Inspection·August 26, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Self-Reported Incident (SRI) Tracking Number 261941, dated 06/23/25, revealed Resident #50 alleges she went too long without pain medication. Review of the investigation revealed a statement authored by Registered Nurse (RN) #152 that indicated on 06/22/25 into 06/23/25 she had walked over to the other unit approximately midnight to get medication and asked the Assistant Director of Nursing (ADON) for the medication room keys. The ADON stated she had given the keys to LPN #133. RN #152 went to ask LPN #133 for the medication keys, and she was observed on the couch in the day area covered up with a blanket, sleeping. RN #152 woke her up and she stated she didn't have the keys and went back to sleep. RN #152 told the ADON that LPN #133 stated she didn't have the keys. The ADON stated LPN #133 had the keys and they just had counted the narcotic drawer. RN #152 stated she returned to her unit and thought she would get the medication she needed later. The lab technician came over at approximately 3:30 A.M. and asked if there were labs on the other unit due to there being no log and the nurse was asleep, and she could not wake her. Both CNAs were present during the conversation. RN #152 had gone back to LPN #133's unit at 5:30 A.M. to get medication out of the medication room and LPN #133 had asked if lab had been there. LPN #133 reported she was unable to print the labs off the computer. RN #152 told LPN #133 she could have called her over and she could have printed them. LPN #133 stated I'm allowed to take a break. RN #152 returned to her unit. Review of a statement authored by Physical Therapist (PT) #999 dated 06/24/25 revealed Resident #50 had reported to PT #999 that LPN #133 had been sleeping for six hours, and she had to wait on her pain medication. Review of a statement authored by the Administrator via phone with CNA #503 on 06/25/25 at 12:14 P.M., revealed CNA #503 was called over to the 200 unit by CNA #888 to help with resident care around 3:00 A.M., on 06/23/25 and she had seen LPN #133 on the couch. CNA #503 returned to her unit. Sometime around 3:30 A.M. the lab tech reported to CNA #503 and #888 she saw someone sleeping on the couch and a resident was taking pictures. Review of CNA #144's statement dated 06/25/25 revealed the CNA had come in early around 1:30 A.M., the RN went over to the other unit to get some medication and reported she couldn't get LPN #133 up and the CNA had asked for help to pull a couple resident up because she couldn't get the LPN awake. Around 3:00 A.M., the lab tech asked if there were any labs because the nurse was asleep and she could not wake her up and there was a resident on the unit taking pictures. The CNA went back over to see what was going on. Review of LPN #133's timecard revealed the LPN worked 18.0 hours on 06/19/25, 12.75 hours on 06/20/25, 17.58 hours on 06/21/25, 11.75 hours on 06/22/25, 10.0 hours on 06/23/25.Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photos dated 06/23/25 at 1:38 A.M., 1:45 A.M. and 4:03 A.M. LPN #133 reported she took her break from 3:30 A.M. to 4:00 A.M. LPN #133 reported staff don't lock out for their 30-minute break. The time clock just asked if you took a break when you clock out and you enter yes or no. Interview on 08/26/25 at 6:43 A.M., with Licensed Practical Nurse (LPN) #148 revealed about four or five months ago she had observed LPN #133 sleeping on the unit. Interview on 08/26/25 at 12:06 P.M., with Assisting Director of Nursing (ADON) #131 confirmed LPN #133 had worked over 16 hours on 06/19/25 and 06/21/25.Interview on 08/25/25 at 1:33 P.M., with the DON, revealed staff don't always communicate with administration changes in schedule but LPN #133 picks up a lot of shifts. There was one other incident 7-8 months ago staff had reported LPN #133 sleeping, however she was not able to verify, nor did she document the incident or investigation. After the incident in June staff are not permitted to work over 16 hours. The DON confirmed LPN #133 had worked several 16-hour shifts in the last few days. The DON confirmed several staff had resigned due to the incident in June. Interview on 08/28/27 at 2:11 P.M., with Registered Nurse (RN) #600 revealed LPN #133 had been reported numerous times to Administration staff for sleeping, not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 2 of 5 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 08/26/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete administering medication as ordered, and not assessing residents. The DON and ADON tolerate her behavior because LPN #133 comes into work, so they don't have to. Review of the facility assessment undated revealed the average daily census was 47.3. The facility provides care and services to individuals with certain medical and cognitive disabilities. The facility care team reviews all referrals prior to admission to determine needed staff, equipment and supply resources to care for the potential admission. The facility's daily staffing was based on the resident's population and acuity taking into consideration staffing needs for each resident unit and shift.Review of LPN #133 job description dated 09/19/23 revealed the LPN would ensure quality resident care. Review of the Nurse Practice Act revealed it does not address employment matters, such as work schedules, nor does it establish limits on the number of hours a licensee may practice within a given period of time. However, nurses must be knowledgeable of the standards of nursing practice in Rule 4723-4-03, OAC (related to RN practice), and Rule 4723-4-04, OAC (related to LPN practice). These rules require RNs and LPNs to demonstrate competence and accountability in all areas of practice in which the nurse is engaged, which includes but is not limited to 1) consistent performance of all aspects of nursing care; and 2) appropriate recognition, referral or consultation and intervention when a complication arises. In addition, all nurses are required to maintain a safe environment for the patient. Rule 4723-4-06(H), OAC. Working under conditions of fatigue may not be safe for the nurse or the patient. A nurse who fails to demonstrate competence or does not provide consistent performance within his or her nursing practice as a result of excessive work hours, or for any other reason, will not have met standards of safe practice. This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308. Event ID: Facility ID: 366128 If continuation sheet Page 3 of 5 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 08/26/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received timely pain management. This affected one (Resident #50) of three residents reviewed for pain management. The census was 48. Findings include: Record review revealed Resident #50 admitted to the facility on [DATE] with diagnoses including anemia, hypertension, thyroid atrophy, hypomagnesemia, anxiety, and femur fracture with surgical intervention.Review of Resident #50 admission Minimum Data Set (MDS) section C for cognition revealed a Brief Interview for Mental Status Score of 15, indicating Resident #50 was cognitively intact.Review of MDS section J for health conditions revealed Resident #50 was receiving a scheduled pain medication regimen, and received as needed (PRN) pain medication.Review of Resident #50 care plan completed on 06/11/25 revealed Resident #50 has a left hip surgical wound. Goals include resident will have controlled pain and a level of comfort maintained daily. Interventions include to administer pain medications per physicians orders, remind the resident that reporting pain early may improve effectiveness of pain medication, try non medication relief measures such as repositioning pillows, pad, support, diversion, and observe and report if resident is experiencing breakthrough pain with current medication.Review of Resident #50 orders revealed an order starting 06/19/25 and ending on 06/23/25 for Oxycodone tablet 5 milligrams (mg) orally (PO) every four hours (q.4h) PRN.Review of grievance filed by Resident #50 on 06/23/25 with the Director of Nursing (DON) revealed Resident #50 wanted her pain medications more frequently.Review of event statement form completed on 06/24/25 by physical therapy assistant (PTA) #999 revealed Resident #50 had reported to her on the night of 06/22/25 into 06/23/25 she had waiting six hours for pain medicationReview of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M. and an eight and a half hour time from 7:47 P.M. until 5:21 A.M. on 06/23/25.Review of Resident #50 Medication Administration Record (MAR) for June of 2025 revealed Oxycodone 5mg PO q.4h PRN administered on 06/22/25 at 12:32 A.M., 4:28 A.M., 9:09 A.M., 1:13 P.M., and 7:47 P.M Resident #50 pain medication was given q.4h until 1:13 P.M. when there was a six and a half hour time between doses.Review of Resident #50 progress notes revealed a note dated 06/22/25 at 8:00 P.M. authored by assistant director of nursing (ADON) stating certified nurse ' s aides (CNA ' s) alerted this nurse that resident was upset, upon entering room Resident #50 demanded a pain pill stating it was due several hours ago. Let the resident know she was just then due to be able to get her PRN dose.Review of Resident #50 Narcotic log, MAR, and progress notes revealed they were due for their PRN dose on 06/22/25 at 5:13 P.M., not 8:00 P.M Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M Record review revealed no documentation of non-pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 1:13 P.M. 7:47 P.M. on 06/22/25.Review of Resident #50 June 2025 MAR revealed Oxycodone 5mg PO q.4h PRN was given on 06/22/25 at 7:47 P.M. and was not administer again until eight and a half hours later on 06/23/25 at 9 and a half hours later at 5:21 A.M.Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was an eight and a half hour time without pain medication from 7:47 P.M. until 5:21 A.M. on 06/23/25. After this time Resident Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 4 of 5 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 08/26/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #50 began receiving her pain medication every four hours as previous until discontinuation of the order. Record review revealed no documentation of non pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 7:13 P.M. on 06/22/25 and 5:21 A.M. on 06/23/25. Interview on 08/25/25 at 9:25 A.M. with certified nursing assistant (CNA) #888 revealed staff was telling Resident #50 her pain medication was due every eight hours however Resident #50 pain medication was due every four hours at that time. CNA #888 stated on 06/22/25 on night shift into 06/23/25 Resident #50 was upset because she had asked for pain medication several hours prior and still had not received any.Interview on 08/26/25 at 8:41 A.M. with ADON revealed Resident #50 wanted pain medication on 06/22/25, stated Resident #50 is very consistent with timing of her pain medication and knows when they are due.Interview on 08/26/25 at 12:36 P.M. with Resident #50 revealed on 06/22/25 on night shift she had requested pain medication, she had fell and broke something and had surgery on a couple weeks prior so she had been in a lot of pain. Resident #50 stated she requested the pain medication on night shift on 06/22/25, she waited several hours and no one brought her pain medication. Their pain continued to get worse as she waited and it got pretty bad due to how long they had been waiting. Resident #50 stated it was not until early morning sometime on 06/23/25 that she received her pain medication.Interview on 08/26/25 at 12:40 P.M. with ADON revealed on 06/22/25 at 8:00 P.M. she authored a note which stated Resident #50 pain medication was just then due. ADON confirmed on 06/22/25 Resident #50 pain medication was actually due at 5:13 P.M. approximately three hours prior to the resident being told it was due. ADON stated she did not get to the building until about 7:00 P.M. on 06/22/25. ADON confirmed after Resident #50 received pain medication from her on 06/22/25 at 7:47 P.M. Resident #50 did not receive pain medication again until 06/23/25 at 5:21 A.M., ADON stated she was not on the floor the entire night shift of 06/22/25. ADON stated Resident #50 was very on top of her pain medication, she always knew when it was due, and she took it right when it was due.Interview on 08/26/25 at 12:55 P.M. with PTA #999 revealed PTA #999 was assisting Resident #50 with therapy on 06/24/25 when Resident #50 had stated on the night of 06/22/25 into 06/23/25 she requested pain medication and had been waiting a long time, at least six hours. PTA #999 stated she immediately went to administration and filed a statement reporting what she had been told by resident #50.Review of Facility policy named Pain Medication Administration revised 05/21/25 revealed It is the facilities policy to administer pain medications in accordance with professional standards of practice. Review the residence care plan to assess for any special needs of the resident. The residents ' experience of pain is highly individual and subjective. Pain is whatever the resident says it is. Intense pain can result from even minor procedures or surgery. Not attempt nonpharmacological interventions as per the residence plan of care prior to administering pharmacological interventions if possible. Administer as needed pain medication as ordered.This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308. Event ID: Facility ID: 366128 If continuation sheet Page 5 of 5