Inspection·August 11, 2022

F 0657 intervention will be implemented. A Change in Plan of Care Communication Form will be initiated. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interview, the facility failed to ensure care plans were revised to reflect new fall prevention interventions added after falls occurred. This affected two (Resident #5 and #28) of four residents reviewed for falls. Residents Affected - Few Findings include: 1. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included seizure disorder, congestive heart failure, history of a stroke with hemiparesis (weakness) and hemiplegia (paralysis) affecting the right dominant side, dementia with behavioral disturbances, muscle weakness, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, need for assistance with personal care, abnormal posture and repeated falls. A review of Resident #5's quarterly Minimum Data Set (MDS) assessment completed on 04/19/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to have any behaviors but was known to reject care one to three days of the seven day assessment period. He required an extensive assist of two for bed mobility, transfers, dressing and toilet use. Balance issues were noted during transitions and walking and he was only able to stabilize himself with staff assistance. He was not indicated to have had any falls since his admission or prior assessment and was not known to have any falls prior to his admission. A review of Resident #5's care plans revealed he had a care plan for being at risk for falls related to behaviors, confusion, history of falls, incontinence, impaired gait stability and medications that increased the risk of falls. The care plan was initiated on 07/25/22. Interventions to prevent the falls from occurring included providing therapy as per plan, encouraging the resident to use call lights for transfers/ ambulation assistance, identifying non-compliance with safety issues and report to the physician as needed, and observe the resident in his room for safety needs when passing the room and re-directing for safety as needed. The resident also had a care plan for behaviors that included non-adherent with care/ services. He displayed behaviors of self transferring and was non-compliant with allowing assistance from staff. A review of the resident's fall events revealed he had had nine falls in the past four months with two falls occurring in April, four falls in May and three falls in June 2022. His last fall was on 06/18/22. All falls were the result of unassisted transfers. He did not sustain any major injuries as a result of those falls. Two of the falls (05/07/22 and 06/18/22) revealed immediate safety approaches taken after the fall included the use of non-skid strips to the floor. With the fall on 05/07/22, non-skid strips were to be added to the floor by his bed. With the fall on 06/18/22, non-skid strips were to be applied to the floor in front of the toilet in his bathroom. On 08/02/22 at 3:10 P.M., an observation of Resident #5's room revealed he did not have any non-skid strips applied to the floor by his bed or in front of the toilet in his bathroom. Findings were verified by Registered Nurse (RN) #37. On 08/02/22 at 3:12 P.M., an interview with RN #37 revealed Resident #37 used to reside on the 200 hall before he was moved to his current room on the 100 hall. He was moved to the 100 hall during the facility's Covid-19 outbreak following his exposure to someone with Covid-19. Further review of Resident #5's medical record confirmed he had been moved from room [ROOM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 2 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 0657 Level of Harm - Minimal harm or potential for actual harm NUMBER]-1 to his current room on the 100 hall on 07/24/22. His fall prevention interventions for the use of non-skid strips to the floor by the bed and on the floor in front of the toilet was not carried over to his new room when he was moved on 07/24/22. His at risk for falls care plan was not revised to reflect the addition of non-skid strips to his floor as a fall prevention intervention following the falls that occurred on 05/07/22 and 06/18/22. Residents Affected - Few On 08/03/22 at 12:00 P.M., an interview with RN #45 confirmed the resident's fall prevention interventions were to include the use of non-skid strips to the floor by the bed and in front of the toilet. She acknowledged he did not have any non-skid strips on his floor by the bed or in front of his toilet in his current room. She confirmed the use of the non-skid strips were added as fall prevention interventions following the falls occurring on 05/07/22 and 06/18/22. She also confirmed the resident did have a recent room change and those fall prevention interventions for the use of non-skid strips did not get carried over to his new room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 3 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 Based on observation, record review and interview, the facility failed to ensure timely intervention for constipation and assessment and treatment orders for a leg wound. This affected three (Resident's #16, #19 and #28) of 15 residents reviewed. Residents Affected - Few Findings include: 1. Review of Resident #16's medical record revealed a 10/29/21 admission with diagnoses including cachexia, hypertension, hypothyroidism, gastro-esophageal reflux disease, vitamin D deficiency, osteoarthritis, diverticulitis, slow transit constipation, mild protein calorie malnutrition, and altered mental status. Review of a 11/19/21 plan of care for constipation related to medications and decreased mobility included the resident will have a soft formed bowel movement at least every three days. Interventions included to administer medications as ordered and observe for bowel movement every three days. Review of the 05/16/22 Significant Change MDS revealed the resident was moderately impaired for daily decision making, extensive assist of two for bed mobility, transfer, did not walk, extensive assist of one for dressing, toilet use, personal hygiene, and totally dependent of one for bathing. The resident was on hospice care. Interview 08/01/22 at 3:24 P.M. with Resident #16 included she has been having constipation issues since arrival and doesn't go very often. She would like to sit on toilet but they said I can't since I can't stand on one leg. Review of the physician orders included as needed orders dated 11/21/21 for Milk of Magnesia, a laxative, 400 milligrams (mg)/5 milliliter (ml) give 30 ml oral once a day as needed for constipation, Miralax, a laxative, 17 Grams (GM) daily as needed for constipation was ordered 05/11/22, a 06/06/22 order for Bisacodyl, a laxative, delayed release delayed release (DR)/enteric coated (EC) 5 milligrams (mg)/ give 10 mg daily as needed for constipation and a 06/29/22 order for Bisacodyl 10 milligram (mg) suppository rectally give daily as needed for constipation. Review of the Point of Care bowel movement record and progress notes revealed the resident had a large bowel movement on 06/07/22. There was no evidence of another bowel movement until 06/20/22, 13 days later, when the resident had a small bowel movement. Review of the as needed medications revealed as needed medication for constipation was not administered when the resident went 13 days without a bowel movement (06/07/22-06/20/22). There was not a bowel movement documented between 06/20/22 and 06/30/22. On 06/20/22 the resident had a small bowel movement. On the seventh day of no bowel movement 06/27/22 the resident received Bisacodyl 5 mg tablet without result. On 06/29/22 Bisacodyl 5 mg was administered. The resident had a small bowel movement 06/30/22 resulting in three bowel movements in the 23 day period. The resident had a small bowel movement 07/29/22. There was no evidence of a bowel movement between 07/29/22 and 08/05/22. On 08/03/22, the fifth day without a bowel movement, Bisacodyl was administered without effect. Interview 08/03/22 at 5:29 P.M. with Registered Nurse (RN) #45 revealed the facility does not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 4 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 Residents Affected - Few a bowel protocol. The nurses were to call the physician if an intervention was needed but they did not have a policy on what day without a bowel movement the doctor was to be called. Interview 08/04/22 at 2:30 P.M. with RN #45 revealed she did not find any documentation of the resident having a bowel movement on days that were not documented in the bowel movement record. She verified there was no evidence in the seven, 10 and 13 days without a bowel movement of intervention on the fourth day. RN #45 included the expectation would be to intervene after three days without a bowel movement. 2. Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia. Review of the 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet. Observation 08/01/22 at 11:31 A.M. with Resident #19 revealed the resident had an undated dressing to left shin. Observation of Resident #19 on 08/02/22 at 2:01 P.M. revealed an open area to her left shin without a dressing. Review of Resident #19's record revealed there was not an order for a dressing to the left shin. There was not an assessment of the wound to the left shin. Interview on 08/02/22 at 2:03 P.M. with State Tested Nurse Aides (STNA) #1 and #46 revealed the resident was dressed when they arrived. They said she did not have a dressing on her shin this morning. Interview on 08/02/22 at 2:05 P.M. with RN #43 verified there was an open area on the resident's left shin without a dressing. She said she did not know about it. Review of the progress notes revealed on 08/02/22 at 3:09 P.M. the state nurse pointed out an open area on the left shin of Resident #19. The area was covered with a dry clean dressing and a message left for the nurse practitioner. On 08/02/22 the facility obtained an order to cleanse left shin with normal saline, pat dry, apply xeroform gauze and secure with dry dressing daily and as needed for loose or soiled dressing. A plan of care was initiated 08/02/22 for a diabetic ulcer to left shin. Review of a 08/04/22 progress note included a venous ulcer to left anterior shin. No signs of infection. No edema. Vascular staining to bilateral lower extremities. Wound margins are irregular. Fibrinous tissue noted to wound bed. Wound periphery intact with minimal localized erythema. No warmth. No drainage. Continue wound care as ordered. An albumin and pre-albumin ordered. Interview 08/04/22 at 11:42 A.M. with RN #45 verified Resident #19's record had no mention of a wound area on the shin or dressing application. RN #45 does not know who put a bandage on without documenting the area or getting a dressing order. 3. Review of Resident #28's medical record revealed a 12/28/21 readmission with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 5 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 Residents Affected - Few intestinal obstruction, intestinal bypass and anastomosis status, muscle weakness, abnormal posture, need for assistance with personal care, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, paroxysmal atrial fibrillation, anemia, unspecified, dysphagia oral phase, emphysema, mild intermittent asthma with status asthmatics, hyperlipidemia, hypothyroidism, vitamin D deficiency, vitamin B deficiency, major depressive disorder, generalized anxiety disorder, anorexia, osteoarthritis, osteoporosis, dementia without behavioral disturbance, hypokalemia, and gastro-esophageal reflux disease. Review of a 10/26/21 plan of care for constipation related to medications and decreased mobility included the resident will have a soft formed bowel movement at least every three days. Interventions included to administer medications as ordered and observe for bowel movement every three days. Review of the 06/14/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, had little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired with little energy, poor appetite, hallucinations, extensive assist of one for bed mobility, transfers, dressing, personal hygiene, limited assist of one for walking in room, and extensive assist of two for toilet. The resident had one fall with major injury since last assessment. The resident was on antidepressant, antianxiety, and opiod medications. The resident was at risk for pressure ulcers and had a skin tear. She utilized pressure reducing devices for bed and chair, application of non surgical dressing and application of ointments and medications. Review of the physician orders included orders dated 01/07/22 for Senna Plus, a stool softener, 8.5/50 mg twice a day for chronic constipation, 02/03/23 for Colace, a stool softener, 100 mg twice a day for constipation and a 05/05/22 order for Bisacodyl a laxative, delayed release delayed release (DR)/enteric coated (EC) 5 milligrams (mg) daily as needed for constipation. Review of the Point of Care bowel movement record and progress notes revealed the resident a large bowel movement on 06/07/22. There was no evidence of another bowel movement until 06/13/22, six days later, when the resident had a small bowel movement. Review of the as needed medications revealed as needed medication for constipation was not administered when the resident went six days without a bowel movement. Email notification on 08/09/22 at 9:18 A.M. with the Administrator provided no evidence of a bowel movement or as needed medication for constipation between 06/07/22 and 06/13/22. There was no evidence of intervention after three days without a bowel movement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 6 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 record review, observation, staff interview, and policy review, the facility failed to ensure pressure ulcers were adequately assessed to identify the correct staging of the pressure ulcer, failed to ensure a laboratory test and supplements recommended by the wound physician were implemented for wound healing, and a resident identified as being at risk for pressure ulcers had appropriate skin prevention interventions in place to help reduce the risk of pressure ulcers from developing. This affected two (Resident #35 and #93) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: 1. A review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a fracture of the right femur at the femoral neck, a history of a stroke with hemiparesis and hemiplegia of the right dominant side, muscle weakness, and difficulty walking. The resident was admitted to the facility with a stage II pressure ulcer (a pressure ulcer that presents as a shallow open crater or a fluid filled blister) on her coccyx. A review of a wound grid observation dated 06/24/22 revealed Resident #35 was indicated to have a stage II pressure ulcer on her coccyx that measured 3 centimeters (cm) x 3 cm with a depth unable to be determined. A description of the wound surface revealed there was a dark area to the coccyx that was not open. The wound was assessed by Licensed Practical Nurse (LPN) #13. A subsequent assessment of the coccyx wound was completed on 06/27/22 that indicated the wound had been resolved/ healed. A review of a wound grid observation dated 07/14/22 revealed Resident #35 was again noted to have a stage II pressure ulcer to her coccyx that originated on that date. The wound measurements were 1.4 cm x 2 cm x 0.1 cm. The wound surface description indicated the wound bed had 75% slough (dead tissue that is found in a full thickness wound and usually a cream or yellow color) and 25% eschar (necrotic tissue that is dryer than slough and tan, brown or black in color) despite a depth of 0.1 cm being recorded for the pressure ulcer. A wound grid observation dated 07/18/22 revealed Resident #35's pressure ulcer to her coccyx was assessed as being a stage III pressure ulcer (full thickness skin loss in which adipose tissue was visible in the ulcer and granulation tissue and rolled wound edges were often present; if slough or eschar obscured the extent of tissue loss, that was an unstageable pressure ulcer). The pressure ulcer measured 1.4 cm x 1.6 cm with a depth not able to be determined. The wound bed was indicated to have been covered with 50% slough. Subsequent assessments of the resident's pressure ulcer on her coccyx completed on 07/25/22 and 08/01/22 continued to classify the wound as a stage III pressure ulcer despite no depth being able to be recorded. Those assessments indicated the wound surface had 20% slough present. A review of an initial wound evaluation and management summary revealed Resident #35 was seen by a wound physician on 07/25/22. The wound physician recommended the resident have a pre-albumin level (a blood test that measures protein levels in your blood to determine malnutrition and the need for protein supplementation) drawn, and to receive a multivitamin (MVI) once daily, Vitamin C 500 milligrams (mg) twice a day, and Zinc Sulfate 220 mg by mouth once daily for 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 7 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #35's physician's orders revealed no evidence of the resident being placed on a MVI, Vitamin C or Zinc Sulfate as recommended by the wound physician on 07/25/22 to help promote wound healing. The medical record also provided no documented evidence of the resident's pre-albumin level being checked as recommended by the wound physician. A review of Resident #35's medication administration record (MAR) for July and August 2022 confirmed there was no evidence of the resident receiving a MVI, Vitamin C or Zinc Sulfate x 14 days as recommended by the wound physician that evaluated her pressure ulcer on 07/25/22. Findings were verified by the Director of Nursing (DON). On 08/04/22 at 2:45 P.M., an interview with the DON revealed the facility's wound nurse was not working that day. She was asked to review Resident #35's wound grid observations for her pressure ulcer to the coccyx from 06/24/22- 06/27/22 and 07/14/22 to present. She confirmed the resident's pressure ulcer that she had upon admission did resolve and re-opened on 07/14/22. She acknowledged the pressure ulcer was not adequately assessed on 06/24/22, when it was classified as a stage II pressure ulcer. She confirmed the wound surface description indicated there was a dark area to the coccyx that was not open. She stated based on that, the pressure ulcer should have been classified as a suspected deep tissue injury and not a stage II pressure ulcer. She then acknowledged the wound assessment dated [DATE] was not accurate as the pressure was classified as a stage II pressure ulcer with a depth of 0.1 cm. while the wound surface description indicated there was 75% slough and 25% eschar present. She agreed, based on the description of the wound bed, the pressure ulcer should have been considered an unstageable pressure ulcer at that time. She was then asked about the assessment completed on 07/18/22 that identified the wound as a stage III pressure ulcer with a depth of the wound not able to be determined. The wound surface was indicated to have been filled with 50% slough. She acknowledged, if the wound bed was covered with 50% slough and a depth was not able to be determined, the wound should have still been classified as an unstageable pressure ulcer. The assessment on 07/25/22 considered the wound to be a stage III pressure ulcer that had 20% slough and 80% epithelization. The depth of the wound was indicated not to be able to be determined. She agreed based on the wound assessment the wound should have been assessed as an unstageable pressure ulcer due to the 20% slough present causing them not to be able to determine the depth of the wound bed. She confirmed she was the nurse who assessed the resident's wound on 07/25/22. The wound physician had looked at it and she only documented what he was reporting. She confirmed, with where the 20% slough was located in the wound bed, they were not able to determine the full depth of the wound. Based on that, she stated it should have been an unstageable pressure ulcer. They could not determine if it was a stage III or stage IV pressure ulcer under the area covered by slough as they could not tell if adipose tissue was present or if bone, tendon, or muscle could be seen. The DON also confirmed the recommendation made by the wound physician (when he visited on 07/25/22) was not carried through with. A pre-albumin level had not been checked and the resident was not started on those medications recommended to help promote wound healing. On 08/04/22 at 4:30 P.M., an interview with Registered Nurse (RN) #45 revealed the facility's DON usually made rounds with the visiting wound physician. She stated the physician would have informed her of any recommendations made as a result of his visit. She reported the wound physician did not share those recommendations verbally with the DON. The recommendations were included on his visit report that they would have received the same day. A nurse should have recognized those recommendations were made in that report and should have written them as orders to be carried out. 2. A review of Resident #93's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, dementia, peripheral vascular disease (PVD) and muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 8 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 weakness. Level of Harm - Minimal harm or potential for actual harm A review of Resident #93's admission assessment completed 07/20/22 revealed a Braden risk assessment was completed as part of the assessment and identified him as being at risk for pressure ulcers. Risk factors included his skin occasionally being moist from exposure to urine, being chair fast, having very limited mobility, and the potential for friction and shearing. He was also known to have PVD and edema. He had calluses at the time of his admission but was not noted to have any known pressure ulcers present upon admission. Residents Affected - Few A review of Resident #93's admission Minimum Data Set (MDS) assessment completed on 07/27/22 revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he known to reject care. He required an extensive assist of two for bed mobility, transfers and ambulation in her room. He was identified as being at risk for pressure ulcers but did not have any unhealed pressure ulcers at the time the assessment was completed. Skin and ulcer treatments indicated to have been implemented was the use of pressure reduction devices for his bed and chair. A review of Resident #93's care plans revealed he had a care plan in place for being at risk for skin breakdown related to impaired mobility, impaired cognition, PVD, and friction/ shearing concerns. The goal was for him not to develop skin breakdown. The interventions included the use of a pressure re-distribution cushion. The care plan and the use of the pressure reduction cushion was initiated on 08/02/22. On 08/01/22 at 3:01 P.M., an observation of Resident #93 noted him to be sitting up in his wheelchair in his room. He was a little restless in his chair and reported his buttocks was sore. He was not noted to have a cushion under him while sitting in the wheelchair. On 08/02/22 at 1:35 P.M. and again on 08/03/22 at 10:44 A.M., observations of Resident #93 noted him to again be sitting up in his wheelchair in his room without any pressure reduction cushions in place under his buttocks. He continued to report his buttocks were sore. On 08/08/22 at 4:07 P.M., an interview with Licensed Practical Nurse (LPN) #13 revealed she did not consider Resident #93 to be at risk for pressure ulcers despite his Braden risk assessment identifying him as being at risk. She denied he had any current pressure ulcers and was known to get up and moved around. She reported the resident had the use of a pressure reduction cushion when up in his wheelchair. She confirmed he was either in bed or up in his wheelchair when she was there. On 08/08/22 at 4:10 P.M., an interview with State Tested Nursing Assistant (STNA) #11 revealed she usually seen Resident #93 up in his wheelchair in the afternoons when she was there. She denied he was ever on a pressure reduction cushion when she seen him up in his wheelchair. They did offer to put a pillow behind his back but he usually declined. On 08/08/22 at 4:15 P.M., Registered Nurse (RN) #37 was asked to assess Resident #93's buttocks due to him complaining of it being sore when he was sitting up in his wheelchair. She observed his bilateral inner buttocks to be reddened but was still blanchable. She confirmed the resident was considered to be at risk for pressure ulcers. He was known to go back and forth between his bed and wheelchair. She was not aware of the resident was supposed to have a pressure reduction cushion under his buttocks when up in his wheelchair as part of his skin prevention interventions. She verified he did not have a pressure reduction cushion present in his wheelchair or anywhere else in his room. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 9 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete acknowledged his at risk for pressure ulcer care plan did include the use of a pressure reduction cushion to his chair. She questioned why that was on his care plan as one of his skin prevention intervention even though he was considered to be at risk for the development of pressure ulcers, sat up in his wheelchair during the day and had limited mobility. She stated the facility's offsite MDS nurse added that to his care plan but she did not know why. She acknowledged the resident verbalized his buttocks were sore when sitting in his wheelchair and the pressure reduction cushion would be beneficial for added padding. Event ID: Facility ID: 366128 If continuation sheet Page 10 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 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, record review, policy review, and staff interview, the facility failed to have fall interventions in place. This affected three residents (#5, #10 and #28) of four residents reviewed for falls. Findings include: 1. Review of Resident #10's medical record revealed a 09/18/21 admission with diagnoses including metabolic encephalopathy, syncope and collapse, acute respiratory disease, muscle weakness, difficulty in walking, muscle wasting and atrophy, Type 2 diabetes mellitus with hyperglycemia, cardiac arrhythmia's, hypertension, Vitamin D deficiency, hypocalcemia, benign prostatic hyperplasia, emphysema, major depressive disorder, anxiety disorder, diverticulosis of intestine, and irritable bowel syndrome. The resident had a 10/12/21 risk for fall plan of care related to behaviors, history of falls, medications including anxiolytic's, antidepressants, antihypertensive's, and diabetes. Interventions included on 02/14/22 to place a sign in room to remind to get assistance with footwear, 06/12/22 to place a sign in the bathroom to ask for assistance with transfers, and 07/16/22 to place sign in room to use call light for assistance with transfers. Review of the medical record for Resident #10 revealed falls on 10/29/21, 01/03/22, 01/23/22, 02/01/22, 02/13/22, 02/19/22, 03/21/22, 04/06/22 (resulting in a fractured elbow), 06/12/22, and 07/16/22. Review of the 05/03/22 quarterly MDS revealed the resident was independent for daily decision making, required extensive assist of two for bed mobility and transfer, supervision of two to walk in room, did not walk in corridor, and had one fall with major injury and one fall with no injury since the last assessment. Resident #10 was moved to a private room [ROOM NUMBER]/22/22 after testing positive for COVID-19. Observation 08/02/22 at 10:26 A.M. revealed Resident #10 did not have any signage in his room or bathroom related to fall safety measures. Observation of Resident #10's prior room revealed a sign to ring for call light, and please ask a staff member to help you with footwear. The bathroom did not have a sign related to safety. Interview 08/02/22 at 3:27 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #45 verified there was no signage in the room with Resident #10 after he was moved to a private room as care planned. 2. Review of Resident #28's medical record revealed a 12/28/21 admission with diagnoses including intestinal obstruction, intestinal bypass and anastomosis status, Muscle weakness, Abnormal posture, need for assistance with personal care, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, paroxysmal atrial fibrillation, anemia, unspecified, dysphagia oral phase, emphysema, mild intermittent asthma with status asthmatics, hyperlipidemia, hypothyroidism, vitamin D deficiency, vitamin B deficiency, major depressive disorder, generalized anxiety disorder, anorexia, osteoarthritis, osteoporosis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 11 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 dementia without behavioral disturbance, hypokalemia, and Gastro-esophageal reflux disease. Level of Harm - Minimal harm or potential for actual harm Review of Resident #28's 10/26/21 Risk for Falls/Injury related to history of falls, incontinence of bowel and urine, anxiolytic, antidepressant, antihistamine, antihypertensive, laxative and narcotic medications plan of care revealed the 06/08/22 intervention to place a sign as a reminder to ask for assistance was not included as an intervention on the plan of care. Residents Affected - Few Review of the 06/08/22 Fall with Injury Event included Resident #28 was out of bed ambulating without assistance, fell and fractured her wrist. The immediate safety approach was to place sign as a reminder to ask for assistance. Review of the 06/14/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, had little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired with little energy, poor appetite, hallucinations. Resident #28 required extensive assist of one for bed mobility, transfers, dressing, personal hygiene, limited assist of one for walking in room, and extensive assist of two for toilet. The resident had one fall with major injury since last assessment. The resident was on antidepressant, antianxiety, and opiod medications. The resident was at risk for pressure ulcers and had a skin tear. She utilized pressure reducing devices for bed and chair, application of non surgical dressing and application of ointments and medications. Observation 08/01/22 at 2:56 P.M. of Resident #28's room revealed no signage related to safety posted. On 08/03/22 at 8:31 A.M. interview with Resident #28 revealed someone put a sign up in her room that morning to please ask for assistance. Observation revealed a sign in the room and bathroom to ask for assistance. Interview 08/03/22 at 11:03 A.M. with Registered Nurse (RN) #45 revealed the facility started a quality assurance and performance improvement plan (QAPI) 08/02/22 after the surveyors found fall interventions not in place. They identified the signage in the room which was the intervention for the 06/08/22 fall was not on the plan of care. The intervention was added to the plan of care 08/03/22. She did not know who put the signs up. The signs were not there on 08/01/22 and the resident said the signs were hung that morning. Review of the facility's Fall Investigation policy dated 06/03/19 included an immediate safety intervention will be implemented. A Change in Plan of Care Communication Form will be initiated. 3. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included seizure disorder, congestive heart failure, history of a stroke with hemiparesis (weakness) and hemiplegia (paralysis) affecting the right dominant side, dementia with behavioral disturbances, muscle weakness, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, need for assistance with personal care, abnormal posture and repeated falls. A review of Resident #5's quarterly Minimum Data Set (MDS) assessment completed on 04/19/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to have any behaviors but was known to reject care one to three days of the seven day assessment period. He required an extensive assist of two for bed mobility, transfers, dressing and toilet use. Balance issues were noted during transitions and walking and he was only able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 12 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 stabilize himself with staff assistance. He was not indicated to have had any falls since his admission or prior assessment and was not known to have any falls prior to his admission. A review of Resident #5's care plans revealed he had a care plan for being at risk for falls related to behaviors, confusion, history of falls, incontinence, impaired gait stability and medications that increased the risk of falls. The care plan was initiated on 07/25/22. Interventions to prevent the falls from occurring included providing therapy as per plan, encouraging the resident to use call lights for transfers/ ambulation assistance, identifying non-compliance with safety issues and report to the physician as needed, and observe the resident in his room for safety needs when passing the room and re-directing for safety as needed. The resident also had a care plan for behaviors that included non-adherent with care/ services. He displayed behaviors of self transferring and was non-compliant with allowing assistance from staff. A review of Resident #5's fall events revealed he had had nine falls in the past four months with two falls occurring in April, four falls in May and three falls in June 2022. His last fall was on 06/18/22. All falls were the result of unassisted transfers. He did not sustain any major injuries as a result of those falls. Two of the falls (05/07/22 and 06/18/22) revealed immediate safety approaches taken after the fall included the use of non-skid strips to the floor. With the fall on 05/07/22, non-skid strips were to be added to the floor by his bed. With the fall on 06/18/22, non-skid strips were to be applied to the floor in front of the toilet in his bathroom. On 08/02/22 at 3:10 P.M., an observation of Resident #5's room revealed he did not have any non-skid strips applied to the floor by his bed or in front of the toilet in his bathroom. Findings were verified by Registered Nurse (RN) #37. On 08/02/22 at 3:12 P.M., an interview with RN #37 revealed Resident #5 used to reside on the 200 hall before he was moved to his current room on the 100 hall. He was moved to the 100 hall during the facility's Covid-19 outbreak following his exposure to someone with Covid-19. Further review of Resident #5's medical record confirmed he had been moved from room [ROOM NUMBER]-1 to his current room on the 100 hall on 07/24/22. His fall prevention interventions for the use of non-skid strips to the floor by the bed and on the floor in front of the toilet was not carried over to his new room when he was moved on 07/24/22. His at risk for falls care plan was not revised to reflect the addition of non-skid strips to his floor as a fall prevention intervention following the falls that occurred on 05/07/22 and 06/18/22. On 08/03/22 at 12:00 P.M., an interview with RN #45 confirmed the resident's fall prevention interventions were to include the use of non-skid strips to the floor by the bed and in front of the toilet. She acknowledged he did not have any non-skid strips on his floor by the bed or in front of his toilet in his current room. She confirmed the use of the non-skid strips were added as fall prevention interventions following the falls occurring on 05/07/22 and 06/18/22. She also confirmed the resident did have a recent room change and those fall prevention interventions for the use of non-skid strips did not get carried over to his new room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 13 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to obtain laboratory testing as ordered to monitor medication use. This affected two Residents (#19 and #31) of five residents reviewed for unnecessary medication. Residents Affected - Few Findings include: 1. Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia. Physician orders included atorvastatin 40 mg daily for high cholesterol and magnesium oxide 400 mg twice a day, both ordered 06/27/21. Review of a 01/04/22 pharmacy recommendation included to add a lipid panel, Vitamin D level and Magnesium yearly. The recommendation was accepted on 01/06/22 to add the orders to the February, 2022 laboratory draw with the HGBA1C. Review of the physician orders revealed the order was entered 01/06/22 for a lipid profile, Vitamin D level and Magnesium on the second monday of every 12th month. Review of the 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet. The resident received antianxiety, antidepressant, and insulin medications. Review of the laboratory reports revealed no evidence of the lipid, Vitamin D and magnesium levels being drawn in February, 2022 per physician accepted pharmacy recommendation. Review of a 07/28/22 physician progress note included the lipid level was to be monitored for hyperlipidemia. On 08/08/22 at 5:07 P.M. the Administrator acknowledged the facility had not obtained Resident #19's lipid, magnesium and Vitamin D levels laboratory testing. 2. Review of Resident #31's medical record revealed a 09/05/19 admission with diagnoses including multiple sclerosis, diabetes, hyperlipidemia, anxiety disorder, hypertension, Schizoaffective disorder, and osteoarthritis. Physician orders included a 06/10/20 order for atorvastatin 10 mg daily for high cholesterol, 07/10/20 order for magnesium oxide 400 mg once a day, and a 10/21/21 lipid profile and magnesium order on the second monday of the 12th month. Review of Resident #31's 07/12/22 annual MDS revealed the resident was independent for daily decision making, little interest, feels down, trouble sleeping, little energy, poor appetite, hallucinations and delusions, receives scheduled pain medication, and as needed. The resident took antipsychotic, antianxiety, antidepressant, anticoagulant, antibiotic, diuretic, and opiod medications. On 02/08/22 the physician documented gradual dose reduction was clinically contraindicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 14 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 0757 Level of Harm - Minimal harm or potential for actual harm Review of Resident #31's medical record revealed no evidence of the lipid profile or magnesium level testing as ordered. On 08/10/22 at 9:35 A.M. , during interview the Administrator acknowledged the facility had not obtained the lipid profile and magnesium level as ordered Resident #31. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 15 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all the residents in the facility except Residents #29 and #93 who did not receive nutrition from the kitchen. The facility census was 43. Findings include: Initial tour of the kitchen 08/01/22 at 8:45 A.M. revealed the following; 1. The ice machine had brown slimy film on the lip of the shoot. The slimy film wiped off with a paper towel. There was dried white debris around the door seal and lid. 2. In the dry storage, breadcrumbs were opened and not dated. 3. The vents above the range top and grill were dusty. There were grease traps on each side of the vents. The trap on the left had blowing dust stringing out an inch long. 4. The ansel system above the rangetop and griddle had dust going up the piping and on the red spray covers. 5. The lights above the griddle and range cooking surface were dusty. 6. The tops of the convention oven and the steamer were dusty, with a greasy texture and crumbs. 7. The reach in refrigerator had six rusty shelves. The top left shelf was peeling white paint. Interview 08/01/22 at 9:07 A.M. with Dietary Coordinator #9 verified the dust on the vents, grease trap, lights, convection oven, and steamer. Further interview verified the rusty and peeling shelves in the reach in refrigerator and undated bread crumbs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 16 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy and interview, the facility failed to ensure personal protective equipment (PPE) and surfaces were sanitized when leaving isolation rooms, isolation linens and personals were washed in a sanitary manner, and a urinary collection bag was maintained off the floor. This affected Residents #17, #25, #28, #34, and #92. This had the potential to affect all the residents in the facility. Residents Affected - Many Findings include: 1. Observation 08/01/22 12:05 PM of the lunch meal revealed State Tested Nurse Aide (STNA) #46 gowned, gloved and had an N-95 mask and goggles on when she delivered a tray to Resident #28 (this resident was in quarantine for exposure to COVID-19). Upon exiting the room, STNA #46 removed the PPE, except for goggles. STNA #46 used hand sanitizer and donned another N-95 mask, walked down the hall, and turned right down the hall. STNA #46 did not sanitize her goggles after leaving the quarantine room. Interview 08/01/22 at 12:09 P.M. with STNA #46 verified she did not clean her goggles when she exited the quarantine room. On 08/01/22 at 12:12 P.M. observation revealed STNA #12 exited Resident #34's room (this resident was positive for COVID-19). STNA #12 set her goggles on the isolation bin outside the room, donned a N-95 mask, picked up the goggles, and cleaned them with an alcohol pad. Once STNA #12 donned the goggles, she was leaving the area without cleaning the top of the isolation bin where she had set the potentially contaminated goggles. On 08/01/22 at 12:15 P.M. interview with STNA #12 verified she did not clean the top of the isolation bin after setting her goggles on it when she exited the room. On 08/01/22 at 12:17 P.M. observation revealed STNA #46 donned PPE gown, gloves and already had on a N-95 mask and goggles. STNA #46 took a lunch tray into the quarantine room of Residents #17 and #25 (these residents were in quarantine due to being unvaccinated and the facility being in outbreak mode for positive cases). STNA #46 exited the room with PPE doffed and set her goggles on the isolation bin outside the room, donned a N-95 mask, picked up the goggles and cleaned them with an alcohol pad. Once STNA #46 donned the goggles, she was leaving the area without cleaning the top of the isolation bin where she had set the potentially contaminated goggles. On 08/01/22 at 12:20 P.M. during interview, STNA #46 verified she did not clean the top of the isolation bin after setting her goggles on it when she exited the room. Review of the facility's Coronavirus (COVID-19) Protocol dated 06/22/22 included eye protection will be cleaned when exiting a residents room when in quarantine/isolation room; recommend supply care givers with two sets of eye protection and paper bags, doff and clean eye protection when exiting the room and place in bag, don the second pair of eye protection, and rotate between the two pieces of eye protection each time exiting a resident room. 2. Observation and interview 08/10/22 at 1:14 P.M. with Laundry Worker #2 included builder break, emulsifier detergent, stainer, cl de-iron, and softener were the products used for washing. Laundry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 17 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 Worker #2 revealed for isolation linen she uses cycle 2/1 (the linens cycle) and isolation personals on cycle 2/3 (no bleach). Observation revealed the Intercon wall sign, indicating which cycle to use for specific types of laundry, indicated cycle 2/7 was to be used for isolation. The first number was the washer program and second number the pump program. Laundry Worker #2 indicated she did not use the cycle 2/7 listed for isolation. She stated she had not been taught to use the cycle. Residents Affected - Many Interview 08/10/22 at 2:57 P.M. with Intercon Employee #47 revealed cycle 2/7 for isolation had a boat load of chemicals: 4.5 ounces of Break, 1.5 ounces of emulsifier detergent, 4.5 ounces of bleach and 0.8 ounces of both neutralizer and softener. For COVID-19 and isolation much heavier chemicals are used. The cycle 2/1 was 3.0 ounces of Break which breaks down linens for better suds, 3.0 ounces of detergent, 3.0 ounces of bleach, 1.5 ounces of both neutralizer and softener. On 08/10/22 at 3:42 P. M . during interview Intercon Employee #47 indicated there were no kill rates for the laundry products with no indication of what they kill. Review of the facility's water temperature sheet for August of 2022 indicated the water temperature at the riser which feeds the laundry was 120 degrees Fahrenheit. Interview 08/10/22 at 3:55 P. M with Maintenance #35 revealed the laundry did not have a water temperature booster. Interview 08/10/22 at 4:59 P.M. with Laundry Worker #2 included she receives the isolation linens and personals from a red bin left outside. The bin is lined with a clear bag. It is filled with individual clear bags of linen or personals. She indicated staff wheel the bins outside instead of through the building and leave it next to the transport van. She periodically looks outside to see if there is a red bin. She indicated the bin would be located 20-30 feet from the door in the parking lot. She did not know of any safety measures to prevent someone from opening the bin outside. Review of Center for Medicare regulation includes the facility should be using the fabric manufacturer's recommended laundry cycles, water temperatures and chemical detergent products: - Recommendations for laundry processed in hot water temperatures is 160ºFahrenheit (71ºCelsius) for 25 minutes; and - For laundry that is not hot water compatible, low temperature washing at 71 to 77 ºF (22-25 ºC) plus a 125-part-per-million (ppm) chlorine bleach rinse has been found to be effective and comparable to high temperature wash cycles. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy (updated 11/2020) included it is the facility's policy to provide a process for the safe and clean handling washing and storage of linen. To minimize possible contamination of the environment use individualized red plastic bags when gathering linens from the residents with infections or colonization with multi drug resistant organisms such as methicillin-resistant staphylococcal aureus or vancomycin-resistant enterococci as necessary per Center for Disease Control guidelines including laundry/linen removed from an isolation room. Wash linen in water that is at least 140 degrees Fahrenheit for at least 25 minutes. Sodium hypochlorite, bleach, should be used on all colorfast loads in the amount of at least 1000 mL of a 1% solution for every 100 pounds of linen except in facilities that utilize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 18 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 ozone system. Level of Harm - Minimal harm or potential for actual harm 3. A review of Resident #92's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic urinary retention and a history of a malignant neoplasm of the kidney status post partial nephrectomy (removal of the kidney). Residents Affected - Many A review of Resident #92's physician's orders revealed the use of a 16 french indwelling urinary catheter to straight drain for the diagnosis of retention. They were to change the urinary drainage bag on the 15 th of every month and as needed. Urinary output was to be measured three times a day. A review of Resident #92's Minimum Data Set (MDS) assessments revealed his 5 day/ admission MDS assessment was still in progress. His baseline care plans were established as part of the clinical admission documentation assessment completed on 07/21/22. The section that addressed his genitourinary status revealed the resident was known to have an indwelling urinary catheter. The care plan section of the assessment revealed the use of an internal urinary catheter (Foley). Urinary catheter approaches included the need for staff to keep the urinary drainage bag covered per policy, below the level of his bladder and off the floor. On 08/01/22 at 4:35 P.M., an observation of Resident #92 revealed he was sitting up in his recliner by the bed. His indwelling urinary catheter drainage bag was noted to be sitting on the floor in between the recliner and the resident's bed. On 08/02/22 at 2:45 P.M., a follow up observation of Resident #92 noted him to be lying in bed in a supine position. His indwelling urinary catheter's drainage bag was on the right side of the bed towards the window. The drainage bag was noted to be in direct contact with the floor. Findings were verified by Registered Nurse (RN) #37. She was overheard advising Resident #92 that his indwelling urinary catheter's drainage bag could not be touching the floor. She asked the resident if he knew how the drainage bag got on the floor and he denied any knowledge of how it got there. She acknowledged indwelling urinary catheter drainage bags should not be placed on the floor to reduce the risk of urinary tract infections. She secured it up off the floor by hooking it to the resident's bed frame at the end of his bed. On 08/02/22 at 2:50 P.M., an interview with Resident #92 revealed he did not put himself in bed after being in his recliner as he was unable to do so. He stated he always asked for help when needing to get into and out of his bed. He reported a male staff member had helped him into bed and denied he transferred himself or placed his indwelling urinary catheter's drainage bag directly onto the floor. A review of the facility's urinary catheter care policy updated November 2019 revealed the staff were instructed to be sure the catheter tubing and drainage bag were kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 19 of 20 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure flu and pneumococcal vaccinations were offered. This affected one resident (Resident #19) of five residents reviewed for vaccines. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia. Review of Resident #19's 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet. Review of Resident #19's Preventative Health Care included the resident had a flu vaccine prior to admission [DATE]. There was no evidence the facility offered a flu vaccine after the 06/27/21 admission. The facility had no information for Resident #19 on a past history of receiving the pneumococcal vaccine. There was no evidence the facility offered a pneumococcal vaccine when admitted . On 08/09/22 at 9:55 A.M. during interview, the Administrator affirmed the facility could not locate a consent for acceptance or decline of the flu or pneumonia vaccine for Resident #19 since admission. Review of the facility's Influenza protocol (dated 11/2019) included the facility will offer an annual flu vaccine to the residents and staff between October and March of each year. The facility shall provide pertinent information about the significant risk and benefits of the vaccines to the staff, residents and residents authorized representatives. We will utilize the Vaccine Authorization Form and it will be filed in our medical records. All residents will be offered the flu vaccine annually. Current vaccine information given to the resident or authorized representation and acknowledgment of receipt completed annually. If residents have declined in prior years continue to offer the flu vaccine annually. Review of the facility's Pneumococcal vaccine policy (updated in 2022) revealed all residents will be offered pneumococcal vaccine to aid in preventing pneumococcal infections. Prior to admission residents will be assessed for eligibility to receive the pneumococcal vaccine PCV15, PCV20 and the pneumococcal PPSV23. Before receiving the pneumococcal vaccination the resident or authorized representative shall receive information, education regarding the benefit of an potential side effects of the pneumococcal vaccine. Residents and authorized representatives have the right to refuse the vaccine. If refused appropriate entries will be documented in the resident medical records indicating the date of refusal of the pneumococcal vaccine. If the resident or authorized representative refuses upon admission the facility will offer the vaccine on an annual basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 20 of 20