Health inspection·December 19, 2022

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/12/22 at 4:00 P.M., with the Director of Nursing (DON) and Administrator revealed the night nurse on 08/11/22 was doing reconciliation with the day shift nurse the morning of 08/12/22 and noticed a 21.5 ml discrepancy in Resident #53's liquid Morphine. The pharmacy sent the Morphine in a 240 ml brown bottle, and it was hard to read. The nurse wrote 176 on the narcotic controlled drug receipt form when reconciled because that was the amount it appeared to be when looking through the bottle even though there was 188 ml when the medication was poured out for reconciliation. The Administrator reported herself and the DON were off during the incident and covering staff told the nurses to document the amount it appeared to be when looking at the bottle (176 ml) instead of the actual amount (188 ml) reconciled. It was originally reported there was 21.5 ml of Morphine missing, however there was only 12.5 ml. The Administrator reported there was no evidence 188 ml was measured out on 08/12/22, however she could have the nurse write a statement or she could be interviewed. Interview on 12/13/22 at 9:19 A.M. and 11:48 A.M., with the Administrator revealed she reconciled the MAR with the Narcotic sheet last night and confirmed there was two doses (08/09/22 and 08/09/22) not documented on the narcotic control sheet that was not originally noted on the initial investigation on 08/12/22. The two missed documented doses on the controlled drug receipt form would change the amount originally reported misappropriated. There would have been 9.5 ml misappropriated instead of the 12.5 ml as they originally reported during the investigation if there was 188 ml remaining during the reconciliation. The Administrator confirmed the Morphine destruction sheet was inaccurate as well do the correct amount reconciled of 188 ml was not documented on the control sheet. Review of facility's policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation dated 2016 revealed misappropriation was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The person investigating the incident should generally take the following actions: if no direct witnesses, then the interviews may be expanded. Obtain all medical reports and review the resident's records. Evidence of the investigation should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 2 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documentation was updated when resident diagnoses changed. This affected three residents (#23, #24, and #32) of three residents reviewed for PASARR. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including bipolar II. The following diagnoses were added after admission: hallucination on 02/28/20, bipolar on 02/28/20, major depressive disorder, recurrent severe without psychotic features, on 04/06/20, schizoaffective disorder bipolar type on 04/06/20, schizoaffective disorder, depressive type on 04/09/20, anxiety disorder on 08/26/20, bipolar on 05/06/21, major depressive disorder on 06/03/21, and obsessive-compulsive behavior on 05/26/22. Review of Resident #23's PASARR dated 11/25/15 revealed the resident had mood disorder and bipolar. There was no evidence of the determination. The PASARR was completed for a sister facility in a different city. Review of Resident #23's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not considered by the state level II PASARR process to have serious mental illness or related condition. Interview on 12/13/22 at 9:18 A.M. and 10/04/22 A.M., with the Administrator confirmed the last PASARR completed was 11/25/15 and there was no evidence of the determination and there was no evidence a new PASARR was completed when a new diagnosis was added. The Administrator provided a copy of the new PASARR submitted; however, it was incorrect as well and did not include all diagnoses. Resident #23 was referred for level II review. The Administrator reported she had staff re-submit the PASARR again with the correct diagnoses and staff was provided education. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type. The following diagnoses were added after admission: delusional disorder on 03/26/20, bipolar disorder, in partial remission, most recent episode depression on 04/30/20, restlessness and agitation on 12/07/20, Schizophrenia 06/29/21, Review of Resident #24's PASARR dated 09/17/17 revealed the resident had Schizophrenia. There was no evidence of the determination. Review of Resident #24's annual MDS assessment dated [DATE] revealed the resident was not considered by the state level II PASARR process to have serious mental illness or related condition. Interview on 12/13/22 at 9:18 A.M. and 10:04 A.M., with the Administrator confirmed the last PASARR completed was 09/17/17 and there was no evidence of the determination and there was no evidence a new PASARR was completed when a new diagnosis was added. The Administrator provided a copy of the new PASARR submitted; however, it was incorrect as well and did not include bipolar diagnosis. Resident #24 was referred for level II review. The Administrator reported she had staff re-submit the PASARR again with the correct diagnoses and staff was provided education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 3 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedure titled PASARR dated 03/2018 revealed a resident with a newly evident or possible serious mental disorder or related condition would have a new PASARR completed as soon as identified. If a resident transferred from another facility staff would obtain the PASARR and review the results from the transferring facility. 3. Review of the medical record for Resident #32 revealed an admission date of 08/24/21 with diagnoses including major depressive disorder, anxiety, post traumatic stress disorder, and schizoaffective disorder. Further review of the medical record revealed a diagnosis of bipolar disorder was added 02/2022. Review of the Pre-admission Screening and Resident Review (PASARR) assessments completed for Resident #32 revealed there was no PASARR completed following the new diagnosis of bipolar disorder. A PASARR was not completed until 12/12/22 to address the new medical diagnosis. On 12/13/22 at 9:18 A.M., interview with the Administrator verified the PASARR was not completed timely following a new medical diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 4 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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. Based on record review and interview, the facility failed to ensure smoking care plans were updated in a timely manner. This affected three (Residents #22, #41, and #43) of six residents reviewed for smoking. The census was 67. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/02/18 with diagnoses including schizoaffective disorder, major depressive disorder, acute and chronic respiratory failure with hypoxia, and nicotine dependence. Review of the physician's orders for December 2022 identified no orders pertaining to smoking. Review of the care plan revised 10/13/22 at 2:35 P.M. revealed Resident #22 was unable to smoke without supervision due to needing assistance from staff for mobility and lack of coordination. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #22 was a safe smoker, was able to understand and comply with facility smoking policy, and was educated on the dangers and health complications of smoking. Review of the care plan revised 12/13/22 at 10:56 A.M. revealed Resident #22 was unable to smoke without supervision due to facility policy with a new intervention dated 11/07/22 indicating resident observed to be safe lighting own cigarette. On 12/13/22 at 5:17 P.M., interview with the Administrator stated the intervention for Resident #22 for lighting his own cigarettes was dated 11/07/22 because that was when the smoking assessment was completed, and she verified the intervention was not added to the care plan until 12/13/22. 2. Review of the medical record for Resident #41 revealed an admission date of 05/07/21 with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and nicotine dependence. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #41 had a moderate problem of inappropriately providing smoking materials to others. The assessment indicated Resident #41 was able to understand and comply with facility smoking policy. Review of the care plan revised 12/01/22 at 4:46 P.M. revealed Resident #41 was unable to smoke without supervision due to reduced mobility. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 5 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. Residents Affected - Few Review of the care plan revised on 12/13/22 at 11:08 A.M. revealed Resident #41 was unable to smoke without supervision due to facility policy with a new intervention dated 11/07/22 indicating resident observed to be safe lighting own cigarette. On 12/13/22 at 5:17 P.M., interview with the Administrator stated the intervention for Resident #41 for lighting his own cigarettes was dated 11/07/22 because that was when the smoking assessment was completed, and she verified the intervention was not added to the care plan until 12/13/22. 3. Review of the medical record for Resident #43 revealed an admission date of 09/15/22 with diagnoses including acute respiratory failure with hypoxia, muscle weakness, and alcohol dependence with withdrawal delirium. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #43 was able to understand and comply with facility smoking policy. Review of the care plan revised 11/07/22 at 1:24 P.M. revealed Resident #43 was unable to smoke without supervision due to reduced mobility. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. Review of the physician's orders for December 2022 identified an order for supervised smoking (initiated 09/15/22). Review of the care plan revised on 12/13/22 at 11:12 A.M. revealed Resident #43 was unable to smoke without supervision due to facility policy with a new intervention dated 11/07/22 indicating resident observed to be safe lighting own cigarette. On 12/13/22 at 5:17 P.M., interview with the Administrator stated the intervention for Resident #43 for lighting his own cigarettes was dated 11/07/22 because that was when the smoking assessment was completed, and she verified the intervention was not added to the care plan until 12/13/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 6 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure Resident #23 received assistance with placement of hearing aids and changing hearing aid batteries. This affected one (Resident #23) of one resident reviewed for hearing. Residents Affected - Few Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, polyneuropathy, muscle weakness, reduced mobility, cognitive communication deficit, and age-related physical debility. Review of Resident #23's plan of care for hearing loss dated 12/05/18 revealed the resident had potential for alteration in communication related to wearing bilateral hearing aids. Staff intervention included to report any change/decline in communication ability. Review of an audiology note dated 05/04/22 revealed the facility would store Resident #23's hearing aids and help with insertion, removal, and batteries. Resident #23 had bilateral sensorineural hearing loss. The left hearing aid was taken for repair and would be sent back. Hearing aid check in six to nine months. Would be seen 12/30/22. Review of Resident #23's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had adequate hearing with devices. Interview and observation on 12/12/22 at 3:02 P.M., with Resident #23 revealed the resident was hard of hearing. The resident reported she had asked staff a long time ago for batteries and still had not received the batteries. The resident reported she had lost almost all her hearing in her right ear. The resident was not wearing hearing aids during the interview. Interview and observation on 12/13/22 at 2:37 P.M., with Resident #23 with Registered Nurse (RN) #881 revealed the resident's hearing aids where in a box on her bedside table and a set of batteries were noted in the box. The resident reported she had the hearing aids, but she did not know she had batteries in the box. RN #881 placed the batteries in the hearing aids; however, they did not work. RN #881 reported the state tested nurse aides should be assisting the resident with putting the hearing aids in her ears. Interview on 12/14/22 at 7:05 A.M., with the Administrator revealed the batteries that RN #881 had put in the hearing aides were the wrong batteries. The facility had the correct batteries and replaced the batteries and the resident's hearing aides were now working. Interview on 12/14/22 at 7:34 A.M., with Resident #23 revealed she was unable to put hearing aids in place or change the batteries herself. The resident did not have hearing aids in at time of observation. She was lying in bed with the head of the bed elevated and the light on waiting for breakfast. Resident had difficulty hearing the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 7 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review revealed the facility failed to ensure duplicate treatments were not applied to the same area. This affected one (Resident #34) of one resident reviewed for skin conditions. Residents Affected - Few Finding include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including moisture associated skin damage (MASD), spinal stenosis, diabetes with diabetic neuropathy, and excoriation disorder. Interview on 12/13/22 at 9:10 A.M., with Resident #34's daughter revealed the resident complained her buttocks hurt. The staff kept the area covered and applied ointment. The daughter indicated her mother had been in bed 24 hours a day since they almost lost her recently. Observation on 12/14/22 at 10:31 A.M., of Resident #34's buttocks with Registered Nurse (RN) #864 whom was also the wound nurse, and the Director of Nursing (DON) revealed the area was difficult to view due to the resident had cream on the coccyx area. The skin appeared scaly on the right buttocks and there was a round pea size area on the coccyx that appeared it may have been opened but was not able to visualize due to the cream. Resident #34 reported the area was painful. Review of Resident #34's treatment administration record (TAR) dated October 2022 to December 2022 revealed staff had applied triad wound paste (coating that facilitates healing and debridement) to the coccyx twice daily and chamosyn (skin barrier) treatment to the coccyx twice a day from 10/18/22 to 12/13/22. The triad wound paste was to be discontinued on 12/05/22. Interview on 12/14/22 at 1:07 P.M., with the DON and RN #864 revealed the area on the coccyx had resolved on 11/14/22 and had just reappeared today. The DON reported the chamosyn cream should have been discontinued on 10/18/22 when the treatment was changed to the triad wound dressing. The DON confirmed Resident #34 was receiving both treatments (triad and chamosyn) to the coccyx from 10/18/22 to 12/13/22 and it should have only been the triad wound dressing from 10/18/22 to 12/05/22 and then from 12/05/22 to present it should have only been the chamosyn cream. Review of skin abrasion/skin tear policy undated revealed it was the facility policy to provide guidelines for prevention and treatment of abrasions/skin tears. Verify there was a physician order for treatment, review the resident's care plan, current orders, and diagnoses to determine the resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 8 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, interview, and policy review the facility failed to ensure a resident was safely transferred with a mechanical lift and resident smoking materials were stored in a secure area. This affected one (Resident #23) of three residents reviewed for falls and six (#22, #29, #37, #41, #43, and #52) of six residents reviewed for smoking. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including laceration with foreign body of the scalp, muscle weakness, other reduced mobility, intervertebral disc degeneration of the lumbar region, chronic pain, stiffness and pain of left knee, difficulty walking, lack of coordination, dizziness, osteoarthritis of knee, needs assistance with personal care, abnormalities of gait and mobility, artificial right knee joint, and age related physical debility. Review of Resident #23's activity of daily living (ADL) plan of care dated 12/05/18 revealed on 04/26/22 the plan of care was updated to reflect the resident was a Hoyer (mechanical) lift with two assists for transfers. Review of Resident #23's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had total dependence of two for transfers. Review of Resident #23's progress notes dated 09/10/22 revealed while the resident was being transferred from the bed to the wheelchair by a Hoyer lift, the overhead piece struck the resident in the right side of the head while coming down. There was heavy bleeding, pressure was applied, and ambulance was called. The bleeding was controlled and stopped before the emergency medical service arrived. Resident was transferred to the emergency room. Review of Resident #23's physician progress note dated 09/12/22 indicated the resident was being transferred from bed to wheelchair via Hoyer lift and she was hit in the head by overhead piece of the Hoyer when she was being lowered. Nursing reported heavy bleeding and pressure was applied. Review of the facility's investigation revealed Resident #23 reported she hit her head on the Hoyer bar when being transferred back to bed. The bar came forward and hit her in the head. Review of staff statements revealed State Tested Nurse Aide (STNA) #825 reported the resident was in the wheelchair and the Hoyer hit the top of her head. STNA #805 reported when spotting the resident in the Hoyer lift the resident leaned her head forward and hit her head on the bar. Review of the emergency room (ER) visit note dated 09/10/22 revealed the ER note was faxed to the facility on [DATE]. The note indicated Resident #23 was being moved with a Hoyer lift and apparently, she was struck with the apparatus on the higher left to the right side of her head. Resident #23 reported she was in her bed and was placed in the Hoyer lift and was in transitioning to the edge of the bed, when the next thing she knew she was on the ground and had struck her head believing to have cut her head along the Hoyer lift. Resident #23 had a shallow three-centimeter (cm) laceration that did not require staples or sutures. The resident's diagnoses included head contusions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 9 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the staff education on Hoyer lift dated 09/14/22 revealed eleven STNAs attended the in-services. The facility provided a letter authored by the Physical Therapist (PT) stating on 09/14/22 she provided staff education and competency testing on Hoyer lifts with staff. Interview on 12/12/22 at 2:57 P.M., with Resident #23 reported she did not know what happened but the Hoyer lift fell on her and it hurt really bad. Interview on 12/13/22 at 2:37 P.M., with Resident #23 revealed again she could not really remember what happed with the Hoyer lift but she was afraid to use it, but it was the only way for staff to transfer her. Interview on 12/14/22 at 8:28 A.M., with the Administrator revealed Resident #23 was transferred with battery operated Hoyer lift from her bed to her wheelchair. Resident #23 was in the wheelchair and when the staff released one strap and the aide did not have control of the bar it swung around a hit Resident #23 in the head causing a laceration. Staff were educated by the PT on the Hoyer lift and competencies were performed. 2. Review of the medical record for Resident #22 revealed an admission date of 11/02/18 with diagnoses including schizoaffective disorder, major depressive disorder, acute and chronic respiratory failure with hypoxia, and nicotine dependence. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #22 was able to understand and comply with facility smoking policy. Review of the care plan revised 10/13/22 at 2:35 P.M. revealed Resident #22 was unable to smoke without supervision due to needing assistance from staff for mobility and lack of coordination. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. Review of the physician's orders for December 2022 identified no orders pertaining to smoking. On 12/12/22 at 1:37 P.M., observation of resident smoking area revealed Resident #22 had a lit cigarette before facility staff had offered him a lighter. Interview at the time of observation with Receptionist #840 verified this observation. Receptionist #840 stated some residents kept their lighters, but she was unable to state who those residents were. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 10 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 in the designated area accessible only by staff. Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #29 revealed an admission date of 08/17/18 with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, epilepsy, polyneuropathy, and nicotine dependence. Residents Affected - Some Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #29 had a moderate problem of inappropriately providing smoking materials to others. The assessment indicated Resident #29 was able to understand and comply with facility smoking policy. Review of the physician's orders for December 2022 identified an order for supervised smoking (initiated 09/24/18). Review of the care plan revised 12/12/22 at 11:27 A.M. revealed Resident #29 was unable to smoke without supervision due to hemiplegia, weakness, and need for assistance with activities of daily living (ADLs). Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. On 12/12/22 at 1:37 P.M., observation of resident smoking area revealed Resident #29 had a lit cigarette before facility staff had offered her a lighter. Interview at the time of observation with Receptionist #840 verified this observation. Receptionist #840 stated some residents kept their lighters, but she was unable to state who those residents were. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained in the designated area accessible only by staff. 4. Review of the medical record for Resident #37 revealed an admission date of 09/27/22 with diagnoses including chronic neuropathy, muscle weakness, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the physician's orders for December 2022 identified an order for supervised smoking (initiated 09/27/22). Review of the Smoking Risk Observation 4.5, dated 12/02/22, revealed Resident #37 was able to understand and comply with facility smoking policy. Review of the care plan revised 12/12/22 at 10:00 A.M. revealed Resident #37 was unable to smoke (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 11 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without supervision due to hemiplegia, weakness, and need for assistance with activities of daily living (ADLs). Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. On 12/12/22 at 1:37 P.M., observation of resident smoking area revealed Resident #37 had a lit cigarette before facility staff had offered him a lighter. Interview at the time of observation with Receptionist #840 verified this observation. Receptionist #840 stated some residents kept their lighters, but she was unable to state who those residents were. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained in the designated area accessible only by staff. 5. Review of the medical record for Resident #41 revealed an admission date of 05/07/21 with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and nicotine dependence. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #41 had a moderate problem of inappropriately providing smoking materials to others. The assessment indicated Resident #41 was able to understand and comply with facility smoking policy. Review of the care plan revised 12/01/22 at 4:46 P.M. revealed Resident #41 was unable to smoke without supervision due to reduced mobility. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. On 12/12/22 at 1:37 P.M., observation of resident smoking area revealed Resident #41 had a lit cigarette before facility staff had offered him a lighter. Interview at the time of observation with Receptionist #840 verified this observation. Receptionist #840 stated some residents kept their lighters, but she was unable to state who those residents were. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 12 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained in the designated area accessible only by staff. 6. Review of the medical record for Resident #43 revealed an admission date of 09/15/22 with diagnoses including acute respiratory failure with hypoxia, muscle weakness, and alcohol dependence with withdrawal delirium. Review of the Smoking Risk Observation 4.5, dated 11/07/22, revealed Resident #43 was able to understand and comply with facility smoking policy. Review of the care plan revised 11/07/22 at 1:24 P.M. revealed Resident #43 was unable to smoke without supervision due to facility policy. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. Review of the physician's orders for December 2022 identified an order for supervised smoking (initiated 09/15/22). On 12/12/22 at 1:30 P.M., observation of the activities room revealed a plastic bag containing cigarettes was laying on the table. Interview at time of observation with Resident #55, who was sitting next to the cigarettes, stated the cigarettes belonged to Resident #43. On 12/12/22 at 1:34 P.M., observation of Receptionist #840 distributing smoking materials and she was unable to locate Resident #43's cigarettes in the box designated for storage of smoking materials. Resident #43 then handed her the plastic bag of cigarettes that was sitting on the table. Interview at time of observation with Receptionist #840 verified Resident #43's cigarettes were not stored in the designated storage box. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained in the designated area accessible only by staff. 7. Review of the medical record for Resident #52 revealed an admission date of 02/21/22 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 13 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0689 Level of Harm - Minimal harm or potential for actual harm diagnoses including acute respiratory failure with hypoxia, muscle weakness, chronic obstructive pulmonary disease, and muscle spasm. Review of the Smoking Risk Observation 4.5, dated 10/28/22, revealed Resident #52 was able to understand and comply with facility smoking policy. Residents Affected - Some Review of the care plan revised 11/08/22 at 2:20 P.M. revealed Resident #52 was unable to smoke without supervision due to facility policy. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible to leave smoking materials at the resident's nursing station, resident must follow the facility smoking policy and adhere to safety rules, resident would be re-assessed quarterly or with an identified significant change, resident would have supervision by facility designated person throughout smoking period, and resident would smoke in facility designated areas. On 12/12/22 at 1:37 P.M., observation of resident smoking area revealed Resident #52 had a lit cigarette before facility staff had offered her a lighter. Interview at the time of observation with Receptionist #840 verified this observation. Receptionist #840 stated some residents kept their lighters, but she was unable to state who those residents were. On 12/12/22 at 4:39 P.M., interview with the Administrator stated there were three residents who were independent smokers (Residents #22, #41, and #43) and they were allowed to light their own cigarettes. The Administrator confirmed they were not allowed to keep their smoking materials per facility policy. Review of facility policy titled Resident Smoking Policy, dated 12/2017, revealed all residents would be supervised by facility staff for smoking. The policy also indicated all smoking materials including lighters, matches, and cigarettes would not be retained by residents and would be maintained in the designated area accessible only by staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 14 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and policy review the facility failed to follow Resident #34's dietary orders for supplements, ensure the resident was encouraged to get up to eat, and substitutes were offered if less then 50 percent of meal was consumed. This affected one (Resident #34) of three residents reviewed for nutrition. Residents Affected - Few Findings include: Record Review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including abnormal weight loss, failure to thrive, dehydration, spinal stenosis, muscle weakness, needs assistance with personal care, lack of coordination, cognitive communication deficit, diabetes, dehydration, age-related physical debility, and dysphagia (difficulty swallowing). Review of Resident #34's plan of care for activities of daily living (ADL), dietary, and non-compliance revealed to offer resident verbal cues if needed for chewing and swallowing, or to finish eating. Help with feeding if needed. Offer and encourage substitute if intakes were less than 50 percent. The resident declined to get out of bed for meals. Review of Resident #34's weights revealed on 09/01/22 the resident's weight was 162 pounds. Review of Resident #34's quarterly nutrition assessment dated [DATE] revealed Resident #34 did not trigger for significant weight loss. Meal intakes varied from 1-75 percent. Resident #34 was on Remeron (used to stimulate appetite), received diabetic health shake four ounces twice daily, which was accepted per the medication administration records (MAR). Recommendation indicated increasing supplement to three times daily and add to weekly weights for closer monitoring. Review of Resident #34's plan of care for nutrition revealed on 12/01/22 no sugar added health shakes were increased to three times daily. Review of Resident #34's physician orders dated December 2022 revealed obtain weekly weight starting 12/02/22, protein snack at bedtime, Remeron, on 12/02/22 the four ounce diabetic health shake was increased to three times a day. The orders indicated Resident #34 ate independently and was extensive assist of two for bed mobility. Further review of Resident #34's weights revealed on 12/08/22 the resident's weight was 147.6 pounds which indicated an 8.89 pound weight loss in three months. Review of Resident #34 dietary note dated 12/12/22 revealed Resident #34 triggered for significant weight loss in three months. Intakes varied from 50 percent to below. The note indicated supplements were just increased to three times daily with 50/50 acceptance. Observation of Resident #34 on 12/12/22 at 8:39 A.M. revealed Resident #34 was asleep in bed and a covered breakfast tray was on the bedside table. Observation at 8:45 A.M. revealed the nurse taking Resident #34's medication into the room at 8:45 A.M. accompanied by Registered Nurse (RN) #864. RN #864 reported she did not know if Resident #34 required assistance. Observation at 8:52 A.M. revealed staff delivered Resident #34 a new hot breakfast tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 15 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Review of physician order dated 12/13/22 revealed encourage Resident #34 to get up for all meals. Level of Harm - Minimal harm or potential for actual harm Interview on 12/13/22 at 9:14 A.M., with Resident 34's daughter revealed her mother had a decline and they almost lost her recently. The daughter reported her mother could use more help with meals. Residents Affected - Few Observation on 12/14/22 from 8:44 A.M. to 9:00 A.M., revealed Resident #34 was asleep in bed. The bed was flat, and a covered breakfast tray was on the bedside table in the room alongside the bed. No staff entered room to assist Resident #34. Upon entering Resident #34's room at 9:00 A.M., Resident #34 responded yes when asked if she wanted to eat breakfast. Resident #34 could not recall if someone had tried to awake her for breakfast. The surveyor activated the call light for assistance. State Tested Nurse Aide (STNA) #874 answered the call light. STNA #874 did not know who delivered the breakfast tray. STNA #874 reported Resident #34 was supposed to receive a beverage brought in by the daughter at each meal. STNA #874 removed a protein drink for the mini refrigerator in the room. STNA #874 was observed to set up Resident #34's breakfast tray. Review of Resident #34's medication administration records (MAR) dated October 10/24/22 to 12/13/22 revealed documentation Resident #34 was receiving diabetic health shakes twice daily from 10/24/22 to present. There was no evidence of the amount given or amount consumed. The MAR indicated Resident #34 was also receiving four ounces of a no sugar added health shake three times a day from 12/02/22 to present. The intakes for December 2022 indicated 10 refusals, 16 intakes of 100 percent, one intake of 50 percent, and two intakes of 25 percent. There was no documentation regarding the protein shake Resident #34's daughter was providing for each meal (as indicated by STNA #874). Review of meal intakes from 11/14/22 to 12/14/22 revealed Resident #34 ate between 00-25 percent and 50-75 percent. Most snacks were documented as none. There was no documentation regarding offering alternative when resident ate less than 50 percent of meals. Interview on 12/14/22 at 1:52 P.M., with the Director of Nursing (DON) revealed the diabetic health shakes were originally order twice a day on 10/24/22 and should have been discontinued on 12/02/22 when the order was changed to four ounces of no sugar added health shakes three times daily. The DON verified there was no documentation in regard to how much of the diabetic health shake was given when the order was twice daily. Staff signed off it was given/offered, not the amount consumed. The DON indicated the night time (HS) protein snack was entered incorrectly and should have been entered as the protein shake the family was bringing in. Resident #34 was not supposed to receive the protein shakes the family was providing three times a day as STNA #874 had indicated, they were to be provided as the HS snack. The computer program did not allow staff to document refusal of the HS snack so they documented none. The DON said the dietitian was at the facility on Monday and reviewed Resident #34's medical record and did not notice the resident was receiving the health shake twice a day and the no added sugar health shake three times a day. The DON confirmed there was no documented evidence the staff offered a substitute when Resident #34 at less than percent. Review of the facility's undated policy and procedure Nutrition/Unplanned Weight Loss revealed the physician and staff would monitor the nutritional status, response to interventions, and possible complications of such interventions of individuals with impaired nutritional status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 16 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Base on observation and interview the facility failed to ensure staffing levels were posted daily as required. This had the potential to affect all residents. The facility census was 67. Residents Affected - Many Findings include: Observation on 12/12/22 at 8:23 A.M. revealed in the glass information case near the facility lobby was the facility daily posted staffing sheet dated 12/09/22. Interview on 12/12/22 at 8:27 A.M. with admission Coordinator #836 revealed the receptionist was responsible for posting the daily staffing information. Admissions Coordinator #836 confirmed the posting was for 12/09/22 and had not been updated for 12/10/22, 12/11/22, or 12/12/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 17 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including bipolar II. The following diagnoses were added after admission: hallucination on 02/28/20, bipolar on 02/28/20, major depressive disorder, recurrent severe without psychotic features, on 04/06/20, schizoaffective disorder bipolar type on 04/06/20, schizoaffective disorder, depressive type on 04/09/20, anxiety disorder on 08/26/20, bipolar on 05/06/21, major depressive disorder on 06/03/21, and obsessive-compulsive behavior on 05/26/22. Review of Resident #23's monthly pharmacy reviews dated 01/2022 to 11/2022 revealed the pharmacist made recommendation for gradual dose reductions (GDR) 01/2022 and 05/04/22. Review of the printed pharmacy recommendation dated 02/09/22 revealed on 01/2022 the pharmacist made recommendation for GDR due to the resident had been on Buspar 7.5 milligrams (mg) twice daily since 04/2021 and Duloxetine 30 mg daily since 07/2021. The pharmacy recommendation was not addressed by the physician until 03/10/22. Review of the printed pharmacy recommendation dated 05/04/22 revealed the pharmacist made recommendation for GDR on Buspar 7.5 mg twice daily, Duloxetine 30 mg daily, and Abilify 2.5 mg daily. The pharmacy recommendation was not addressed by the physician until 06/17/22. Interview on 12/15/22 at 11:46 AM with the Director of Nursing (DON) revealed the attending physician referred psych pharmacy reviews to the psych doctors to review. The Psych provider addressed the pharmacy review when he/she sees the resident on their next scheduled visit. Psych visited weekly but only saw a few residents at a time and did not address the pharmacy recommendation until it was the resident's scheduled day. The facility did not fax the pharmacy recommendation to psych to address before the next visit. Interview on 12/15/22 at 1:02 P.M. with the DON and Registered Nurse (RN) #900 revealed they believed addressing pharmacy recommendation at the next visit was timely, even if was 30 days or more. The DON and RN #900 verified the pharmacist had 72 hours to provide the DON with the recommendation. Both confirmed the pharmacy recommendation for January 2022 was printed on 02/09/22 and not addressed until 03/10/22 and the 05/04/22 pharmacy recommendation was not printed until 05/19/22 and not addressed 06/17/22. Review of the facility's policy titled Consultant Pharmacist Reports dated 05/2020 revealed the monthly pharmacy findings were communicated within 72 hours to the DON or designee and were made readily retrievable. The prescriber and or Medial Director would be notified by the facility nursing staff and action taken noted on the form. Any electronic communication of patient specific data must be encrypted and facilitated in a HIPPA complaint manner. Review of the facility's policy titled Medication monitoring and management dated 05/2020 revealed during the first year in which a resident was admitted on a psychopharmological medication (other than an antipsychotic or a sedative hypnotic), or after the facility had initiated such medication, the facility attempted a GDR during the least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering would be attempted annually, unless clinically contraindicated. The GDR was considered clinically contraindicated if: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 18 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 Target symptoms returned or worsened after the most recent attempt at a GDR and the prescriber was to document the clinical rational for why any additional attempted dose reduction would likely impair the resident's function, increase distressed behavior, or cause the psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed timely. This affected three (#9, #23, and #32) of four residents reviewed. The census was 67. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/25/22 with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, acute kidney failure, and hallucinations. Review of the physician's orders for Resident #9 identified an order for Trazodone 50 milligrams (mg) once a day as needed (PRN) initiated 06/28/22 with no scheduled end date. Review of the pharmacy monthly medication review dated 08/08/22 revealed the PRN use of Trazodone should be limited to 14 days. The recommendation was not addressed by the prescribing practitioner until 09/06/22, 29 days later. Review of the physician's orders for Resident #9 identified the order for Trazodone 50 milligrams (mg) once a day PRN was discontinued on 09/06/22. On 12/14/22 at 5:03 P.M., interview with the Director of Nursing (DON) and Corporate Registered Nurse (RN) #900 verified the pharmacy recommendation was addressed once month after it was received. They explained psychiatric services addressed pharmacy recommendations for psychotropic medications during their monthly visit. The DON stated the attending physician did not address the recommendation sooner because it was a recommendation for an extension of a PRN medication order and not urgent. On 12/15/22 at 9:46 A.M., interview with Certified Nurse Practitioner (CNP) #905 confirmed the pharmacy recommendation was addressed one month after it was received because psychiatric services monitored the use of psychotropic medications. On 12/15/22 at 11:47 A.M., interview with the DON and Corporate RN #900 stated they did not fax pharmacy recommendations to psychiatric services when they were received, they delivered the recommendations when psychiatric service practitioners were in the building. 2. Review of the medical record for Resident #32 revealed an admission date of 08/24/21 with diagnoses including major depressive disorder, anxiety, post traumatic stress disorder, schizoaffective disorder, and bipolar disorder. Review of the pharmacy monthly medication review dated 03/23/22 revealed a recommendation for a gradual dose reduction for psychotropic medications. This recommendation was not addressed by the prescribing practitioner until 04/21/22, 29 days later. Review of the pharmacy monthly medication review dated 07/05/22 revealed a recommendation for a gradual dose reduction for psychotropic medications. This recommendation was not addressed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 19 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 prescribing practitioner until 08/11/22, 37 days later. Level of Harm - Minimal harm or potential for actual harm On 12/14/22 at 5:03 P.M., interview with the Director of Nursing (DON) and Corporate Registered Nurse (RN) #900 revealed the pharmacy recommendations were addressed once month after they were received because psychiatric services addressed pharmacy recommendations for psychotropic medications during their monthly visit. Residents Affected - Few On 12/15/22 at 9:46 A.M., interview with Certified Nurse Practitioner (CNP) #905 confirmed the pharmacy recommendations were addressed one month after they were received because psychiatric services monitored the use of psychotropic medications. On 12/15/22 at 11:47 A.M., interview with the DON and Corporate RN #900 stated they did not fax pharmacy recommendations to psychiatric services when they were received, they just delivered the recommendations when psychiatric service practitioners were in the building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 20 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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** 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including bipolar II. The following diagnoses were added after admission: hallucination on 02/28/20, bipolar on 02/28/20, major depressive disorder, recurrent severe without psychotic features, on 04/06/20, schizoaffective disorder bipolar type on 04/06/20, schizoaffective disorder, depressive type on 04/09/20, anxiety disorder on 08/26/20, bipolar on 05/06/21, major depressive disorder on 06/03/21, and obsessive-compulsive behavior on 05/26/22. Review of Resident #23's monthly pharmacy reviews dated 01/2022 to 11/2022 revealed the pharmacist made recommendation for gradual dose reductions (GDR) 01/2022, 05/04/22, and 09/05/22. Review of the printed pharmacy recommendation dated 02/09/22 revealed on 01/2022 the pharmacist made recommendation for GDR due to the resident had been on Buspar 7.5 milligrams (mg) twice daily since 04/2021 and Duloxetine 30 mg daily since 07/2021. The pharmacy recommendation was declined on 03/10/22 with a note to see progress note. Review of the printed pharmacy recommendation dated 05/04/22 revealed the pharmacist made recommendation for GDR on Buspar 7.5 mg twice daily, Duloxetine 30 mg daily, and Abilify 2.5 mg daily. The pharmacy recommendation was declined on 06/17/22 with a box checked with a standard note stating no change at this time. GDR contraindicated because tapering would not achieve the desired therapeutic effects and the current dose was necessary to maintain or improve the resident's function, well-being, safety, and quality of life. Review of the printed pharmacy recommendation dated 09/05/22 revealed the pharmacist made recommendation for GDR on Buspar 7.5 mg twice daily, Duloxetine 30 mg daily, and Abilify 2.5 mg daily. The pharmacy recommendation was declined on 06/17/22 with a box checked with a standard note stating no change at this time. GDR contraindicated because tapering would not achieve the desired therapeutic effects and the current dose was necessary to maintain or improve the resident's function, well-being, safety, and quality of life. Review of the psych progress note dated 03/10/22 revealed the nurse practitioner (NP) refused GDR due to the resident did not wish to have a dose reduction. Review of psych note dated 06/17/22 revealed the resident was not sleeping due to staff were waking her up for incontinence care. The NP declined GDR due to the resident had continued issues. Review of psych note dated 09/29/22 revealed GDR contraindicated because tapering would not achieve the desired therapeutic and current dose was necessary to maintain or improve the resident's function, wellbeing, safety, pain, and quality of life. The resident reported periods of depression. Review of psych noted 10/20/22 revealed the resident mood was stable, denied increase anxiety, and was still having trouble sleeping because she could not fall back to sleep after staff awakened her for incontinence care. Review of the Minimum Data Set assessment dated 10/04/ 22 revealed the resident had no behaviors, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 21 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 rejection of care or wandering. The resident reported 7-11 days of little interest or pleasure doing things, hopeless, having trouble falling or staying asleep, and has trouble concentrating on things. She had 12-14 days of feeling tired or having little energy. The resident denied feeling bad about self or thoughts that she would be better off dead or hurting self. Review of Resident #23's progress dated 09/14/22 to 12/15/22 revealed on 09/22/22 there was a behavior meeting, and no increased behaviors were noted. On 10/25/22 the resident was noted to have increased confusion and was discussed with daughter. On 11/02/22 and 11/30/22 behavior meeting were held but no notes were documented. Review of behavior documents dated 11/15/22 and 12/15/22 revealed no evidence Resident #23 had exhibited behaviors. Interview on 12/15/22 at 1:02 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #900 revealed they were not able to provide supporting clinical rational why the GDRs were not attempted on 03/10/22, 06/17/22, or 09/29/22. The DON and RN #900 verified resident wishes and incontinence issues were not appropriate rational to decline GDR. The resident had not had any documented behaviors to support not attempting a trial GDR. Review of the facility's policy titled Consultant Pharmacist Reports dated 05/2020 revealed the monthly pharmacy findings were communicated within 72 hours to the DON or designee and were made readily retrievable. The prescriber and or Medical Director would be notified by the facility nursing staff and action taken noted on the form. Any electronic communication of patient specific data must be encrypted and facilitated in a HIPPA complaint manner. Review of the facility's policy titled Medication monitoring and management dated 05/2020 revealed during the first year in which a resident was admitted on a psychopharmological medication (other than an antipsychotic or a sedative hypnotic), or after the facility had initiated such medication, the facility attempted a GDR during the least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering would be attempted annually, unless clinically contraindicated. The GDR was considered clinically contraindicated if: Target symptoms returned or worsened after the most recent attempt at a GDR and the prescriber documented the clinical rational for why any additional attempted dose reduction would likely impair the resident's function, increase distressed behavior, or cause the psychiatric instability by exacerbating an underlying medial or psychiatric disorder. The continued use was in accordance with relevant current standard of practice and the prescriber documented the clinical rational for why any additional attempted dose reductions would likely impair the resident's function, increase distress behavior, or cause psychiatric instability by exacerbating and underlying medical or psychiatric disorder. 3. Review of Resident #56's medical record revealed admission date of 09/18/22 and diagnoses included dementia, restlessness and agitation, delirium (sundowning), and psychotic disorder with delusions. Review of Medicare Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #56 had impaired cognition. Resident #56 had no behaviors and reported trouble concentrating on two to six days of review period. Resident #56 was noted to receive antipsychotic medications on a routine basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 22 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 Review of the care plan dated 10/01/22 revealed Resident #56 had behavioral symptoms of wandering, agitation, and restlessness. Interventions included allow resident right to refuse care, praise for appropriate behaviors, encourage resident to accept assistance, notify physician of new or escalated behaviors, encourage family and resident involvement in care, psychiatry consult as needed, and administer medications as ordered. Residents Affected - Few Review of the physician's order dated 12/08/22 revealed Resident #56 was ordered 12.5 milligrams (mg) Seroquel once per day. Review of medication administration record (MAR) from October 2022 to December 2022 revealed Resident #56 had gradual dose reduction on 11/15/22 from 25 mg of Seroquel to 12.5 mg Seroquel daily. The MAR revealed on 12/08/22 Seroquel was discontinued then reordered at 12.5 mg daily. Review of the Psychiatry Initial Consult dated 10/05/22 revealed Resident #56 was seen for dementia and insomnia. Resident #56 was reported to have occasional outbursts with screaming and yelling and had history of wandering off. There were no reported behaviors since admission. Psychiatry indicated if behaviors remained stable consider for dose reduction. Review of progress note dated 11/15/22 revealed physician saw Resident #56 and gave order to decrease Seroquel dose to 12.5 mg daily. Family was made aware of change. Review of Psychiatry Progress Note dated 12/08/22 revealed Resident #56 was noted to be confused but there was no reported or observed agitation, depression, or paranoia. Staff reported no behaviors and denied hallucinations. Resident #56 was noted to be stable since transferring to facility. Psychiatrist noted Resident #56 continued Seroquel daily and indicated given stability in mood and high-risk nature of medication to discontinue. Review of progress notes from September 2022 to December 2022 revealed no reported behaviors. Review of behavior documentation from November 2022 to December 2022 revealed no reported behaviors. Review of follow up Psychiatry Progress Note dated 12/09/22 revealed Resident #56's family disagreed with discontinuation of Seroquel. Psychiatry Nurse Practitioner reinstated Seroquel per family request despite no reported behaviors or outbursts. Observations of Resident #56 throughout the annual survey from 12/12/22 to 12/15/22 revealed no concerns with behaviors. Resident #56 was noted to come out of room and spend time with others in common areas. Resident #56 was noted to be quiet and calm during interactions. No noted restlessness, agitation, or wandering. Interview on 12/14/22 at 3:01 P.M. with he Director of Nursing (DON) revealed Resident #56's Seroquel was reinstated per family wishes. Interview on 12/15/22 at 9:50 AM with the DON confirmed Resident #56 was deemed stable by psychiatry services and medication was discontinued. The DON confirmed the family wanted Resident #56 to stay on antipsychotic medication despite stability, so the facility kept the medication in place. Review of Food and Drug Administration (FDA) prescribing information for Seroquel revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 23 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 medication was not approved for elderly patients with dementia-related psychosis. Indications for use of Seroquel included Schizophrenia, Bipolar I disorder with manic episodes, and bipolar disorder with depressive episodes. Based on record review and interview, the facility failed to ensure Resident #9's order for as needed Trazodone was re-assessed within the required 14-day time frame, Resident #23 had a gradual dose reduction attempted or evidence of a clinical indication why it was not attempted, and Resident #56 had a clinical indication for the continued use of Seroquel. This affected three of five residents reviewed for unnecessary medication. The census was 67. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/25/22 with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, acute kidney failure, and hallucinations. Review of the physician's orders for Resident #9 identified an order for Trazodone 50 milligrams (mg) once a day as needed (PRN) initiated 06/28/22 with no scheduled end date. The order was discontinued on 09/06/22. Review of the progress notes for June 2022 through September 2022 revealed no evidence that the continued use of Trazodone PRN was re-assessed every 14 days or documentation of a clinical rationale for extended use beyond 14 days. On 12/15/22 at 9:46 A.M., interview with Certified Nurse Practitioner (CNP) #905 verified the PRN order for Trazodone was not re-assessed every 14 days and she was unable to provide documentation of a clinical rationale for extended use beyond 14 days. On 12/15/22 at 1:08 P.M., interview with Corporate Registered Nurse (RN) #900 verified there was no documentation of a clinical rationale for extended use of Trazodone PRN beyond 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 24 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review the facility failed to ensure residents received timely dental services. This affected two residents (#12 and #34) of four residents reviewed for dental. Residents Affected - Few Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dysphagia, muscle weakness, and respiratory failure. Review of Resident #12's dental consent dated 10/03/18 revealed the resident consented to see the dentist. Review of Residents #12's dental care plan dated 10/08/19 revealed the resident was at risk for oral complication related to full upper and lower dentures. If resident stopped using dentures assess why resident did not wear and contact dentist if needed. Review of Resident #12's dental note dated 03/17/22 revealed the dental note was not legible. The dentist office sent a clarification email dated 12/15/22 to clarify the note said the resident's lower dentures were adjusted, adhesive would be only means of retention for full lower dentures. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no issues with broken or loose fitting full or partial dentures. Interview on 12/12/22 at 3:11 P.M., with Resident #12 revealed when she wore her bottom dentures, she bit the inside of her jaw. The resident reported her bottom dentures were in a cup in her bathroom. Interview and observation on 12/13/22 at 4:06 P.M., revealed the resident's bottom dentures were still in a cup in her bathroom. The resident reported again that she had not been wearing them because they cut the inside of her jaw. Interview and observation on 12/14/22 at 8:41 A.M., with State Tested Nurse Aide (STNA) #874 revealed Resident #12 was eating breakfast and her bottom teeth were still in the cup in her bathroom. STNA #874 reported she tried to get the resident to put her bottom dentures in this morning, however she refused. STNA #874 reported she did not know why the resident would not wear the dentures. STNA #874 reported the refusal to the nurse. 2. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including needs assistance with personal care, age-related physical debility, and gastro-esophageal reflux. Review of Resident #34's dental consent dated 05/16/22 revealed the resident signed consent to see the dentist. Review of Resident #34's annual MDS assessment dated [DATE] revealed the resident had obvious or likely cavities or broken teeth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 25 of 26 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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 0791 Level of Harm - Minimal harm or potential for actual harm Review of Resident #34's plan of care revealed no evidence of a dental plan of care. The Activity of daily Living (ADL) plan of care indicated to consult dental as needed. Review of Resident #34's progress note dated 10/19/22 revealed the resident's loose tooth fell out. Resident ate her oatmeal for breakfast with no problems. Residents Affected - Few Review of Resident #34's quarterly MDS dated [DATE] revealed the resident had no difficulty chewing. Interview on 12/13/22 at 9:05 A.M., with Resident #34's daughter revealed she was not sure if her mom had been a dentist, but her teeth were in bad shape. Interview and observation on 12/13/22 at 2:41 P.M., of Resident #34's teeth revealed the resident's teeth were in poor condition. They were discolored, decayed, and some missing. The resident reported her teeth were falling out. Interview and observation of Resident #34 on 12/14/22 at 10:13 A.M., with the Director of Nursing (DON) revealed the resident's teeth were in poor shape and had several missing teeth. The resident reported she did not eat much this morning because it was hard to chew with her teeth. The resident denied pain. Interview on 12/14/22 at 11:21 A.M., with the Administrator revealed the facility was still looking for Resident #34's dental consent. The Administrator confirmed the resident had not seen the dentist but was put on the scheduled to be seen next time. Review of ancillary service policy dated 07/17 revealed the social service department would ensure any resident's need for any ancillary services was met to maintain a full continuum of medical care and services and would assist and/or oversee the referral. Individual ancillary services consents forms would be obtained upon resident's admission to the facility or prior to referral to any ancillary service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 26 of 26