Health inspection·August 29, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the progress notes from 03/01/23 to 08/23/23 revealed no documentation of Resident #61 refusing a shower or bath. Review of the shower schedules revealed Resident #61 was to receive a shower on Tuesdays and Thursdays on midnight shift. Residents Affected - Few Review of the shower sheet and bathing task revealed no documentation Resident #61 received her scheduled shower on 08/03/23, 08/08/12, 08/10/23, 08/15/23, and 08/17/23 She did receive a shower on 08/12/23 which was a non-schedule day. On 08/21/23 at 3:50 P.M. an interview with Resident #61 revealed you were lucky to get one shower a week because they do not have enough staff. On 08/23/23 at 3:25 P.M. an interview with Regional Clinical Nurse #600 confirmed no evidence to indicate showers for Resident #61 had been completed as scheduled. 3. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses include metabolic encephalopathy, diabetes, spinal stenosis, major depressive disorder, hypertension, low back pain, anxiety disorder, arthritis, wedge compression fracture of the third and fourth lumbar vertebra, contractures of the right and left ankles, and Barrett's esophagus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 intact cognition. She required extensive assistance with one staff member for bed mobility, dressing, toilet use, personal hygiene, and bathing and two staff members for transfers. Review of the progress notes from 03/01/23 to 08/23/23 revealed no documentation of Resident #65 refusing a shower or bath. Review of the shower schedules revealed Resident #65 was to receive a shower on Wednesday and Sunday on day shift. Review of the shower sheet and bathing task revealed no documentation Resident #65 received her scheduled shower on 07/30/23, 08/06/23, 08/09/23, 08/13/23, and 08/20/23. She was washed up at the bathroom sink on 08/02/23 and therapy gave her a shower on 08/08/23. On 08/21/23 at 3:45 P.M., an interview with Resident #65 revealed she was only receiving one shower per week because they do not have the staff to do the showers. On 08/23/23 at 3:25 P.M. an interview with Regional Clinical Nurse #600 confirmed no evidence to indicate showers for Resident #65 had been completed as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH 00145464. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide adequate care and services to prevent the development of in-house acquired pressure injuries to the sacrum and bilateral heels of Resident #47. The facility also failed to ensure pressure reducing interventions were in place, wound treatments were competed as ordered by the physician, and proper infection control practices were followed during dressing changes to promote wound healing for Resident #47. Residents Affected - Few Actual harm occurred on 08/15/23 when the facility failed to prevent the development of an unstageable (a full-thickness tissue loss with exposed bone, tendon or muscle with slough/eschar present which prevents accurate staging of the ulcer and often include undermining and tunneling) pressure ulcer to the resident's sacrum. Resident #47 who was assessed to be at risk for pressure ulcer development (but admitted to the facility on [DATE] with no pressure ulcers) and required extensive assistance of two staff member for bed mobility developed an avoidable in-house unstageable pressure ulcer to the sacrum which measured 11.0 centimeters (cm) in length by 7.5 cm width with less than 0.1 cm depth, with a wound bed of 25 percent (%) yellow slough (dead skin cells) and 55% eschar (black, dead tissue). Following the initial development, the pressure ulcer deteriorated and also exhibited signs of potential infection. In addition, the resident was also noted to develop avoidable pressure ulcers to his bilateral heels which deteriorated to unstageable pressure ulcers due to a lack of timely and appropriate interventions. This affected one resident (Resident #47) of three residents reviewed for pressure ulcers. The facility census was 78. Findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including right artificial hip, osteoarthritis to the right hip, hypothyroidism, iron deficiency anemia, hyperlipidemia, hypertension, and hypotension. Resident #47 was admitted to the facility for surgical after-care following hip surgery. Review of a Clinical admission Assessment document, dated 08/04/23 indicated to See Wound Grid observation. However, there was no skin observation documented. Review of the admission Braden scale assessment dated [DATE] revealed Resident #47 was at risk for pressure ulcer injuries. Review of the physician's orders dated 08/04/23 revealed Resident #47 had an order for skin prep to bilateral heels every shift as a preventative intervention . Review of a baseline care plan/Clinical admission Documentation dated 08/04/23 revealed Resident #47 would not develop skin breakdown through the next 30 days. Treatment approaches were to check skin with daily care and bathing weekly and report any skin concerns to the nurse. Review of wound grid documentation dated 08/05/23 revealed Resident #47 had a surgical wound to his right hip. There was no additional documentation to indicate the resident had any other skin impairment noted at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of a progress note dated 08/05/23 at 12:19 A.M. revealed Resident #47 had a surgical dressing on the right hip that was to remain intact for seven to ten days, his feet were dry, he had a scar to the left outer leg and a bruise to the left arm from his intravenous line. Review of the Illustration of Documentation and Measurement of Skin areas dated 08/08/23 revealed the only skin concerns Resident #47 had on admission included a surgical dressing on the right hip. Review of the physician's progress note dated 08/08/23 revealed the nurse and aides stated there were no issues to address for Resident #47 at this time. The review of systems revealed Resident #47 had no skin rashes and he had no treatments. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition. The assessment revealed the resident required extensive assistance from two staff members for bed mobility, transfers, toilet use and extensive assistance from one staff member for dressing, personal hygiene. The assessment indicated the resident had two Stage II in-house pressure injuries and one unstageable pressure ulcer. However, this documentation of these areas of skin impairment was determined to be inaccurate during the course of the onsite complaint investigation. Review of a progress note dated 08/15/23 at 5:14 P.M. revealed the nurse was asked by therapy to assess the sacrum of Resident #47. The resident had a large open area to the sacrum. The physician was notified, and a new order was received. The resident was also noted to have open areas to both his right and left heel and a serum filled blister to his left great toe. New treatment orders were received from the physician. Review of the Occupational Therapy Note dated 08/15/23 revealed the nurse was immediately notified of the resident's buttocks and surrounding areas of skin breakdown. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house unstageable pressure ulcer to the sacrum which measured 11.0 centimeters (cm) length by 7.5 cm width with less than 0.1 cm depth. The wound bed had 25% yellow slough with 55% eschar tissue. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house Stage II (partial thickness skin loss with exposed dermis) pressure ulcer to the left heel which measured 5.0 cm length by 4.0 cm width with less than 0.1 cm depth. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house Stage II pressure ulcer to the right heel which measured 5.0 cm length by 2.4 cm width with less than 0.1 cm depth. Review of the physician's orders dated 08/15/23 revealed an order to cleanse the left heel with normal saline, pat dry, cover with piece of Adaptic and abdominal dressing secure with cling wrap every day and as needed until healed and to cleanse the right heel with normal saline, pat dry, cover with a piece of Adaptic, abdominal dressing and wrap with cling wrap every day and as needed until healed. For the sacrum, an order was noted to cleanse with normal saline, pat dry, apply nickel thick Santyl and cover with alginate with a dry secure dressing every day and as needed. Review of the physician's orders dated 08/17/23 (following the identification of the pressure ulcers) revealed an order for an air mattress and foam boots to bilateral feet at all times while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of physician's orders revealed a new order, dated 08/18/23 to cleanse wound to the sacrum with Dakin's soaked gauze then lightly fill wound space with Dakins-soaked gauze and cover with protective foam dressing twice a day and as needed for loose or soiled dressing. Review of the August 2023 Treatment Administration Record revealed the new order for wound care for the sacral pressure ulcer written on 08/18/23 was only documented as being completed once on 08/19/23 on the day shift (6:00 A.M to 6:00 P.M.). There was no documentation of the treatment for the left heel being completed on 08/18/23, 08/20/23 or 08/21/23. There was no documentation of the treatment to the right heel being completed on 08/18/23, 08/20/23, and 08/21/23. On 08/22/23 at 8:10 A.M. an interview with State Tested Nursing Assistant (STNA) #200 revealed two-hour turns and showers were not being done because there was not enough staff working in the facility. She stated one aide was scheduled per hall which was not enough to get showers and every two hour turns completed . On 08/22/23 at 11:15 A.M. an interview with Regional Clinical Nurse #600 verified there were no weekly skin assessments/weekly bathing reports for Resident #47 available for review. On 08/22/23 at 11:40 A.M. Resident #47 was observed in bed. However, the resident was noted to be too tall for the bed. He had his feet over the foot board sitting on top of the air mattress. The resident was not observed to have any type of dressing on his left heel and the dressing on the right heel was dated 08/19/23. On 08/22/23 at 11:45 A.M. an interview with Registered Nurse #205 revealed the dressing to Resident #47's right heel was to be completed daily. She verified the dressing to his right heel was dated 08/19/23. She stated she took the dressing off the left foot earlier because it was falling off and she stated it was also dated 08/19/23. She stated the order for wound care for the sacral wound was to completed twice daily, but there was only documentation of it being completed once daily on 08/19/23. Observation on 08/22/23 at 1:10 P.M. with RN #205 revealed the right heel of Resident #47 had a black necrotic area covering the whole heel area, the skin of the peri wound was peeling away from the necrotic area and was beefy red. The left heel dressing had a large amount of serosanguineous drainage soaked through the dressing. The wound was covered in yellow slough and the peri-wound edges were peeling away and the exposed skin was beefy red. The resident did not have his ordered foam heel protectors on. The resident indicated his heels hurt really bad. RN #205 stated she had medicated the resident (for pain) prior to the observation. Observation on 08/22/23 at 2:00 P.M. with RN #205 revealed Resident #47 did not have foam heel boots on and a search of the room revealed there were not any in his room to put on. On 08/22/23 at 3:22 P.M. an interview with Licensed Practical Nurse (LPN) #201 revealed staffing was horrible. The LPN revealed as a result of inadequate staffing, care was not getting done, showers were not getting done, turning and repositioning was not getting done and wound care was not completed as ordered. On 08/23/23 at 12:55 P.M. an interview with RN #206 revealed she had worked on 08/21/23 but she could not remember if she had completed any dressing changes for Resident #47. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few Observation on 08/23/23 at 1:00 P.M. revealed Resident #47 did not have his foam heel protectors on in bed. An interview at this time LPN #207 verified the resident did not have his physician ordered foam heel protectors on while in bed. On 08/23/23 beginning at 1:00 P.M. LPN #207 and RN #206 (the facility wound nurse) were observed completing wound care for Resident #47. LPN #207 gathered the equipment needed, took it into the resident's room and placed it directly on the bedside stand without disinfecting the stand or placing a protective barrier down. She removed the resident's sacral dressing, cleaned the wound, removed her gloves, washed her hands, and applied the new dressing as ordered. RN #206 measured the sacral wound which measured 11 cm in length by 10.0 cm width with an undetermined depth due to yellow slough covering the wound. There was a large amount of drainage from the wound and the wound had a foul odor. RN #206 proceeded to cut the bandage off the resident's right heel and measured the wound. The wound measured 3.4 cm length by 4.3 cm width with an undetermined depth due to a black eschar covering the entire wound. The edges were beefy red in color and there was a moderate amount of serosanguineous drainage. LPN #207 cleaned the wound and used her scissors, which were in her pocket to cut the Adaptic without cleaning the scissors prior to cutting it. She then laid the scissors down directly on the bedside table. She finished the dressing change with no further issues. The resident's left heel wound was observed to be bleeding through the old dressing. LPN #207 cut the old dressing off the left heel and placed the scissors back on the bedside table. RN #206 measured the left heel wound which measured 5.0 cm length by 5.2 cm width with an undetermined depth due to eschar covering 90 percent of the wound. The peri wound was beefy red. LPN #207 cleaned the wound and cut the Adaptic using the same scissors without cleaning them again. She proceeded to redress the wound as ordered. All three wounds were larger in size and had deteriorated since the original wound grid measurements dated 08/15/23. On 08/23/23 at 1:25 P.M. an interview with LPN #207, she verified she had not cleaned the bedside table, had not placed a barrier down or cleaned her scissor while doing the dressing change on Resident #47 and stated she knew better. The LPN also verified the sacral wound had a foul odor. On 08/24/23 at 9:50 A.M. an interview with Resident #47 revealed he did not have any skin issues when he was admitted to the facility. He stated he had a different mattress on his bed not the air mattress but it was fairly comfortable. He stated the staff were not turning him off his bottom and they were not putting anything on his heels prior to them getting sore. He stated staff did not provide treatments as ordered and stated he had never seen foam boots until the day before. On 08/24/23 at 10:15 A.M. an interview with Certified Occupational Therapy Assistant #400 revealed she was providing care to Resident #47 when she noticed he had a very large open area to his bottom. She stated it looked really bad and the center was all yellow. She stated she noticed his toe also that day but had not looked at his heels. On 08/24/23 at 11:10 A.M. an interview with RN #206 revealed on 08/21/23 she had documented the resident was unavailable on 08/21/23 because he was in therapy, had company and was sleeping on her shift. She stated she had passed it on to the next shift nurse that his treatment needed done but they would not have populated in the electronic record (Matrix) for her because it was a day shift treatment but stated she did remember telling her they needed done. On 08/28/23 at 5:12 P.M. an interview with the Administrator revealed the facility's traveling MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few nurse completed the admission MDS assessment dated [DATE] for Resident #47 and it was done incorrectly regarding the resident's skin status. The Administrator explained the MDS was completed on 08/17/23 by the traveling MDS nurse with the assessment reference date being 08/09/23, and the MDS nurse mistakenly documented the in-house acquired wounds from 08/15/23 on the admission assessment dated [DATE]. Review of the undated facility policy titled, Wound Care, revealed it was the facility policy to provide guidelines for the care of wounds to promote healing. During wound treatments, a clean field should be established. Review of the facility policy titled Pressure Injuries: Assessment, Prevention and Treatment, undated, indicated it is the facility's policy to identify resident's at risk, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. Skin will be assessed routinely and documented on the nursing skin tool. Residents will be checked for incontinence every two hours and position changed every two hours or more frequently as needed. Heels should be kept off the bed or other devices used for pressure relief. Wound treatments should be provided per physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00145464. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain sufficient levels of nursing services staff to meet the total care needs of all residents. This affected four residents (Resident #31, Resident #47, Resident #61 and Resident #65) and had the potential to affect all 78 residents residing in the facility. Findings include: 1. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided activity of daily living (ADL) information for 78 residents. The facility identified 41 residents who required the assistance of one or two staff for bathing and 35 residents who were totally dependent on staff. The facility identified 76 residents who required the assistance of one or two staff for dressing. The facility identified 54 residents who required the assistance of one or two staff for transfers and 19 residents who were totally dependent on staff. The facility identified 74 residents who required the assistance of one or two staff for toileting and one resident who was totally dependent on staff. The facility identified eight residents who required the assistance of one to two staff for eating and five residents who were totally dependent on staff. The 672 form also identified 54 residents who were occasionally or frequently incontinent of bladder and 55 residents who were occasionally or frequently incontinent of bowel. Review of the Facility Assessment, dated July 2023, revealed the staffing was planned for an average daily census of 74.5 residents. Licensed nurses would provide 0.75 to 1.00 hours per resident per day, nurse aides 1.7 to 2.2 hours per resident per day and administrative nursing staff would provided 0.23 to 0.35 hours per resident per day. In total, licensed nurses would provide 0.98 to 1.35 hours per resident per day plus the nurse aides 1.7 to 2.2 hours day equated to a minimum of 2.68 to 3.55 hours per resident per day to meet the resident population acuity needs. Review of the staffing tool for the date range of 08/05/23 to 08/11/23 revealed the direct nursing care per resident per day was 2.57 to 3.16 with an average census that week of 76 residents. On 08/21/23 at 11:45 A.M.staffing observations of staff present in the facility included three licensed nurses and seven State Tested Nursing Assistants (STNAs) on duty to provide care for 78 residents currently residing in the facility. One of the STNAs was on light duty and one was the Human Resource Director helping on the floor due to call offs. On 08/24/23 at 8:25 A.M. an interview with Human Resource (HR) #403 revealed the facility had six STNA and three nurse positions open. HR #403 explained the facility just started to use agency staff again to cover open shifts because there were not enough facility staff coming in to work to cover the staffing needs for resident care on all shifts. 2. On 08/21/23 at 3:40 P.M. an interview with Resident #31 revealed she was only receiving one of her two scheduled showers a week. Review of the medical record revealed Resident # 31 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, osteoporosis, peripheral vertigo, sciatica, gout, major depressive disorder, vascular dementia, hypothyroidism, reduced mobility, anxiety disorders, chronic pain, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0725 contractures of the right and left hips, endocarditis, anemia, and hypertension. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 moderately impaired cognition. She required extensive assistance with one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Residents Affected - Many Review of the progress notes from 03/16/23 to 08/23/23 revealed no documentation of Resident #31 refusing a shower or bath. Review of the shower schedules revealed Resident #31 was to receive a shower on Wednesday and Saturday on day shift. Review of the shower sheet and bathing task revealed no documentation Resident #31 received her scheduled shower of 08/05/23 and 08/19/23. She refused on 08/09/23 because the facility had no hot water. On 08/23/23 at 3:25 P.M. an interview with Regional Clinical Nurse #600 confirmed no evidence to indicate showers for Resident #31 had been completed as scheduled. 3. On 08/21/23 at 3:50 P.M. an interview with Resident #61 revealed you were lucky to get one shower a week because they do not have enough staff. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnosis included diabetes, bipolar disorder, major depressive disorder, generalized anxiety disorder, anemia, hypertension, hypothyroidism, dysphagia, acute kidney failure, seizures, chronic rhinitis, acute lymphangitis, insomnia, schizoaffective disorder, chronic kidney disease, low back pain, and vitamin D deficiency. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had intact cognition. She required supervision for bed mobility, transfers, personal hygiene, limited assistance with dressing, and extensive assistance of one staff member for toilet use and bathing. Review of the progress notes from 03/01/23 to 08/23/23 revealed no documentation of Resident #61 refusing a shower or bath. Review of the shower schedules revealed Resident #61 was to receive a shower on Tuesdays and Thursdays on midnight shift. Review of the shower sheet and bathing task revealed no documentation Resident #61 received her scheduled shower on 08/03/23, 08/08/12, 08/10/23, 08/15/23, and 08/17/23 She did receive a shower on 08/12/23 which was a non-schedule day. On 08/23/23 at 3:25 P.M. an interview with Regional Clinical Nurse #600 confirmed no evidence to indicate showers for Resident #61 had been completed as scheduled. 4. On 08/21/23 at 3:45 P.M., an interview with Resident #65 revealed she was only receiving one shower per week because they do not have the staff to do the showers. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Diagnoses include metabolic encephalopathy, diabetes, spinal stenosis, major depressive disorder, hypertension, low back pain, anxiety disorder, arthritis, wedge compression fracture of the third and fourth lumbar vertebra, contractures of the right and left ankles, and Barrett's esophagus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 intact cognition. She required extensive assistance with one staff member for bed mobility, dressing, toilet use, personal hygiene, and bathing and two staff members for transfers. Review of the progress notes from 03/01/23 to 08/23/23 revealed no documentation of Resident #65 refusing a shower or bath. Review of the shower schedules revealed Resident #65 was to receive a shower on Wednesday and Sunday on day shift. Review of the shower sheet and bathing task revealed no documentation Resident #65 received her scheduled shower on 07/30/23, 08/06/23, 08/09/23, 08/13/23, and 08/20/23. She was washed up at the bathroom sink on 08/02/23 and therapy gave her a shower on 08/08/23. On 08/23/23 at 3:25 P.M. an interview with Regional Clinical Nurse #600 confirmed no evidence to indicate showers for Resident #65 had been completed as scheduled. 5. On 08/24/23 at 9:50 A.M. an interview with Resident #47 revealed he did not have any skin issues when he was admitted to the facility. He stated he had a different mattress on his bed not the air mattress but it was fairly comfortable. He stated the staff were not turning him off his bottom and they were not putting anything on his heels prior to them getting sore. He stated staff did not provide treatments as ordered and stated he had never seen foam boots until the day before. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including right artificial hip, osteoarthritis to the right hip, hypothyroidism, iron deficiency anemia, hyperlipidemia, hypertension, and hypotension. Resident #47 was admitted to the facility for surgical after-care following hip surgery. Review of wound grid documentation dated 08/05/23 revealed Resident #47 had a surgical wound to his right hip. There was no additional documentation to indicate the resident had any other skin impairment noted at that time. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house unstageable pressure ulcer to the sacrum which measured 11.0 centimeters (cm) length by 7.5 cm width with less than 0.1 cm depth. The wound bed had 25% yellow slough with 55% eschar tissue. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house Stage II (partial thickness skin loss with exposed dermis) pressure ulcer to the left heel which measured 5.0 cm length by 4.0 cm width with less than 0.1 cm depth. Review of a wound grid dated 08/15/23 revealed Resident #47 acquired an in-house Stage II pressure ulcer to the right heel which measured 5.0 cm length by 2.4 cm width with less than 0.1 cm depth. On 08/22/23 at 8:10 A.M. an interview with State Tested Nursing Assistant (STNA) #200 revealed two-hour turns and showers were not being done because there was not enough staff working in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm facility. She stated one aide was scheduled per hall which was not enough to get showers and every two hour turns completed . On 08/22/23 at 11:15 A.M. an interview with Regional Clinical Nurse #600 verified there were no weekly skin assessments/weekly bathing reports for Resident #47 available for review. Residents Affected - Many On 08/22/23 at 11:40 A.M. Resident #47 was observed in bed. However, the resident was noted to be too tall for the bed. He had his feet over the foot board sitting on top of the air mattress. The resident was not observed to have any type of dressing on his left heel and the dressing on the right heel was dated 08/19/23. On 08/22/23 at 11:45 A.M. an interview with Registered Nurse #205 revealed the dressing to Resident #47's right heel was to be completed daily. She verified the dressing to his right heel was dated 08/19/23. She stated she took the dressing off the left foot earlier because it was falling off and she stated it was also dated 08/19/23. She stated the order for wound care for the sacral wound was to completed twice daily, but there was only documentation of it being completed once daily on 08/19/23. On 08/22/23 at 3:22 P.M. an interview with Licensed Practical Nurse (LPN) #201 revealed staffing was horrible. The LPN revealed as a result of inadequate staffing, care was not getting done, showers were not getting done, turning and repositioning was not getting done and wound care was not completed as ordered. On 08/23/23 at 10:08 A.M. an interview with State Tested Nursing Assistant # 203 revealed if there was only one aide on the hallway then they were not able to get the showers done. She stated they work one to a hallway a lot. On 08/23/23 at 10:11 A.M. an interview with STNA #204 revealed staffing was horrible and there was usually only one aide to a hallway and showers were not getting done as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH 00145464. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 11 of 11