resident #5 and his anti-psychotic medication was increased. Review of a form titled, Event Statement Form, dated 11/08/19, revealed that LPN #36 stated she heard Resident #5 calling out from her room and saw Resident #46 in the room. LPN #36 stated she re-directed Resident #46 and Resident #5 had reported he had kicked her in the shins. LPN #36 stated there were no injures to either resident noted. Review of a nursing progress note, dated 11/08/19 at 10:00 A.M., it was noted that another resident was in Resident #5's room and had kicked her in the shins. The note stated there were no visible signs or symptoms of injury and that Resident #5 denied injury. The other resident was redirected. The incident was reported to Resident #5's physician and Director of Nursing (DON). Review of Resident #46's medical record revealed he admitted to the facility 08/07/18. Diagnoses included traumatic brain injury, impulse disorder, and schizophrenia. Review of Resident #46's MDS, dated [DATE], revealed he refused to participate in his cognitive assessment. Review of Resident #46's physician orders dated 11/08/19 revealed his anti-psychotic medication was increased to 1 milligram a day in the morning. Review of Resident #46's care plan, started 08/14/18 revealed Resident #46 exhibited behaviors such as kicking exit doors, going in and out of other resident rooms and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 2 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0600 Level of Harm - Minimal harm or potential for actual harm physically aggressive with staff. His goal stated Resident #46 would not harm himself or others. Interventions included observing for inappropriate or wandering behaviors that are disruptive to other residents and provide comfort measures. Interventions also included observing for behavior that endangered the resident and/or others and to carefully intervene to promote safety of other residents. The care plan stated to redirect Resident #46 from other resident's rooms and unsafe situations as needed. Residents Affected - Few Review of an interdisciplinary progress note dated 10/30/19 revealed Resident #46 had been having increased behaviors and had attempted to hit and kick staff. It noted staff would continue to monitor. A nursing progress note dated 11/01/19 at 2:53 P.M. revealed Resident #46 was having increased physical aggression with staff and was tearing pictures and note racks off the wall at the nurses station and was aggressive when redirected. a urinalysis was ordered and was negative per nursing progress notes. A progress note dated 11/08/19 at 11:17 A.M. revealed Resident #46 was in Resident #5's room and kicked her in the shins and no injury was noted to either resident. Resident #46 had been successfully redirected. Review of a nursing note dated 11/09/19 at 1:29 P.M. revealed Resident #46 had increased behaviors and was attempting to go in and out of other resident's rooms but was redirected. Review of Resident #46's medical record revealed he was on 15 minute checks from 11/08/19 at 11:30 A.M. through 11/10/19 at 1:30 P.M. Interview on 01/02/20 at 11:40 A.M. with Resident #5 revealed Resident #46 had come into her room on 11/08/19. She revealed she told Resident #46 to leave and he started kicking her in the shins. She stated at times he continued to come into her room. An interview with Resident #46 was attempted 01/04/20 at 9:38 A.M. related to the incident between Resident #46 and Resident #5, but Resident #46 refused to participate. Interview on 01/06/20 at 9:09 A.M. with Director of Nursing confirmed resident-to-resident physical abuse occurred when Resident #46 kicked Resident #5 in the shins on 11/09/19. Interview on 01/06/20 at 9:15 A.M. with Administrator confirmed Resident #46 had increased behaviors including physical aggression noted in his medical record beginning on 10/30/19. No further interventions were put into place for Resident #46's increased physical aggression. Administrator confirmed 11/08/19 Resident #46 entered Resident #5's room and kicked her in the shins. She stated she immediately attempted to interview Resident #46, who refused to participate. Administrator interviewed Resident #5 who confirmed Resident #46 had come into her room and began kicking her. Administrator confirmed no other residents or staff were interviewed other than Resident #46, Resident #5, and LPN #36. She verified the policy stated the interviews would include other residents and staff who may have came into contact with the perpetrator of victim on the day of the incident. She verified a thorough investigation was not completed and that the facility's abuse policy was not followed. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the facility would not tolerate abuse of its residents by anyone and that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse sustained by its residents. Under the heading, Investigation Protocol, revealed that the investigation must be completed within five working days and that the person investigating would interview the resident, the accused, and all witnesses. Witnesses included anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 3 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility's Self Reported Incident (SRI), medical record review, and interview, the facility failed to implement the facility's abuse policy. This affected three (Resident #60, #46, and #5) of the five residents reviewed for abuse. The facility census was 68. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/25/17 with the diagnoses of cellulite of the right and left lower limbs, difficulty in walking and unsteadiness on his feet. Review of Resident #60's quarterly Minimum Data Set (MDS) 3.0 dated for 11/29/19 revealed resident with an intact cognition. Interview on 01/02/20 at 11:27 A.M. with Resident #60 revealed a few months ago, another resident came into his room and started going through his clothes. This was when Resident #60 claimed he yelled at the other resident and that was when the other resident came over and punched him in the face and made his nose bleed. Review of the SRI #181538, completed for Resident #60 revealed the incident occurred on 10/03/19 at 11:00 P.M. where a male resident had entered into Resident #60's room. It was noted that Stated Tested Nursing Assistant (STNA) #24 saw the male resident entering Resident #60's room and that was when she ran down the hall to try to stop him. Upon entering the room she saw Resident #60 sitting in his wheelchair holding his nose which was bleeding. The facility's findings of this incident was unsubstantiated for abuse. Interview on 01/06/20 at 2:30 P.M. with the Administrator revealed she did not feel like it was abuse because the male resident who had punched Resident #60 had a severe cognitive impairment and did not even remember the incident. After reviewing the abuse policy, the Administrator confirmed this was a willful act and should have been substantiated for resident-to-resident abuse. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the facility would not tolerate abuse of its residents by anyone and that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse sustained by its residents. Under the heading, Investigation Protocol, revealed that the investigation must be completed within five working days and that the person investigating would interview the resident, the accused, and all witnesses. Witnesses included anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. 2. Review of Resident #5's medical record revealed she admitted to the facility 12/17/13. Diagnoses included bipolar disorder, personality disorder, anxiety disorder, and major depressive disorder. Review of Resident #5's Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact and independent with activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 4 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a form titled, Self Reported Incident Form, (SRI) tracking #183486, dated 11/08/19, revealed physical contact occurred between two residents and that there was no negative outcome to either resident. The SRI revealed Resident #46 had entered Resident #5's room and kicked her in her shins. Staff immediately intervened and re-directed Resident #46 out of Resident #5's room. The SRI stated Administrator attempted to interview Resident #46 following the incident, but he refused to participate. The SRI revealed Resident #46 had a history of traumatic brain injury and reduced mobility. Further review of the SRI revealed Administrator asked Resident #5 as to if she had any concerns related to Resident #46 or any other residents, to which Resident #5 replied, I think I will live. The SRI stated Resident #5 was laughing as she replied to Administrator. Under the heading, Facility Conclusion/Disposition, the SRI revealed the facility did not conclude that abuse occurred because the involved residents experienced no physical harm, pain, or mental anguish. The SRI stated Resident #46 could not provide a reason as to why he kicked Resident #5 and his anti-psychotic medication was increased. The SRI stated the facility followed their abuse policy. A witness statement stated 11/08/19 by Administrator revealed on 11/08/19 at 11:17 A.M., Licensed Practical Nurse (LPN) #36 heard Resident #5 calling out from her room. LPN #36 immediately responded and re-directed Resident #46 out of the room. Resident #5 reported to LPN #36 that Resident #46 had kicked her in the shins. The statement revealed, when interviewed, Resident #46 could not provide a reason as to why he had kicked Resident #5. Resident #5 was immediately interviewed who stated, I'm fine, I think I will live. Further review of the statement revealed as a result of the investigation, the facility did not conclude abuse occurred because no physical harm, pain, or mental anguish occurred nor could Resident #46 provide a reason why he kicked Resident #5 and his anti-psychotic medication was increased. Review of a form titled, Event Statement Form, dated 11/08/19, revealed that LPN #36 stated she heard Resident #5 calling out from her room and saw Resident #46 in the room. LPN #36 stated she re-directed Resident #46 and Resident #5 had reported he had kicked her in the shins. LPN #36 stated there were no injures to either resident noted. Review of a nursing progress note, dated 11/08/19 at 10:00 A.M., it was noted that another resident was in Resident #5's room and had kicked her in the shins. The note stated there were no visible signs or symptoms of injury and that Resident #5 denied injury. The other resident was redirected. The incident was reported to Resident #5's physician and Director of Nursing (DON). Review of Resident #46's medical record revealed he admitted to the facility 08/07/18. Diagnoses included traumatic brain injury, impulse disorder, and schizophrenia. Review of Resident #46's MDS, dated [DATE], revealed he refused to participate in his cognitive assessment. Review of Resident #46's physician orders dated 11/08/19 revealed his anti-psychotic medication was increased to 1 milligram a day in the morning. Review of Resident #46's care plan, started 08/14/18 revealed Resident #46 exhibited behaviors such as kicking exit doors, going in and out of other resident rooms and was physically aggressive with staff. His goal stated Resident #46 would not harm himself or others. Interventions included observing for inappropriate or wandering behaviors that are disruptive to other residents and provide comfort measures. Interventions also included observing for behavior that endangered the resident and/or others and to carefully intervene to promote safety of other residents. The care plan stated to redirect Resident #46 from other resident's rooms and unsafe situations as needed. Review of an interdisciplinary progress note dated 10/30/19 revealed Resident #46 had been having increased behaviors and had attempted to hit and kick staff. It noted staff would continue to monitor. A nursing progress note dated 11/01/19 at 2:53 P.M. revealed Resident #46 was having increased (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 5 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical aggression with staff and was tearing pictures and note racks off the wall at the nurses station and was aggressive when redirected. a urinalysis was ordered and was negative per nursing progress notes. A progress note dated 11/08/19 at 11:17 A.M. revealed Resident #46 was in Resident #5's room and kicked her in the shins and no injury was noted to either resident. Resident #46 had been successfully redirected. Review of a nursing note dated 11/09/19 at 1:29 P.M. revealed Resident #46 had increased behaviors and was attempting to go in and out of other resident's rooms but was redirected. Review of Resident #46's medical record revealed he was on 15 minute checks from 11/08/19 at 11:30 A.M. through 11/10/19 at 1:30 P.M. Interview on 01/02/20 at 11:40 A.M. with Resident #5 revealed Resident #46 had come into her room on 11/08/19. She revealed she told Resident #46 to leave and he started kicking her in the shins. She stated at times he continued to come into her room. An interview with Resident #46 was attempted 01/04/20 at 9:38 A.M. related to the incident between Resident #46 and Resident #5, but Resident #46 refused to participate. Interview on 01/06/20 at 9:09 A.M. with Director of Nursing confirmed resident-to-resident physical abuse occurred when Resident #46 kicked Resident #5 in the shins on 11/09/19. Interview on 01/06/20 at 9:15 A.M. with Administrator confirmed Resident #46 had increased behaviors including physical aggression noted in his medical record beginning on 10/30/19. No further interventions were put into place for Resident #46's increased physical aggression. Administrator confirmed 11/08/19 Resident #46 entered Resident #5's room and kicked her in the shins. She stated she immediately attempted to interview Resident #46, who refused to participate. Administrator interviewed Resident #5 who confirmed Resident #46 had come into her room and began kicking her. Administrator confirmed no other residents or staff were interviewed other than Resident #46, Resident #5, and LPN #36. She verified the policy stated the interviews would include other residents and staff who may have came into contact with the perpetrator of victim on the day of the incident. She verified a thorough investigation was not completed and that the facility's abuse policy was not followed. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the facility would not tolerate abuse of its residents by anyone and that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse sustained by its residents. Under the heading, Investigation Protocol, revealed that the investigation must be completed within five working days and that the person investigating would interview the resident, the accused, and all witnesses. Witnesses included anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 6 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility's Self Reported Incident (SRI), medical record review, and interview, the facility failed to complete a full investigation into a reported abuse incident. This affected three (Resident #60, #46, and #5) of the five residents reviewed for abuse. The facility census was 68. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/25/17 with the diagnoses of cellulite of the right and left lower limbs, difficulty in walking and unsteadiness on his feet. Review of Resident #60's quarterly Minimum Data Set (MDS) 3.0 dated for 11/29/19 revealed resident with an intact cognition. Interview on 01/02/20 at 11:27 A.M. with Resident #60 revealed a few months ago, another resident came into his room and started going through his clothes. This was when Resident #60 claimed he yelled at the other resident and that was when the other resident came over and punched him in the face and made his nose bleed. Review of the SRI #181538, completed for Resident #60 revealed the incident occurred on 10/03/19 at 11:00 P.M. where a male resident had entered into Resident #60's room. It was noted that Stated Tested Nursing Assistant (STNA) #24 saw the male resident entering Resident #60's room and that was when she ran down the hall to try to stop him. Upon entering the room she saw Resident #60 sitting in his wheelchair holding his nose which was bleeding. The facility's findings of this incident was unsubstantiated for abuse. Review of the facility's investigation for SRI #181538 revealed an interview with both residents and with the staff involved but no interviews were conducted with other residents who had or would have come in contact with the perpetrator. Interview on 01/06/20 at 2:30 P.M. with the Administrator confirmed the facility's abuse policy noted for the facility to interview other residents and that this was not completed and a complete investigation had not been completed. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the facility would not tolerate abuse of its residents by anyone and that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse sustained by its residents. Under the heading, Investigation Protocol, revealed that the investigation must be completed within five working days and that the person investigating would interview the resident, the accused, and all witnesses. Witnesses included anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. 2. Review of Resident #5's medical record revealed she admitted to the facility 12/17/13. Diagnoses included bipolar disorder, personality disorder, anxiety disorder, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 7 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #5's Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact and independent with activities of daily living. Review of a form titled, Self Reported Incident Form, (SRI) tracking #183486, dated 11/08/19, revealed physical contact occurred between two residents and that there was no negative outcome to either resident. The SRI revealed Resident #46 had entered Resident #5's room and kicked her in her shins. Staff immediately intervened and re-directed Resident #46 out of Resident #5's room. The SRI stated Administrator attempted to interview Resident #46 following the incident, but he refused to participate. The SRI revealed Resident #46 had a history of traumatic brain injury and reduced mobility. Further review of the SRI revealed Administrator asked Resident #5 as to if she had any concerns related to Resident #46 or any other residents, to which Resident #5 replied, I think I will live. The SRI stated Resident #5 was laughing as she replied to Administrator. Under the heading, Facility Conclusion/Disposition, the SRI revealed the facility did not conclude that abuse occurred because the involved residents experienced no physical harm, pain, or mental anguish. The SRI stated Resident #46 could not provide a reason as to why he kicked Resident #5 and his anti-psychotic medication was increased. The SRI stated the facility followed their abuse policy. A witness statement stated 11/08/19 by Administrator revealed on 11/08/19 at 11:17 A.M., Licensed Practical Nurse (LPN) #36 heard Resident #5 calling out from her room. LPN #36 immediately responded and re-directed Resident #46 out of the room. Resident #5 reported to LPN #36 that Resident #46 had kicked her in the shins. The statement revealed, when interviewed, Resident #46 could not provide a reason as to why he had kicked Resident #5. Resident #5 was immediately interviewed who stated, I'm fine, I think I will live. Further review of the statement revealed as a result of the investigation, the facility did not conclude abuse occurred because no physical harm, pain, or mental anguish occurred nor could Resident #46 provide a reason why he kicked Resident #5 and his anti-psychotic medication was increased. Review of a form titled, Event Statement Form, dated 11/08/19, revealed that LPN #36 stated she heard Resident #5 calling out from her room and saw Resident #46 in the room. LPN #36 stated she re-directed Resident #46 and Resident #5 had reported he had kicked her in the shins. LPN #36 stated there were no injures to either resident noted. Review of a nursing progress note, dated 11/08/19 at 10:00 A.M., it was noted that another resident was in Resident #5's room and had kicked her in the shins. The note stated there were no visible signs or symptoms of injury and that Resident #5 denied injury. The other resident was redirected. The incident was reported to Resident #5's physician and Director of Nursing (DON). Review of Resident #46's medical record revealed he admitted to the facility 08/07/18. Diagnoses included traumatic brain injury, impulse disorder, and schizophrenia. Review of Resident #46's MDS, dated [DATE], revealed he refused to participate in his cognitive assessment. Review of Resident #46's physician orders dated 11/08/19 revealed his anti-psychotic medication was increased to 1 milligram a day in the morning. Review of Resident #46's care plan, started 08/14/18 revealed Resident #46 exhibited behaviors such as kicking exit doors, going in and out of other resident rooms and was physically aggressive with staff. His goal stated Resident #46 would not harm himself or others. Interventions included observing for inappropriate or wandering behaviors that are disruptive to other residents and provide comfort measures. Interventions also included observing for behavior that endangered the resident and/or others and to carefully intervene to promote safety of other residents. The care plan stated to redirect Resident #46 from other resident's rooms and unsafe situations as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 8 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an interdisciplinary progress note dated 10/30/19 revealed Resident #46 had been having increased behaviors and had attempted to hit and kick staff. It noted staff would continue to monitor. A nursing progress note dated 11/01/19 at 2:53 P.M. revealed Resident #46 was having increased physical aggression with staff and was tearing pictures and note racks off the wall at the nurses station and was aggressive when redirected. a urinalysis was ordered and was negative per nursing progress notes. A progress note dated 11/08/19 at 11:17 A.M. revealed Resident #46 was in Resident #5's room and kicked her in the shins and no injury was noted to either resident. Resident #46 had been successfully redirected. Review of a nursing note dated 11/09/19 at 1:29 P.M. revealed Resident #46 had increased behaviors and was attempting to go in and out of other resident's rooms but was redirected. Review of Resident #46's medical record revealed he was on 15 minute checks from 11/08/19 at 11:30 A.M. through 11/10/19 at 1:30 P.M. Interview on 01/02/20 at 11:40 A.M. with Resident #5 revealed Resident #46 had come into her room on 11/08/19. She revealed she told Resident #46 to leave and he started kicking her in the shins. She stated at times he continued to come into her room. An interview with Resident #46 was attempted 01/04/20 at 9:38 A.M. related to the incident between Resident #46 and Resident #5, but Resident #46 refused to participate. Interview on 01/06/20 at 9:09 A.M. with Director of Nursing confirmed resident-to-resident physical abuse occurred when Resident #46 kicked Resident #5 in the shins on 11/09/19. Interview on 01/06/20 at 9:15 A.M. with Administrator confirmed Resident #46 had increased behaviors including physical aggression noted in his medical record beginning on 10/30/19. No further interventions were put into place for Resident #46's increased physical aggression. Administrator confirmed 11/08/19 Resident #46 entered Resident #5's room and kicked her in the shins. She stated she immediately attempted to interview Resident #46, who refused to participate. Administrator interviewed Resident #5 who confirmed Resident #46 had come into her room and began kicking her. Administrator confirmed no other residents or staff were interviewed other than Resident #46, Resident #5, and LPN #36. She verified the policy stated the interviews would include other residents and staff who may have came into contact with the perpetrator of victim on the day of the incident. She verified a thorough investigation was not completed and that the facility's abuse policy was not followed. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the facility would not tolerate abuse of its residents by anyone and that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse sustained by its residents. Under the heading, Investigation Protocol, revealed that the investigation must be completed within five working days and that the person investigating would interview the resident, the accused, and all witnesses. Witnesses included anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closed with the accused and/or alleged victim the day of the incident. The policy revealed if there were no direct witnesses, then interviews may be expanded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 9 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 observation, review of resident medical records, interview with facility staff, and review of facility policy, the facility failed to develop a care plan to address chronic kidney disease and failed to implement fall interventions for two (Resident #30 and Resident #21) of 18 residents reviewed for appropriate development and implementation of care plans. The census was 68. Findings include: 1. Review of Resident #30's medical record revealed she was admitted to the facility 07/15/17. Diagnoses included chronic kidney disease and type one diabetes. Review of her Minimum Data Set (MDS) dated [DATE], revealed Resident #30 was severely cognitively impaired, required extensive assistance from staff for activities of daily living, and had diagnoses including type one diabetes and chronic kidney disease. Review of Resident #30's progress notes revealed on 11/01/19 she was sent to the emergency room for evaluation and treatment as she was observed to be unresponsive with a blood sugar of 33. An After Visit Summary from the hospital, dated 11/02/19 at 1:07 A.M., revealed diagnoses of hypoglycemia and stage four chronic kidney disease. Review of Resident #30's care plan, last revised, 10/31/19, revealed no care plan for chronic kidney disease. After surveyor investigation, the facility initiated a care plan addressing Resident #30's chronic kidney disease on 01/04/20. During an interview on 01/04/20 at 3:53 P.M. with Regional MDS Nurse #45 confirmed Resident #30 did not have a care plan addressing her diagnoses of chronic kidney disease. 2. Review of Resident #21's medical record revealed she was admitted to the facility 10/05/19. Diagnoses included fracture of her left femur, cerebral infarction, and flaccid hemiplegia. Review of her Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a severe cognitive impairment and required extensive assistance with all activities of daily living except eating. The MDS also revealed Resident #21 had a fall with major injury in the facility. Review of a nursing progress note dated 12/14/19 at 4:01 P.M. revealed the interdisciplinary team reviewed Resident #21's fall interventions and her intervention for her bed to the wall was discontinued per Resident #21's request. Review of a physician order dated 12/15/19 revealed an order to have Resident #21's bed in the low position and a mat to the floor on the right side. Review of Resident #21's fall care plan last revised 12/15/19 at 4:00 P.M. revealed she was at risk for falls and that her risk of injury would be reduced with daily routine and care. An intervention, last revised 10/05/19, stated, mats to floor beside bed (10/05/19). Observation on 01/04/20 at 9:41 A.M. revealed Resident #21 was in bed with a mat on the right side of her bed. Interview on 01/04/20 at 9:42 A.M. with State-tested nursing assistant (STNA) #48 confirmed there was only one mat to Resident #21's bed on the right side. She confirmed the care plan stated plural mats. Interview on 01/04/20 at 10:49 A.M. with Licensed Practical Nurse #88 stated Resident #21 only needed a mat on the right side per physician orders. Interview on 01/06/20 at 7:33 A.M. with Director of Nursing (DON), revealed when inquired about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 10 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 Resident #21's fall interventions, that she was not sure and needed to look in the record because they had made so many changes. DON stated from 12/01/19 to 12/15/19 Resident #21's fall interventions included having her bed against the wall with a mat on the left side, but that on 12/15/19 Resident #21 no longer wanted to have her bed against the wall. DON stated at that time, Resident #21's fall interventions should have included bilateral mats to the floor. DON confirmed Resident #21's care plan intervention that had last been revised 10/05/19 was correct in stating mats to floor beside bed. DON stated the physician's order was incorrect and that the STNA's and nursing staff did not have matching interventions/orders on Resident #21's fall interventions. She stated she would have Resident #21's physician update the fall intervention orders. She confirmed Resident #21 should have had bilateral mats to the floor while in bed per her care plan. Review of a facility policy titled, Care Planning-Interdisciplinary Team Guidelines, undated, revealed the facility was responsible for the development of an individualized comprehensive care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 11 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 record review as well as staff interviews, the facility failed to revised a care plan to include as-needed anti-psychotic medication on her care plan for one (Resident #21) of seven residents reviewed for unnecessary medications. The facility identified 25 residents who had orders for antipsychotic medications. Findings include: Review of Resident #21's medical record revealed she was admitted to the facility 10/05/19. Diagnoses included anxiety, altered metal status, and major depressive disorder. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed she had a severe cognitive impairment and required extensive assistance from staff with activities of daily living. Review of Resident #21's physician order history revealed from 12/06/19-01/03/20 she had orders for prochlorperazine maleate (an antipsychotic medication) 10 milligrams (mg) 1-2 tabs as needed, every four to six hours for nausea and vomiting. Review of Resident #21's psychotropic drug use care plan, dated 11/17/19 and last revised 11/17/19, lacked evidence Resident #21's care plan was revised to include her antipsychotic medication use between 12/06/19 and 01/03/20. Interview on 01/04/20 at 2:17 P.M. with Director of Nursing (DON) confirmed the last time Resident #21's psychotropic medication care plan had been revised was 11/17/19, and that she had a new order for an antipsychotic on 12/06/19 and that her care plan was never revised to include the use. The DON stated that her care plan should have been revised to include the antipsychotic medication use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 12 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 Based on resident medical record review, observation, and interview, the facility failed to provide a resident (dependent on staff for bathing) with showers as per schedule and personal preference. This affected one (Resident #38) of two residents sampled for Activities of Daily Living care. The facility census was 68. Residents Affected - Few Findings include: Review of the medical record for Resident #38 revealed an admission date of 10/13/16 with the diagnoses of contracture of the left hand, muscle weakness, and abnormal posture. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 dated for 11/08/19 revealed resident with a severely impaired cognition. Resident #38 required extensive assistance from two staff members for dressing, toilet use, and personal hygiene and was dependent on two staff members for bathing. Resident #38 was noted to have impairment on one unspecified side of his upper extremity. Resident #38 was noted to be frequently incontinent of bowel and bladder and required extensive assistance from two staff members for incontinence care. Review of the shower sheet for Resident #38 from 10/01/19 through 01/03/20 revealed resident had received a shower 15 of the 41 scheduled showers. Resident #38 received eight showers in October, seven showers in November, and eight showers in December. Review of the weekly shower schedule revealed Resident #38 was to receive a shower every Tuesday, Thursday, and Saturday between 11:00 P.M. and 7:00 A.M. Observation on 01/02/20 at 1:30 P.M. of Resident #38 revealed resident with hair that appeared dirty and greasy and not brushed. Resident #38's nails appeared to be long with a noted dark colored substance under them. Interview on 01/03/19 at 10:00 A.M. with Resident #38 revealed he likes to take showers and becomes upset when the staff tell him he has to take a bath. Resident #38 revealed he does not get as many showers as he would like to and most of the time he has to ask the staff for a shower because they will not offer him one. Resident #38 denies ever refusing to take a shower. Interview on 01/03/20 at 1:23 P.M. with the Director of Nursing (DON) revealed all residents are interviewed when they are admitted to what their bathing preferences are and based on this information, shower or bath are assigned for that resident. The DON confirmed the noted days and time on the facility's weekly shower schedule was per Resident #38's preference. Continued interview with the DON confirmed Resident #38's shower schedule or preference was not being followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 13 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 review of resident medical records including hospital documentation as well as interview with facility staff revealed the facility failed to ensure hospital discharge instructions were followed and failed to ensure hospital documentation was in the medical record for Resident #30. This had the potential to affect one (Resident #30) of 18 residents reviewed for quality of care. The census was 68. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed she was admitted to the facility 07/15/17. Diagnoses included chronic kidney disease and type one diabetes. Review of her Minimum Data Set (MDS) dated [DATE], revealed Resident #30 was severely cognitively impaired, required extensive assistance from staff for activities of daily living, and had diagnoses including type one diabetes and chronic kidney disease. Review of Resident #30's progress notes revealed on 11/01/19 she was sent to the emergency room for evaluation and treatment as she was observed to be unresponsive with a blood sugar of 33. An After Visit Summary from the hospital, dated 11/02/19 at 1:07 A.M., revealed diagnoses of hypoglycemia and stage four chronic kidney disease. The instructions stated to follow up with Resident #30's established nephrologist as soon as possible. There was a hand-written note on the After Visit Summary that stated, Must see [nephrologist] ASAP due to abnormal labs. The After Visit Summary revealed there were 11 pages in the document; however, contained in Resident #30's medical record, were pages 1-4 as well as page 7. The abnormal laboratory results that were referenced were not present in the electronic or paper medical record. A nursing progress note, dated 11/02/19 at 1:15 A.M., revealed that the emergency room called and reported that Resident #30's labs were not within a normal limit and that she needed to see her nephrologist as soon as possible. Further review of Resident #30's entire medical record lacked evidence a nephrology appointment was ever scheduled. There was no further mention of the abnormal laboratory results or nephrology appointment in Resident #30's medical record. Review of Resident #30's care plan, last revised, 10/31/19, revealed no care plan for chronic kidney disease. After surveyor investigation, the facility initiated a care plan addressing Resident #30's chronic kidney disease on 01/04/20. During an interview on 01/04/20 at 3:53 P.M. with Regional MDS Nurse #45 confirmed Resident #30 did not have a care plan addressing her diagnoses of chronic kidney disease. Interview on 01/04/20 at 4:41 P.M. with Director of Nursing (DON) confirmed the referenced abnormal laboratory results from the hospital were not in Resident #30's medical record and that she was going to request them from the hospital immediately. DON confirmed Resident #30 admitted to the facility with a diagnoses of chronic kidney disease and that she had an established nephrologist. The DON stated there was no evidence in the medical record the discharge instructions from the hospital were followed as there was no evidence Resident #30 attended or was even scheduled a nephrology appointment to follow up on her abnormal laboratory results. The DON also confirmed there was no care plan for chronic kidney disease for Resident #30. Interview on 01/06/20 at 8:52 A.M. with DON revealed she received the abnormal laboratory results from the hospital and that an appointment had been scheduled 01/13/20 with Resident #30's nephrologist. Interview on 01/06/20 at 12:22 P.M. with Administrator revealed the facility did not have a policy to guide staff on following hospital discharge instructions once a resident returned to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 14 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records, interview with facility staff, as well as review of the facility's dialysis policy and service contract, the facility failed to obtain pre-dialysis vitals, including weights as care planned and ordered. The facility also failed to have on-going communication with the dialysis center. This affected one (Resident #218) of one resident reviewed for dialysis services. Resident #218 was the only resident who resided in the facility who received dialysis services. Residents Affected - Few Findings include: Review of Resident #218's medical record revealed she admitted to the facility 12/12/19. Diagnoses included chronic kidney disease, stage five and dependence on renal dialysis. Review of Resident #218's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact, required extensive assistance from staff for activities of daily living, and received dialysis. Review of Resident #218's physician orders dated 12/12/19 with no end date, revealed staff was to record her vital signs each shift. Her physician's orders dated 12/14/19 revealed Resident #218 is picked up from the facility at 10:30 A.M. for dialysis on Tuesdays, Thursdays, and Saturdays. Review of Resident #218's renal care plan dated 12/16/19, revealed Resident #218 received renal hemo dialysis and would receive renal dialysis without complications in coordination with the dialysis center and the facility. An intervention dated 12/16/19 revealed to obtain vital signs as ordered. Another intervention included to encourage the dialysis center to forward dialysis treatment notes to the facility. Review of Resident #218's Medication and Treatment Administration Record for January 2020 revealed her vitals were not taken or recorded for first shift on 01/02/20 and 01/04/20. Under the heading, Reasons/Comments, staff documented, Not administered: Resident Unavailable. Further review of the medical record, including the paper chart and electronic medical record lacked evidence of on-going communication between the facility and Resident #218's dialysis center. Interview on 01/04/20 at 11:04 A.M. with Licensed Practical Nurse (LPN) #88 confirmed she had not recorded Resident #218's vitals before she left for dialysis at 10:30 A.M. because the state-tested-nursing assistants (STNA) had not taken them. LPN #88 confirmed Resident #218 should have her vitals, including her weight so that fluid could be monitored, prior to leaving for dialysis on Tuesdays, Thursdays and Saturdays. She confirmed both Resident #218's care plan and and physician orders stated to record her vitals every shift. LPN #88 also confirmed vital signs were not obtained as care planned and ordered on first shift on 01/02/20. LPN #88 stated dialysis communication forms were sent with Resident #218 every time, but that the facility never received communication forms including the dialysis treatment report back from the dialysis center. LPN #88 confirmed there were no dialysis treatment reports in the medical record, nor was there evidence of on-going communication between the dialysis center and the facility as care planned. LPN #88 stated because pre-dialysis vitals were not obtained 01/02/20 and 01/04/20 and that the dialysis center was not sending dialysis treatment reports, there was no evidence of ongoing assessment of Resident #218's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. LPN #88 stated she had never called the dialysis center to request the dialysis reports because she thought the dialysis center would call if there were any issues. Review of the Outpatient Dialysis Services Agreement, dated 02/01/18, between the facility and Resident #218's dialysis center, revealed, both parties shall ensure that there was documented evidence of collaboration of care and communication between the nursing facility and the dialysis center. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 15 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a facility policy titled, Dialysis Care Planning Policy, undated, revealed it was the policy of the facility that all Residents who utilized renal dialysis received comprehensive interdisciplinary monitoring to ensure safety and support of dialysis services. The policy stated the facility would initiate and maintain a professional relationship with the dialysis center for and resident who received renal dialysis. The policy further stated the dialysis center would send reports from resident dialysis treatments to the facility after each visit. Further review of the policy stated the facility would communicate with the dialysis center for any concerns/questions in regard to the resident's care on any renal dialysis and that the facility would utilize dialysis center information in care planning for the resident. Event ID: Facility ID: 365750 If continuation sheet Page 16 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on resident medical review and interview, this facility failed to ensure reviewed pharmacy recommendations were put in place in a timely manner. This affected one (Resident #13) of six resident sampled for pharmacy review. The facility census was 68. Finding include: Review of Resident #13's medical record revealed an admission date of 06/20/19 with the diagnoses of acute respiratory failure, muscle weakness, and major depressive disorder with recurrent severe psychotic symptoms. Review of Resident #13's physician orders revealed an order dated for 01/04/20 for Amlodipine 2.5 milligrams (mg) to be given by mouth once a day for hypertension. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 dated for 12/12/19 revealed resident with severely impaired cognition. Review of Resident #13's blood pressure (BP) results between 12/09/19 and 12/16/19 revealed the highest BP result of 138/62. Review of December, 2019 pharmacy recommendation for Resident #13 printed on 12/17/19, revealed a recommendation for the Amlodipine 5 mg tablet to be discontinued due to the recommended use of this medication was for hypertension with BP results greater than 150/90. Resident #13's physician reviewed this recommendation on 12/26/19 and decided to lower the Amlodipine from 5 mg to 2.5 mg a day. Interview on 01/04/20 at 2:02 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendation was made on 12/17/19, the physician reviewed and made changes on 12/26/19 and the new changes were not put in place until 01/04/20. The DON agreed this was a long period of time between the physician making changes to the order and the facility changing the order in Resident #13's record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 17 of 18 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to ensure as needed antipsychotic orders did not exceed 14 days for one (Resident #21) of seven residents reviewed for unnecessary medications. The facility identified 25 residents who had orders for antipsychotic medications. Findings include: Review of Resident #21's medical record revealed she was admitted to the facility 10/05/19. Diagnoses included anxiety, altered metal status, and major depressive disorder. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed she had a severe cognitive impairment and required extensive assistance from staff with activities of daily living. Review of Resident #21's physician order history revealed from 12/06/19-01/03/20 she had orders for prochlorperazine maleate (an antipsychotic medication) 10 milligrams (mg) 1-2 tabs as needed, every four to six hours for nausea and vomiting. Review of Resident #21's psychotropic drug use care plan, dated 11/17/19 and last revised 11/17/19, lacked evidence Resident #21's care plan was revised to include her antipsychotic medication use between 12/06/19 and 01/03/20. Further review of Resident #21's medical record revealed a note to the Prescriber from the consulting pharmacist, dated 12/17/19 that stated Resident #21 had an order for an as-needed (PRN) antipsychotic for nausea. The physician documented that he would discontinue the PRN antipsychotic and signed the form 12/26/19. Interview on 01/04/20 at 2:02 P.M. with Director of Nursing (DON) revealed she gave Resident #21's physician a stack of pharmacy recommendations, including Resident #21's on 12/26/19 during a facility staff meeting. DON confirmed that by 12/26/19, the 14 day PRN order had already surpassed the allotted 14 days. She confirmed she waited from 12/17/19 to 12/26/19 to give the recommendations to the physician. DON stated while the physician signed the recommendation 12/26/19, he did not return Resident #21's pharmacy recommendation with the order to discontinue the PRN antipsychotic medication until 01/03/20. Review of a facility policy titled, Psychoactive Medication Policy and Procedure-Therapeutic, undated, revealed when a psychoactive medication was ordered, the facility would ensure that the attending physician assessed the resident and determined the need to continue the use of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 18 of 18