Inspection·November 13, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to safely transfer Resident #71 according to the plan of care. This affected one resident (#71) of one resident observed for transfer assistance. The facility identified 17 residents (#4, #5, #12, #17, #18, #19, #23, #26, #28, #32, #44, #46, #63, #65, #67, #69, and #71) who required mechanical transfer assistance. The facility census was 75. Findings include: Review of Resident #71's medical records revealed an admission date of 03/05/19. Diagnoses included muscle weakness, need for personal care assistance, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had severe cognitive impairment. Resident #71 required extensive assistance with toileting and transfers. Review of the care plan dated 08/16/23 revealed Resident #71 was at risk for falls. Interventions included the use of Hoyer (mechanical lift) for all transfers. Review of the current physician's orders for November 2023 revealed an order for Hoyer lifts for all transfers. Observation on 11/07/23 at 9:25 A.M. revealed Resident #71 was in a wheelchair in the hall, and she appeared to be incontinent. Interview with Licensed Practical Nurse (LPN) #208 revealed Resident #71 required a Hoyer lift for transfers and stated the staff could not have transferred her using a Hoyer because Resident #71 did not have a Hoyer pad underneath of her. At time of interview, LPN #208 asked State Tested Nursing Assistant (STNA) #244 how she had gotten Resident #71 up due to there was no Hoyer pad under her, and STNA #244 stated she had not used a Hoyer and had stood and pivoted Resident #71 by herself. LPN #208 stated to STNA #244 She's a Hoyer and you should have known that. Observation of transfer assistance at 9:33 A.M. for Resident #71 with STNAs #233 and #280 revealed STNA #280 had stood and pivoted Resident #71 out of wheelchair and into the resident's bed without the use of a Hoyer lift. Review of the undated facility policy titled Safe Lifting and Movement of Residents revealed the use of mechanical lifts are to be used to protect the safety and wellbeing of residents. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00147458. 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 11/13/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided to Residents #46 and #71. This affected two residents (#46 and #71) of two residents observed for incontinence care. The facility census was 75. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 09/10/21. Diagnoses included difficulty walking and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition and was incontinent of bowel and bladder. Review of the care plan dated 11/01/23 revealed Resident #46 was incontinent of bowel and bladder. Interventions included checking and providing incontinence care as needed. Observation of incontinence care for Resident #46 on 11/07/23 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #213 and STNA #244 revealed Resident #46 was incontinent of a large amount of dark colored and stale smelling urine as well as a large amount of stool. Further observation revealed Resident #46 had dried stool on his inner thighs. Interview with STNAs #213 and #244 at time of observation revealed they had not provided incontinence care for Resident #46 since they had started their shift at 6:00 A.M. Interview with Resident #46 at time of observation revealed he could not recall exactly when he had last been changed; however, the resident stated it may have been between 2:00 A.M. and 3:00 A.M. Resident #46 further stated he had to wait between 30 to 45 minutes for incontinence care on occasions. 2. Review of Resident #71's medical records revealed an admission date of 03/05/19. Diagnoses included muscle weakness, need for personal care assistance, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #71 had severe cognitive impairment. Resident #71 required extensive assistance with toileting and transfers. Resident #71 was incontinent of bowel and bladder. Review of the care plan dated 08/16/23 revealed Resident #71 was incontinent of bowel and bladder. Interventions included checking and providing incontinence care as needed. Observation on 11/07/23 at 9:25 A.M. revealed Resident #71 was in a wheelchair in the hallway yelling out, and her pants appeared to be wet. At time of the observation, Licensed Practical Nurse (LPN) #208 confirmed Resident #71's pants appeared to be wet and stated the resident was nonverbal and would yell out when she was soiled. Observation of Resident #71's incontinence care on 11/07/23 at 9:33 A.M. with STNA #244 and STNA #281 revealed resident was incontinent of a large amount of stale smelling urine, as well as a large amount of stool that had soaked through the resident's pants. Interview with STNAs #244 and #281 at time of observation revealed they had not provided Resident #71 with incontinence care since they had begun their shift at 6:00 A.M. and were unable to state when the resident had last been provided with care. Resident #71 was not interviewable. (continued on next page) 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 11/13/2023 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 0690 This deficiency represents non-compliance investigated under Complaint Number OH00147458. 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: 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 11/13/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, the facility failed to maintain proper infection control practices/procedures to prevent the spread of infection including COVID-19. This had the potential to affect all 75 residents residing in the facility. Residents Affected - Many Findings include: Observation on 11/07/23 at 8:21 A.M. revealed State Tested Nursing Assistant (STNA) #280 entered Residents #52 and #65's room with signs posted outside of the room that indicated residents were on isolation precautions. Posted signs included the use of gown, gloves, mask, and eye protection to be worn prior to entering. STNA #280 was observed not wearing gloves or a face shield, and she was wearing a surgical mask underneath an N95 mask with the bottom strap of the N95 not secured and hanging below her chin. STNA #280 exited Residents #52 and #65's room and was observed doffing her personal protective equipment (PPE) prior to exiting. She did not complete hand hygiene upon exiting. Interview with Licensed Practical Nurse (LPN) #208 at 8:24 A.M. revealed the residents on isolation precautions did not have isolation bins in their rooms to dispose of PPE. LPN #208 further stated some of the isolation bins did not contain proper PPE and stated, no one knows what to do around here, and management gives no guidance on what to do. Interview at 8:31 A.M. with STNA #280 revealed she did not wear a face shield and gloves into Residents #52 and #65's room because she was unable to locate any in the isolation bin outside of the room. STNA #280 stated she worked for agency and was unaware of where to locate the items. STNA #280 further stated she doffed the PPE prior to exiting Residents #52 and #65's room; however, there was no isolation bin inside of the room to place the used items, and she placed them inside of trashcan in the room. STNA #280 confirmed she did not complete hand hygiene after doffing her PPE and prior to exiting Residents #52 and #65's room. Observation on 11/07/23 at 8:44 A.M. revealed the Director of Nursing (DON) was placing isolation bins outside of the isolation room for disposal of PPE on the 300-hall. Observation on 11/07/23 at 9:57 A.M. revealed STNA #212 entered Resident #69's room that had signs posted indicating the resident was on isolation precautions. STNA #212 was observed wearing a surgical mask underneath an N95 mask, no face shield, or gloves prior to entering resident's room. Observation on 11/07/23 at 12:22 P.M. revealed STNA #244 entered Resident #20's room to assist the resident with eating. Resident #20 had signs posted outside of her room that indicated the resident was on isolation precautions. STNA #244 was observed to have her N95 mask over a surgical, and she was not wearing a face shield or gloves prior to entering. STNA #244 exited Resident #20's room at 12:39 P.M. and did not complete hand hygiene upon exiting. Interview with STNA #22 at time of observation revealed she did not wear a face shield in Resident #20's room because she was unable to locate one in the isolation supplies outside of the room. STNA #244 confirmed she had not worn gloves while providing feeding assistance to Resident #20 and stated she did not complete hand hygiene after exiting Resident #20's room. Interview on at 12:53 PM with DON, revealed staff were to complete hand hygiene in between resident encounters, and stated staff were to don a gown, gloves, masks, and face shield prior to entering a Covid positive room. Review of staffing assignments for 11/07/23 revealed LPN #208 was assigned residents on the 300 (continued on next page) 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 11/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hall and part of the 200 hall, LPN #212 was assigned residents on the 100 hall, LPN #244 was assigned residents on the 300 hall and part of the 200 hall. STNA #280 stated she was not assigned a specific hall, and she was helping with resident care throughout the facility. Review of the facility policy titled Coronavirus Covid 19, updated 10/01/23, revealed signs were to be posted outside of rooms to alert staff of the proper PPE required upon entering, perform proper hand hygiene before and after all resident contact and upon removal of PPE. Review of the facility policy titled Coronavirus Covid 19 Protocol, revised 10/02/23, revealed staff will wear eye protection and N95 mask in isolation rooms. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes revealed older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for SARS-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalizations, and death. In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g., use of Transmission-Based Precautions for those that have had close contact to someone with SARS-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. Manage Residents with suspected or confirmed SARS-CoV-2 infection HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: • Not been fully vaccinated; or • Suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or • Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infectionfor 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing.SARS-CoV-2 transmission (i.e., outbreak); or • Moderate to severe immunocompromise; or (continued on next page) 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 11/13/2023 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 0880 • Level of Harm - Minimal harm or potential for actual harm Otherwise had source control and physical distancing recommended by public health authorities should still consider continuing to practice physical distancing and use of source control. Implement Universal Use of Personal Protective Equipment for HCP If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: NIOSH-approved N95 or equivalent or higher-level respirators should be used for: Residents Affected - Many • All aerosol-generating procedures (refer to which procedures are considered aerosol generating procedures inhealthcare settings) • All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) • Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. One example might be if the patient is unvaccinated, unable to use source control, and the area is poorly ventilated. • Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during worn during all patient care encounters. This deficiency represents non-compliance investigated under Complaint Number OH00147454. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 7 of 7