Inspection·February 27, 2025

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, manufacture guideline review and interview, the facility failed to ensure Resident #284's pin care was completed as ordered and Resident #181's left hand rash was provided appropriate skin treatments. This finding affected one (Resident #284) of three residents reviewed for wounds and one (Resident #181) of one for general skin conditions. Residents Affected - Few Findings include: 1. Review of Resident #284's Internal Medicine admission Note History and Physical form dated 02/16/25 revealed the resident had a comminuted, mildly displaced tibia and fibular fractures with associated soft tissue swelling and a prior left total knee arthroplasty. Review of Resident #284's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified fracture of the left tibia subsequent encounter for closed fracture with routine healing, muscle wasting and muscle weakness. Review of Resident #284's physician orders revealed an order dated 02/19/25 (discontinued 02/20/25) for pin care to the left lower leg, swab around the sites with half sterile saline and half hydrogen peroxide once per day, wrap in sites with gauze; an order dated 02/20/25 (discontinued 02/24/25) for pin care to the left lower leg, swab around the sites with half sterile saline and half hydrogen peroxide once per day, wrap pin sites with gauze twice a day; and an order dated 02/24/25 for pin care to the left lower leg, swab around sites with half sterile saline and half hydrogen peroxide once per day, wrap pin sites with gauze. Review of Resident #284's Treatment Administration Records (TARS) from 02/20/25 to 02/27/25 revealed on 02/20/25 at 3:31 P.M. the staff documented the pin care treatment was completed the previous shift and on 02/20/25 at 11:53 P.M. the staff documented the pin care was completed on the previous shift. The TAR on 02/21/25 from the 6:30 A.M. to 10:30 A.M. shift and on 02/22/25 from 6:00 P.M. to 10:00 P.M. revealed the entries were blank. Interview on 02/26/25 at 7:17 A.M. with Resident #284 revealed the facility staff did not complete his left lower leg pin care per the physician's order. Interview on 02/26/25 at 8:10 A.M. with Registered Nurse (RN) Wound Nurse #803 confirmed Resident #284's medical record did not have evidence the resident's left lower leg pin care was completed as ordered. Review of the undated Wound Care policy revealed the was the facility's policy to provide guidelines for the care of wounds to promote healing. 2. Review of Resident #181's medical record revealed the resident was admitted on [DATE] with diagnoses including difficulty in walking, muscle weakness and acute kidney failure. Review of Resident #181's physician orders revealed an order dated 02/05/25 for triamcinolone acetonide cream 0.1% apply topically as needed for a rash. Review of Resident #181's treatment administration records (TARS) from 02/05/25 to 02/27/25 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 2 of 6 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 02/27/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm reveal evidence the triamcinolone acetonide cram was applied for the resident's rash on the top of the left hand. Review of Resident #181's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Residents Affected - Few Observation on 02/24/25 at 9:55 A.M. of Resident #181's left hand revealed the top of the hand was edematous with a reddened rash noted. The hand appeared contracted with the fingers curled inward. Interview on 02/24/25 at 9:59 A.M. with Resident #181 indicated the resident's wife was bringing in a splint for his left hand because the splint from the facility had caused a rash on the top of the left hand. Interview on 02/25/25 at 3:53 P.M. with the Certified Occupational Therapy Assistant (COTA) #919 indicated the family was to bring in a splint for the left hand and she was aware of the rash on the top of the left hand for several weeks. COTA #919 confirmed the resident's TARS did not have evidence the triamcinolone acetonide cream for the resident's rash was applied from 02/05/25 to current. Review of Triamcinolone Acetonide Cream 0.1% manufacturer directions dated 02/10/22 revealed the cream was indicated for the relief of the inflammatory and pruritic (intense itching) manifestations of corticosteroid-responsive dermatoses (thousands of different skin conditions). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 3 of 6 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 02/27/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to arrange transportation for Resident #53's appointment resulting in Resident #53's eye surgery being canceled. This affected one resident (#53) of one reviewed for vision. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 06/21/24 with diagnoses including type two diabetes mellitus, hypertension, hyperlipidemia, generalized anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/25/25, revealed Resident #53 was cognitively intact, had impaired vision and wore corrective lenses. Review of the physician's order, dated 02/11/25, revealed Resident #53 had an appointment on 02/24/25 at a surgical center and transportation would need updated. Review of the progress note dated 02/20/25 at 5:10 P.M. revealed Resident #53 had a scheduled surgery on 02/24/25 and was to receive nothing by mouth (NPO) after midnight. Review of the progress note dated 02/24/25 at 7:00 A.M. indicated Resident #53 was NPO after midnight for an eye appointment for cataracts. The note indicated transportation did not arrive to pick up Resident #53. On 02/24/25 at 9:49 A.M., interview with Resident #53 stated the facility did not arrange transportation for her eye surgery and her surgery had to be canceled. On 02/24/25 at 10:21 A.M., interview with Registered Nurse (RN) #886 confirmed transportation never arrived to pick up Resident #53 for her scheduled surgery. On 02/24/25 at 12:13 P.M., interview with Licensed Practical Nurse (LPN) #896 verified Resident #53's eye surgery had to be rescheduled due to transportation issues. LPN #896 said the surgery center did not inform the facility of an arrival time for Resident #53's surgery. On 02/25/25 at 3:37 P.M., interview with Surgery Center Clinical Manager #914 stated Resident #53's eye surgery on 02/24/25 was canceled because Resident #53 did not show up. She further stated she called the facility at the end of the previous week to notify them that Resident #53's arrival time for surgery was 10:00 A.M. On 02/26/25 at 9:22 A.M., interview with RN #801 verified the surgery center had called on 02/20/25 to notify of Resident #53's arrival time of 10:00 A.M. on 02/24/25. RN #801 stated she did not inform transportation because that was the responsibility of LPN #896. On 02/26/25 at 10:56 A.M., interview with RN #884 confirmed the surgery center called on 02/20/25 and notified that Resident #53 was scheduled to arrive at 10:00 A.M. on 02/24/25. RN #884 stated LPN #896 was notified of the arrival time so transportation could be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 4 of 6 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 02/27/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure dentist recommendations for oral surgery services were implemented for one (Resident #21) of two residents reviewed for dental services. Residents Affected - Few Findings include: Review of Resident #21's medical record revealed diagnoses including difficulty swallowing, morbid obesity, type two diabetes mellitus, and vascular dementia. A care plan initiated 06/04/21 revealed the potential for alteration in dental/oral status related to age related changes. Interventions included dental evaluations with treatment as necessary. On 02/27/25 at 9:10 A.M., dental notes dated 08/27/24 were reviewed with Dentist representative #920, via interview, who indicated the resident had an examination and prophylaxis provided. Prior authorization had been obtained. A referral had been sent to an oral surgeon and full dentures had been approved. The note indicated would like full mouth extraction with upper and lower dentures. The dentist indicated at least #17, #19, #31, and #32 root tips needed extracted at a minimum. There was no documentation located in the medical record indicating staff sought an oral surgeon or attempted to make an appointment. On 11/27/24, Resident #21 was admitted to hospice. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 had obvious or likely cavity or broken teeth. On 12/11/24 an order was written to discontinue all upcoming appointments due to hospice. On 02/24/25 at 11:24 A.M., Resident #21 stated his teeth were falling out left and right. Resident #21 stated he had received dental services and was informed he needed to go to an oral surgeon. Resident #21 believed he could not take his wheelchair to the oral surgeon. Resident #21 was observed to have missing and broken teeth. On 02/27/25 at 2:06 P.M., Regional Registered Nurse (RN) #916 verified staff were unable to locate any evidence the referral for an oral surgeon to extract all Resident #21's teeth and root tips and provide full upper and lower dentures was addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 5 of 6 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 02/27/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to ensure the laundry room and washers were maintained in clean working order. This had the potential to affect all 75 residents residing in the facility. Residents Affected - Few Findings include: On 02/25/25 at 3:19 P.M., a large buildup of lint was observed behind the washers in the second laundry area including lint built up on the cement floors, up the walls, on all pipes, and in the water drain. On 02/25/25 at 3:20 P.M., the observation was verified with Maintenance Coordinator (MC) #804. MC #804 verified he was unaware staff members were required to clean behind the washers and dryers. The dryer lint logs were reviewed and demonstarted that the lint traps were cleaned daily and the overhead and behind the dryer lint traps were cleaned weekly and signed off by MC #804 and Environmental Service Coordinator (EC) #831. There was no mention of checking behind the washers for lint build-up. On 02/25/25 at 3:33 P.M., the observation was verified with (EC) #831 that lint was built up behind the washers. On 02/25/25 at 3:43 P.M, MC #804 and EC #831 confirmed that the lint built up behind the washers in the second laundry area had not been cleaned and was the responsibility of the maintenance department. On 02/25/25 at 3:52 P.M., Regional Registered Nurse (RN) #915 verified the lint was built up behind the washers in the second laundry area, confirming it could be a fire hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366027 If continuation sheet Page 6 of 6