Inspection·July 24, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to immediately notify the physician and responsible parties of a fall incident involving Resident #8. This affected one resident (Resident #8) of five residents reviewed for accidents. The facility census was 77. Findings include:Review of the medical record for Resident #8 revealed an admission date of 02/27/25 with diagnoses including acute and chronic respiratory failure, multiple sclerosis, unsteadiness on feet and diabetes.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had no cognitive impairment and required extensive assistance with toileting. Review of the incident log revealed Resident #8 had a fall on 07/06/25 at 8:00 A.M.Review of the STNA Event Witness Statement dated 07/06/25 and timed for 8:00 A.M. authored by Registered Nurse (RN) #205 revealed Resident #8 was reported by a Certified Nursing Assistant (CNA) to have had a fall during the night while transferring to the toilet. It did not disclose the name of the CNA who reported the incident nor did it specify what time during the night the resident fell.Review of a progress note dated 07/06/25, timed 8:45 A.M. and authored by RN #205 revealed it was reported to her Resident #8 fell in her bathroom while transferring to the toilet. Resident #8 was complaining of left knee pain. RN #205 notified the Nurse Practitioner (NP). Review of the fall investigation dated 07/06/25 and authored by RN #205 revealed there were two different times listed as the time of incident: 5:00 A.M. and 8:30 A.M. It stated Resident #8 slipped off the toilet. No injuries were noted. The immediate intervention was to use the call light.An interview on 07/22/25 at 3:52 P.M. with Resident #8 revealed she had fallen on 07/06/25 around 5:00 A.M. Resident #8 stated an agency nurse was assigned to her that shift. An interview on 07/23/25 at 2:00 P.M. with RN #205 revealed she did not witness the fall on night shift. She stated a CNA told her about the fall. RN #205 stated the agency nurse did not tell her in report that Resident #8 fell, and she did not remember the name of the agency nurse. RN #205 stated she was not sure why she wrote 8:00 A.M. for the time of the incident because the CNA told her that the fall occurred during the night shift around 5:00 A.M. RN #205 confirmed there was no documentation in the medical record about the fall from the agency nurse nor any record of notification to the NP until she completed a progress note on 07/06/25 at 8:45 A.M. An interview on 07/23/25 at 2:04 P.M. with Licensed Practical Nurse (LPN) #216 revealed the agency nurse who worked nights did not report to anyone Resident #8 had a fall on 07/06/25. LPN #216 said it was expected a nurse whose resident had a fall would be responsible to complete the investigation report, write a progress note, notify the physician and responsible party as well as share in report to the next shift.An interview on 07/23/25 at 4:45 P.M. with the Director of Nursing and Regional Nurse revealed the dayshift nurse found out about Resident #8's fall after the nightshift agency nurse left. The nightshift agency nurse was expected to complete the investigation report and the notifications to the physician and responsible party, chart in the progress notes and relay in report but did not. Review of the facility policy titled Change in the Resident's Condition or Status, dated 05/01/25, revealed the facility would ensure the resident's attending physician and the resident's authorized representative or interested family member were notified of changes in the resident's physical, mental or psychosocial status. The nurse would immediately notify the resident, consult with their attending physician, on-call physician or nurse practitioner and notify the authorized representative when there was an accident or incident which resulted in injury and had the potential for requiring physician intervention. The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 2 of 14 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 07/24/2025 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 0580 notifications, interventions and response). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 3 of 14 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 07/24/2025 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and review of facility policy, the facility failed to ensure personal privacy and confidentiality of records for Resident #42 and #85. This affected two residents (Residents #42 and #85) of 23 residents reviewed for privacy/confidentiality. The facility census was 77.Findings include:1. Review of the medical record for Resident #85 revealed an admission date of 07/18/25. Diagnoses included stroke, weakness, atrial fibrillation, diabetes and heart disease. Residents Affected - Few An observation on 07/23/25 at 10:36 A.M. of the medication cart on the 100 hall revealed the computer on the medication cart was open to the electronic medical record (EMR) of Resident #85 and his picture, personal demographic information and list of medical orders was visible to anyone passing by the cart which was unattended by facility staff. An interview on 07/23/25 at 10:39 A.M. with Licensed Practical Nurse (LPN) #216 verified the EMR of Resident #85 was open on the medication cart in the hallway and his private information was in view of passersby. Review of the facility policy titled Matrix: Medical Record Policy and Procedure, dated 08/16/10, revealed the facility would monitor and protect health information including but not limited to care plans, nursing information, dietary, social service, activity, therapy and progress notes. 2. Review of the medical record for Resident #42 revealed an admission date of 05/19/25. Diagnoses included malignant neoplasm of the bone, malignant neoplasm of the breast, congestive heart failure, radiculopathy, diabetes, atrial fibrillation glaucoma, and chronic kidney failure. Review of the July 2025 physician orders revealed Resident #42 had an order to cleanse the right heel with normal saline, pat dry, apply skin prep, cover with an abdominal dressing and wrap in kerlix once a day. An observation of wound care on 07/23/25 at 1:07 P.M. revealed the Director of Nursing (DON) provided wound care to the right heel of Resident #42 without maintaining privacy during the treatment. Resident #42 was in bed during the treatment. The DON did not close the door or draw the blinds to the room which exposed the resident to anyone outside or in the hallway. An interview on 07/23/25 at 1:07 P.M. with the DON at the time of the observation of the wound care verified privacy during treatment was not maintained for Resident #42. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 4 of 14 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 07/24/2025 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 observation, record review, interview and review of facility policy, the facility failed to ensure a physician order was obtained for Resident #7's right lower arm skin tear. This affected one resident (#7) of one resident reviewed for general skin conditions. The facility census was 77.Findings include: Residents Affected - Few Review of Resident #7’s medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia, aphasia and chronic systolic congestive heart failure. Review of Resident #7’s care plan for skin care revealed an intervention dated 04/15/25 to perform treatments as per the physician orders. Review of Resident #7’s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #7’s Wound Information form dated 07/07/25 revealed the resident had a right lower arm skin tear which measured one centimeter (cm) length by 0.8 cm width. Review of Resident #7’s Wound Information form dated 07/21/25 at 7:33 P.M. revealed the resident had a right lower arm skin tear first identified on 07/02/25 at 10:28 P.M. which measured 1.2 cm length by 1.2 cm width. Review of Resident #7’s physician orders for July 2025 revealed no treatment orders for the resident’s right lower arm skin tear. Observation on 07/21/25 at 9:07 A.M. revealed Resident #7 was lying in bed and had a dressing on the right arm. The dressing was dated 07/19/25. An interview on 07/21/25 at 9:18 A.M. with Certified Nursing Assistant (CNA) #223 verified Resident #7 had a dressing on the right arm dated 07/19/25. An interview on 07/22/25 at 2:59 P.M. with the Director of Nursing (DON) revealed Resident #7 did not have an active physician order for treatment to the skin tear on the right arm. A follow-up interview on 07/22/25 at 4:30 P.M. with the DON revealed a treatment plan was obtained on 07/02/25 for Resident #7 to receive treatment to the right lower arm skin tear including cleanse the right forearm with normal saline, pat dry, and cover with a clean dressing every other day. The DON verified it had not been written as a physician order. Review of the Clean Technique Wound Care policy updated 05/01/25 revealed it was the facility policy to provide wound care to residents using professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 5 of 14 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 07/24/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of facility policy, the facility failed to ensure Resident #5's left lower leg/foot dressing was administered as ordered. This affected one resident (Resident #5) of three residents reviewed for pressure ulcers/injury. The facility census was 77.Findings include:Review of Resident #5's medical record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, cellulitis of the right and left lower limbs and chronic pain.Review of Resident #5's Pressure Ulcer Care Plan revealed an intervention dated 01/29/25 to perform current treatment as ordered and observe treatment for effectiveness.Review of Resident #5's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #5's physician orders revealed an order dated 07/17/25 to flush the left medial ankle and posterior Achilles with normal saline, pat dry, pack with iodoform and cover with a dry dressing daily; an order dated 07/17/25 to apply betadine wet to dry to bilateral heels once a day; an order dated 07/22/25 to cleanse the left heel and right heel with normal saline, pat dry, apply xeroform gauze into the wound, cover with an abdominal dressing, wrap with kerlix and secure with tape once a day.Review of Resident #5's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/22/25 revealed on 07/20/25 Licensed Practical Nurse (LPN) #213 documented the wound care was on hold and wound rounds were the next day and on 07/21/25 the betadine was unavailable to be administered to the resident's right and left heel per the physician's order.Review of Resident #5's progress notes from 07/01/25 to 07/22/25 did not reveal evidence that the resident's left medial ankle and posterior Achilles wound care were on hold by the physician.An observation including interview was conducted on 07/21/25 at 2:56 P.M. with Physical Therapist (PT) #293 of Resident #5's left foot and ankle's dressing that was observed with a date mark of 07/19/25. PT #293 verified Resident #5's left foot and ankle dressing was dated 07/19/25. An observation on 07/22/25 at 3:45 P.M. with the Director of Nursing (DON) of wound care treatment for Resident #5 revealed the nurse removed the dressing to Resident #5's right heel, removed her gloves, washed her hands, put on gloves, cleaned the right heel with normal saline, removed gloves, washed hands, put on gloves, applied xeroform non-stick dressing, an abdominal dressing and kerlix to the right heel. Betadine was not applied to the right heel.An observation on 07/22/25 at 4:00 P.M. with the DON of wound care treatment for Resident #5 revealed the nurse removed the dressing to Resident #5's left heel, removed her gloves, washed her hands, put on gloves, cleansed the left heel with normal saline, removed her gloves, washed her hands, put on gloves, placed a xeroform non-stick dressing, an abdominal dressing and kerlix to the left foot. Betadine was not applied to the left heel.An observation on 07/23/25 from 10:35 A.M. to 10:42 A.M. with the DON of the treatment administration cart and treatment storage rooms did not reveal evidence of betadine in the facility.An interview on 07/23/25 at 10:42 A.M. with the DON revealed she had called the Nurse Practitioner (NP) to change the order for Resident #5 to have betadine applied to bilateral heels once a day because the facility ran out of betadine. The DON confirmed Resident #5 had not received wound care treatment as ordered. Review of the Pressure Injuries: Assessment, Prevention and Treatment policy updated 05/01/25 revealed the facility should identify the residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00167333 (1373385). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 6 of 14 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 07/24/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observations, record review, interview and review of facility policy, the facility failed to ensure fall interventions were in place for Resident #27. This affected one resident (Resident #27) of five residents reviewed for accidents. The facility census was 77.Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses include senile degeneration of the brain, dementia, chronic kidney disease, depression, Alzheimer's disease, impulsiveness, repeated falls, generalized anxiety disorder, psychotic disorder, insomnia, and sundowning. Review of the July 2025 physician orders revealed Resident #27 had orders for a defined perimeter mattress to the bed to alert resident of bed boundaries, maintain the bed in the lowest position when occupied by the resident, and the resident was a high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had severely impaired cognition and had two or more falls with no injuries. Review of the care plan dated 10/02/22 revealed Resident #27 was at risk for falls/injury related to behavior, confusion, antidepressants, antihypertensives, and unsteady gait. Interventions included a defined perimeter mattress to the bed provided by hospice, Ativan at bedtime, medication review, staff to offer and encourage toileting approximately every two hours, provide the urinal and encourage use during the night, offer and assist resident to bed to rest between meals, assess the resident for bowel and bladder program needs, maintain the bed in the lowest position when occupied by the resident, gripper socks/shoes when out of bed, call light for assistance sign in room, bed against the wall to help define bed boundaries, encourage common areas while awake, encourage resident to use call light and observe resident in their room, dining room, and meal services for safety needs. Observation on 07/22/25 at 10:42 A.M. revealed Resident #27 was up in the Broda chair (reclining wheelchair) in the middle of the room and his call light was tucked up under the blanket on his bed and out of his reach. An interview at this time with Certified Nursing Assistant (CNA) #218 verified the call light for Resident #27 was not within his reach. Observation on 07/22/25 at 2:19 P.M. revealed Resident #27 was in bed on his right side towards the wall and his bed was not in the lowest position. CNA #240 was observed entering the room, walked to the bed and lowered it to the floor. CNA #240 verified the bed had not been in the low position until the CNA entered the room. Observation on 07/22/25 at 5:00 P.M. revealed Resident #27 was up in the Broda chair in the main dining room with regular nonslip socks on both his feet. An interview at this time with Agency CNA #333 verified Resident #27 did not have gripper sock or shoes on at the time of the observation. Observation on 07/23/25 at 9:55 A.M. revealed Resident #27 was up in the Broda chair in the middle of the room and his call light tucked under the blanket on the bed out of his reach. An interview at this time with the Director of Nursing verified the call light for Resident #27 was not within his reach.Review of the facility policy titled, Fall Investigation, dated 05/01/25 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. A member of the team would review current intervention and implement additional fall interventions based on the residents risk factors and results of the root cause analysis. Event ID: Facility ID: 365993 If continuation sheet Page 7 of 14 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 07/24/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #7's percutaneous endoscopic gastrostomy (PEG) tube dressing was administered as ordered. This affected one resident (Resident #7) of one resident reviewed for tube feeding. The facility identified one resident (#7) as ordered a tube feeding. The facility census was 77.Findings include:Review of Resident #7's medical record revealed Resident #7 was admitted on [DATE] with diagnoses including aphasia following a cerebral infarction, gastrostomy status and chronic pain syndrome.Review of Resident #7's physician orders revealed an order dated 03/26/25 to cleanse the PEG tube site with normal saline (NS) and apply a t-sponge dressing to the site daily.Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #7's care plan for skin care revealed an intervention dated 04/01/25 to administer the skin treatment to the PEG tube site as ordered.Review of Resident #7's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/21/25 revealed Licensed Practical Nurse (LPN) #213 documented she completed the care for Resident #7's PEG tube dressing.An observation was conducted on 07/21/25 at 9:07 A.M. of Resident #7 lying in bed with his body exposed from the hip line up to his head. The PEG tube site was visible and there was no dressing on the PEG tube site. The resident had one dressing on his right arm dated 07/19/25. An observation was conducted on 07/21/25 at 9:18 A.M. with Certified Nursing Assistant (CNA) #223 of Resident #7 lying in his bed. CNA #223 confirmed Resident #7 did not have a dressing on the PEG tube site.Review of the Enteral Feeding Site Care policy, updated 05/01/25 revealed it was the policy of the facility to provide ostomy site care for residents with enteral tubes in accordance with professional standards. Event ID: Facility ID: 365993 If continuation sheet Page 8 of 14 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 07/24/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #17's oxygen therapy was administered as ordered and Residents #55 and #87's aerosol masks were stored in a protective barrier to prevent cross contamination of the masks. This affected three residents (Resident#17, #55 and #87) of four residents reviewed for respiratory care. The facility census was 77.Findings include:1. Review of Resident #17's medical record revealed the resident was readmitted on [DATE] with diagnoses including chronic diastolic congestive heart failure, muscle weakness and chronic obstructive pulmonary disease. Residents Affected - Few Review of Resident #17's Alteration in Respiratory Function Care Plan revealed an intervention dated 12/10/23 to administer oxygen as ordered. Review of Resident #17's physician orders revealed an order dated 03/10/25 for continuous oxygen at two liters per nasal cannula and check placement every shift for shortness of breath. Review of Resident #17's Quarterly Minimum Data Set (MDS) 3.0 Assessment revealed the resident exhibited moderate cognitive impairment. Review of Resident #17's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/22/25 revealed the oxygen therapy was implemented as ordered. An observation on 07/21/25 at 9:39 A.M. revealed Resident #17's oxygen tubing via nasal cannula was wrapped up and in a protective plastic bag hanging on the bedside dresser drawer knob. The oxygen tubing was dated 07/18/25. Interview on 07/21/25 at 9:45 A.M. with Licensed Practical Nurse (LPN) #211 confirmed Resident #17's oxygen therapy was not administered as ordered. LPN #211 stated it was hard to keep the oxygen on the resident and that was why it was not implemented. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included chronic obstruction pulmonary disease, chronic respiratory failure, dysphagia, dementia, peripheral vascular disease, major depressive disorder, hypothyroidism, chronic kidney disease, bipolar disorder, hypertension, Alzheimer's disease, osteoarthritis of the knees, generalized anxiety disorder, and chronic pain syndrome. Review of the July 2025 physician orders revealed Resident #55 had an order for ipratropium albuterol 0.5 milligrams/3.0 milligrams solution for nebulization in a 3.0 milliliters unit twice daily. Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #55 had severely impaired cognition. An observation on 07/21/25 at 9:44 A.M revealed the aerosol mask for Resident #55 was lying directly on the bedside table without a protective barrier. An interview on 07/21/25 at 9:49 A.M. with LPN #209 verified the aerosol mask of Resident #55 was lying directly on the bedside stand and it should be stored in a protective barrier to prevent contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 9 of 14 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 07/24/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia due to coronavirus disease, chronic obstructive pulmonary disease, obstructive sleep apnea, insomnia, anxiety disorder, bipolar disorder, pulmonary embolism, congestive heart failure, chronic pain syndrome, Barrett's esophagus, ulcerative colitis, irritable bowel syndrome, osteoarthritis, shortness of breath, chest pain, and chronic kidney disease. Residents Affected - Few Review of the physician orders revealed Resident #87 had an order for albuterol sulfate solution 2.5 milligrams/3.0 milligrams solution for nebulization in a 3.0 milliliters unit every four hours as needed. Observation on 07/21/25 at 9:59 A.M. revealed the aerosol mask for Resident # 87 was lying directly on the bedside stand. An interview on 07/21/25 at 10:01 A.M. with LPN #209 verified the aerosol mask of Resident #55 was lying directly on the bedside stand and it should be stored in a protective barrier to prevent contamination. Further observations on 07/21/25 at 10:04 A.M. revealed LPN #209 picked the aerosol mask up off the bedside stand placed medication in the reservoir and placed it on the residence face without getting a new one or cleaning the contaminated one. LPN #209 verified at this time she had not obtained a new aerosol mask or cleaned the contaminated one prior to placing it on the resident. Review of the facility policy titled, Oxygen Equipment-Change, dated 05/01/25 revealed it was the facility policy that professional standards were followed to reduce the risk of transmission of infection when utilizing respiratory equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 10 of 14 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 07/24/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure pre and post dialysis assessments were completed as required for Resident #5. This affected one resident (Resident #5) of one resident reviewed for dialysis services. The facility identified one resident (#5) as receiving dialysis services. The facility census was 77.Findings include:Review of the medical record for Resident #5 revealed an admission date of 05/05/25 with diagnoses including end stage renal disease, sepsis, diabetes and chronic pain.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact. Review of the June 2025 orders for Resident #5 revealed he had hemodialysis scheduled for Tuesday, Thursday and Saturdays at 5:00 A.M. Review of the Pre/Post Dialysis Assessments dated 06/01/25 through 07/01/25 revealed the following dates were missing at least one of the two (pre/post) assessments: 06/05/25, 06/07/25, 06/14/25, 06/17/25, 06/21/25, 06/24/25, 06/28/25 and 07/01/25. An interview on 07/23/25 at 2:21 P.M. with Licensed Practical Nurse (LPN) #216 revealed she noticed when agency nurses worked at the facility the pre and post dialysis assessments did not get done as required for Resident #5. LPN #216 verified multiple dialysis assessments were not completed. An interview on 07/23/25 at 4:47 P.M. with the DON and Regional Nurse revealed there was no other place staff documented pre/post dialysis assessments except on the assessment. Both the DON and Regional Nurse verified the missing assessments for Resident #5. Review of the facility policy titled Dialysis Policy, dated 05/01/25, revealed residents utilizing renal dialysis will complete pre/post dialysis observations. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 11 of 14 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 07/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure Resident #81 was administered medication according to physician orders. The affected one resident (#81) of five residents reviewed for medication administration. The facility census was 77.Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Resident #81 discharged from the facility on 04/09/25.Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #81 had intact cognition, had lower extremity impairment on one side, required substantial assistance with turning in bed, urinary continence was not rated, and he was frequently incontinent of bowels. Resident #81 was at risk of developing pressure injuries however he was not admitted with any unhealed pressure injuries. Review of the physician orders revealed Resident #81 had an order for Mounjaro (diabetic medication)15 milligrams subcutaneous one a week on Monday dated 02/26/25 and discontinued on 03/24/25 (changed to Tuesday on 03/24/25 so they could give him the injection after it came in from the pharmacy)Review of the March 2025 Medication Administration Record (MAR) revealed Resident #81 was not administered his once weekly Mounjaro on 03/03/25, 03/17/25, and 03/24/25. The comment section of the MAR indicated on 03/03/35 the medication was discontinued, on 03/17/25 it was on hold, and on 03/24/25 it was on hold. Resident #81 was administered the medication on 03/10/25. Review of the pharmacy delivery sheet dated 02/27/25 revealed Resident #81 received one 15 milligram injection of Mounjaro.Review of the pharmacy delivery sheet dated 03/25/25 revealed Resident #81 received four-15 milligram injections of Mounjaro.An interview on 07/23/25 at 10:45 A.M with Regional Nurse #292 revealed on 03/03/25 the nurse working had inadvertently put in the comment section of the MAR that the Mounjaro for Resident #81 was discontinued because she had discontinued his Lantus insulin and she wrote that in error for his Mounjaro. RN #292 verified the nurse never administered the Mounjaro on 03/03/25. RN #292 stated Resident #81 was given one dose of the Mounjaro on 03/10/25 which had been delivered on 02/26/25 however, the pharmacy had not sent any more doses and no one in management was aware the facility had not received any more doses from the pharmacy and Resident #81 had missed several doses until 03/24/25 when they reached out to the pharmacy and had them deliver the medication and it was administered the next day. RN #292 stated the facility had not realized pharmacy had not sent it. RN #292 stated Resident #81 had not received the 03/17/25 and 03/24/25 dose because it was not available from the pharmacy and it was then given on 03/25/25. Event ID: Facility ID: 365993 If continuation sheet Page 12 of 14 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 07/24/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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** Based on record review, interview and review of facility policy, the facility did not ensure gradual dose reduction recommendations pertaining to anti-anxiety medications for Resident #58 were addressed by the physician. This affected one resident (Resident #58) of five residents reviewed for unnecessary medications. The facility census was 77.Findings include:Review of the medical record for resident #58 revealed an admission date of 04/28/23. Diagnoses included senile degeneration of the brain, difficulty walking, muscle weakness, dementia, depression and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, required supervision for eating, substantial assistance for oral hygiene, dressing and personal hygiene and was totally dependent for toileting and showering. Review of the physician orders for September 2024 revealed an order for Ativan (for anxiety) one milligram every two hours (mg) as needed (prn) for anxiety. The order began on 09/02/24 with a stop date of 01/28/25. Review of the facility document for gradual dose reduction (GDR) recommendations by pharmacy, dated 09/09/24, revealed a request by pharmacy to the physician to address the use of as needed Ativan for longer than 14 days. There was no evidence the form had been reviewed by the physician. An interview on 07/23/25 at 9:16 A.M. with the Administrator confirmed the September 2024 GDR recommendation for Resident #58 was not addressed by the physician. Review of the facility policy titled Psychoactive Medication dated 05/01/25 revealed the facility would report irregularities with medications to the physician. The facility would comply with federal and state regulations regarding the use of psychopharmacological medications to include regular review of continued need, appropriate dosage, side effects and risk or benefits. Event ID: Facility ID: 365993 If continuation sheet Page 13 of 14 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 07/24/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and review of facility policy, the facility failed to ensure staff performed hand hygiene during medication administration for Resident #21. This affected one resident (Resident #21) of five residents (Resident #7, #21, #22, #30, and #71) observed for medication administration. The facility census was 77.Findings include:Observation of medication administration on 07/23/25 at 9:45 A.M. revealed Registered Nurse (RN) #205 pushed the medication cart from the nurses station down to the room of Resident #21. RN #205 went into Resident #21's room, obtained his blood pressure, walked back out to the medication cart, prepared his medication, took the medication to Resident #21 and administered the medication all without performing any hand hygiene. After she administered the medications to Resident #21, RN #205 walked back out to the medication cart and started to push the medication cart up the hall way to continue the medication administration. An interview on 07/23/25 at 9:50 A.M. with RN #205 verified she had not washed hands before going into Resident #21's room, obtaining his blood pressure, before administering his medication or after coming out of the room. Review of the undated facility policy titled, Hand Hygiene, revealed it was the facility policy for employees to conduct proper hand hygiene that would aid in the prevention and transmission of infectious diseases. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365993 If continuation sheet Page 14 of 14