Health inspection·September 1, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm On 08/30/22 at 9:05 A.M., State Tested Nursing Assistant (STNA) #891 stated she was uncertain how often residents had meals served in Styrofoam containers on other shifts. STNA #891 stated on afternoon shift dinner was usually served on Styrofoam twice a week when there was nobody to wash dishes. STNA #891 stated Resident #68 had reported this upset her. STNA #891 verified staff were unable to re-heat food served on Styrofoam. Residents Affected - Few On 08/31/22 at 2:22 P.M., interview with Registered Nurse (RN) #847 stated meals were frequently served in Styrofoam containers. She stated all meals on the weekends were usually served in Styrofoam containers and at least four meals throughout the week. Review of the Patient Handbook revealed a list of Residents' Rights included the right to be treated at all times with courtesy, respect and full recognition of dignity and individuality. 2. Review of Resident #27's medical record revealed diagnoses including protein-calorie malnutrition and diabetes mellitus. A quarterly MDS dated [DATE] revealed Resident #27 was able to make herself understood and was able to understand others. On 08/29/22 at 4:29 P.M., observations of dinner trays being served on the 100 and 300 halls revealed meals were served in Styrofoam containers. On 08/29/22 at 4:36 P.M., [NAME] #881 verified dinner was being served in Styrofoam containers facility wide because there was nobody to wash dishes. On 08/29/22 at 4:41 P.M. the Administrator stated there was a dishwasher scheduled and he had been pulled to the floor to assist with non-direct care duties. The scheduled dishwasher would return to the dietary department at 6:00 P.M. and wash dishes. The Administrator acknowledged serving meals on Styrofoam dishes could be a dignity concern. On 08/30/22 at 9:40 A.M., Resident #27 stated meals were served on Styrofoam dishes when the facility did not have anybody to wash dishes. Resident #27 stated this occurred nearly every weekend meal and sometimes during the week over the past six months. Resident #27 stated breakfast and dinner were served on Styrofoam dishes on 08/29/22 and voiced displeasure with the use of Styrofoam dishes. Resident #27 stated residents did not like being served on Styrofoam because food got cold and staff were unable to heat meals served on Styrofoam because the container would melt. Resident #27 stated she was unable to tolerate cold food so she would skip meals which caused her concern because of her diabetes. On 08/30/22 at 11:57 A.M., STNA #873 stated residents had meals served in Styrofoam containers two to three times per week. Some residents had voiced concerns. On 08/30/22 starting at 5:20 P.M., Licensed Practical Nurse (LPN) #854 was being interviewed regarding Resident #27's meal intakes and compliance with her diet. LPN #854 invited RD #890 to participate in the interview. RD #890 indicated Resident #27 sometimes refused meals. Information was shared with RD #890 regarding Resident #27's stated information regarding refusals being related to cold food temperatures because the food was served on Styrofoam. RD #890 was also informed of staff and resident interviews indicating Styrofoam was used to serve meals two to three days a week. LPN #854 stated it occurred more often than that. LPN #854 stated residents were not happy that food was served on Styrofoam, indicating partially because the food could not be reheated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 2 of 7 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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 0550 Level of Harm - Minimal harm or potential for actual harm On 08/31/22 at 2:22 P.M., interview with RN #847 stated meals were frequently served in Styrofoam containers. She stated all meals on the weekends were usually served in styrofoam containers and at least four meals throughout the week. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 3 of 7 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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 observation, record review and interview, the facility failed to ensure Resident #3 was assisted with meals timely and offered supplements or alternate food items when she refused her meal. This finding affected one (Resident #3) of two residents reviewed for activities of daily living (ADL). Residents Affected - Few Findings include: Review of Resident #3's medical record revealed she was readmitted on [DATE] with diagnoses including dyspahgia oral phase, cognitive communication deficit and vascular dementia without behavioral disturbance. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment, held food in her mouth or cheeks and did not have significant weight loss. Review of Resident #3's physician orders revealed an order dated 08/15/22 for a regular diet, pureed texture with thin liquids consistency using Kennedy cups (cups with lids). Review of Resident #3's undated Treatment Encounter Notes form from 08/20/22 to 08/31/22 revealed on 08/21/22 at 9:54 A.M., 08/21/22 at 12:20 P.M., 08/21/22 at 10:20 P.M., 08/27/22 at 12:13 P.M., 08/28/22 at 9:21 A.M., 08/28/22 at 12:38 P.M., 08/28/22 at 8:20 P.M., 08/29/22 at 8:31 A.M., and 08/31/22 at 7:36 P.M., the resident consumed zero percent (0%) of the meals. Review of Resident #3's progress notes from 08/20/22 to 08/31/22 did not include evidence Resident #3 was offered supplements or alternative food items for a decline in meal intakes on 08/21/22, 08/27/22, 08/28/22, 08/29/22 or 08/31/22. Review of Resident #3's medication administration records (MARS) and treatment administration records (TARS) from 08/20/22 to 08/31/22 did not reveal evidence the resident was offered supplements for a decrease in meal intakes on 08/21/22, 08/27/22, 08/28/22, 08/29/22 or 08/31/22. Review of Resident #3's medical record revealed an order dated 08/29/22 indicating she was admitted to hospice services for a diagnosis of degeneration of the brain. Review of Resident #3's breakfast meal ticket dated 08/31/22 indicated she was served eight ounces of coffee, eight ounces of two percent milk, eight ounces of orange juice, eight ounces of cran-apple juice, pureed cheese omelet, pureed sausage patty and pureed toast. Observation on 08/31/22 at 8:34 A.M. with Registered Nurse (RN) Wound Nurse #848 revealed Resident #3's covered breakfast tray was sitting on her tray table in her room. The resident was in bed sleeping at the time of the observation. RN Wound Nurse #848 attempted to assist Resident #3 with the breakfast meal at this time. Resident #3 was observed drinking the orange juice and cranberry juice. She consumed zero to 25% of the breakfast meal and was not offered alternatives or supplements. Interview on 08/31/22 at 8:48 A.M. with [NAME] #885 stated Resident #3's breakfast tray left the kitchen on a food cart between 7:38 A.M. and 7:50 A.M. [NAME] #885 confirmed the breakfast tray was potentially sitting on Resident #3's bedside approximately thirty to forty minutes. Observation on 09/01/22 at 7:37 A.M. revealed Licensed Practical Nurse (LPN) #868 assisting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 4 of 7 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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 Resident #3 with her breakfast meal. Resident #3 was observed holding the food in her mouth. Level of Harm - Minimal harm or potential for actual harm Interview on 09/01/22 at 8:15 A.M. with Dietitian #890 indicated she was unaware Resident #3 was holding food in her mouth and confirmed she was not placed on supplements when she did not consume her meals. She stated Resident #3 was placed on hospice services on 08/29/22, was working with a speech therapist and did not have significant weight loss. Residents Affected - Few Interview on 09/01/22 at 8:26 A.M. with the Director of Nursing (DON) indicated she met with Resident #3's family and hospice regarding the decline in her condition including the decrease in meal intake. The DON confirmed Resident #3's medical record did not have evidence she was offered alternative meals or supplements for a decrease in meal intakes on 08/21/22, 08/27/22, 08/28/22, 08/29/22 or 08/31/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 5 of 7 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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 0727 Level of Harm - Potential for minimal harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of schedules and interview, the facility failed to ensure the director of nursing did not work as a charge nurse when the average daily census was greater than 60. This had the potential to affect all 65 residents. Findings include: Review of staffing schedules revealed the Director of Nursing (DON) worked as a charge nurse on 08/01/22 with a census of 75, 08/05/22 with a census of 76, 08/10/22 with a census of 74, and 08/15/22 with a census of 72. On 09/01/22 at 9:54 A.M., Staffing Coordinator #833 verified the DON had worked as a charge nurse, stating she did not realize the DON was not supposed to work as a charge nurse if the average daily census was greater than 60. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 6 of 7 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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 Based on observation, review of schedules, and interview, the facility failed to ensure posted nurse staffing information was accurate. This had the potential to affect all 65 residents. Residents Affected - Many Findings include: Upon entrance to the facility the facility identified a census of 65 residents in house. On 08/29/22 at 10:00 A.M., staff information was posted for 08/29/22 for the entire day. The posting indicated one Licensed Practical Nurse (LPN) and one Registered Nurse (RN) were scheduled to work from 5:30 A.M. to 2:00 P.M., one RN was scheduled to work from 5:30 A.M. to 6:00 P.M., four nursing assistants were scheduled to work from 6:00 A.M. to 2:00 P.M., one nursing administration staff was scheduled to work from 8:00 A.M. to 5:00 P.M., one Minimum Data Set (MDS) nurse was scheduled to work 8:30 A.M. to 5:00 P.M., one LPN was scheduled to work from 1:30 P.M. to 10:00 P.M., one RN was scheduled to work from 1:30 P.M. to 6:00 P.M., four nursing assistants were scheduled from 2:00 P.M. to 10:00 P.M., one nursing assistant was scheduled to work from 4:00 P.M. to 8:00 P.M., one LPN was scheduled from 5:30 P.M. to 6:00 A.M. and one nursing assistant was scheduled to work from 10:00 P.M. to 6:00 A.M. The census was documented as 70 for the entire day. The posting remained the same on 08/29/22 at 2:53 P.M. On 08/29/22 at 2:53 P.M., Staffing Coordinator #833 stated she was responsible for staffing schedules but the receptionists posted staffing information. On 08/29/22 at 2:55 P.M., Lead Receptionist #886 stated receptionists print the staff posting information which was generated from schedules. Lead Receptionist #886 was unable to reveal why there were discrepancies between staffing schedules and information on the posting. On 08/29/22 at 2:57 P.M., Staffing Coordinator #886 verified the staff posting was filled out for the entire day and indicated there was one nursing assistant working on night shift on 08/29/22 but the schedule indicated six nursing assistants were scheduled. On 08/29/22 at 3:00 P.M., the Administrator stated receptionists ran staff posting on Fridays for Friday, Saturday, Sunday and Monday. Receptionists were responsible for updating and ensuring information on the staff posting was accurate. The Administrator verified the census on 08/29/22 was 65 but the staff posting reflected it was 70. On 09/01/22 at 8:47 A.M., Lead Receptionist #886 stated she was never told receptionists were responsible for updating information on the staff posting as it changed. While reviewing schedules with Staff Coordinator #886 starting on 09/01/22 at 8:35 A.M., she verified staff posting information on 08/29/22 was incorrect because the schedule identified RN #847 as a LPN, eight aides worked from 6:00 A.M. to 2:00 P.M. instead of the four aides reflected on the staff posting. There were two Nursing Administrative staff who worked and the posting indicated one did. Staff Coordinator #886 verified multiple days where staff (RN/LPN) identified/categorized incorrectly on the schedules. Because the staff posting was generated from the schedules, the posting would also be incorrect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 7 of 7