Health inspection·September 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a care plan related to hospice needs and oxygen status for Resident #19 and did not implement a care plan for anticoagulant use for Resident #16. This affected two residents (#16 and #19) of 19 residents whose care plans were reviewed. The facility census was 35. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/24/23 with diagnoses including cachexia, dysphagia, malignant neoplasm of colon, hypertension, depression, chronic systolic heart failure, anxiety disorder, and actinic keratosis. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition. Review of the physician order dated 08/09/23 revealed Resident #19 was admitted to hospice care. Observation on 09/05/23 at 10:02 A.M. revealed Resident #19 had oxygen in place. Review of the plan of care revealed it was absent for hospice or oxygen use. Interview on 09/05/23 at 5:09 P.M. with the Director of Nursing (DON) verified Resident #19 was on oxygen and had not had a care plan for this prior to 09/05/23. Interview on 09/07/23 at 2:45 P.M. with MDS nurse #101 and Regional MDS #133 verified they had initiated the care plans for hospice and oxygen on 09/05/23. 2. Review of the medical record for Resident #16 revealed an admission date of 12/25/22. The resident was admitted with diagnoses including hypothyroid, atrial fibrillation, hypertension, dysphagia, and anorexia. Review of the quarterly MDS dated [DATE] revealed Resident #16 had severe cognitive loss. The resident required supervision with Activities of Daily Living (ADLs). Further review revealed Resident #16 had needed physical help for bathing of one person. Additionally, the resident was documented as having anticoagulant. Review of the physician orders dated 08/09/23 revealed Resident #16 had order for warfarin tablet 2.5 milligram (mg) oral at bedtime on Tuesday and warfarin 5 mg tablet at bedtime on Sunday, Monday, Wednesday, Thursday, Friday, and Saturday. Review of Resident #16's most recent care plan revealed no goals or interventions in place for anticoagulant. Interview 09/07/23 with Regional Director #131, verified that no plan of care was implemented for the usage of an anticoagulant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 2 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the policy Care plan- Use of undated, revealed changes in a residents condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan could be made. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 3 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review, observation, interview, and facility policy review the facility failed to revise Resident #14's care plan with changes to meet the need of resident care interventions as determined by the resident's need or as requested by the resident. This effected one resident (# 14) of 19 resident's for plans of care reviewed. The census was 35. Findings include: Review of the medical record for Resident #14 revealed an admission date of 12/17/22 with diagnoses including , dysphagia, unspecified injury of the head, acute respiratory failure, cerebral aneurysm, chronic ischemic heart disease, epileptic seizures, displaced fracture of the first cervical vertebra, candida sepsis, Unspecified hearing loss, bilateral, Cervical disc disorder with myelopathy, mid-cervical region, unspecified level and closed displaced fracture of acromial end of left clavicle. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 07/28/23 revealed Resident #14 had moderate cognitive loss. Further evaluation of Resident #14's functional status required supervision for bed mobility, walk in corridor, locomotion off unit, dressing and personal hygiene. Resident #14 was independent for transfers, walk in room, locomotion on unit, eating, toilet use and was continent of bowel and bladder. Record review of Resident #14 medical records revealed that on 08/15/23 at 7:30 A.M., Resident #14 was found by staff in room on floor with 1 inch laceration on left side of head in hairline and unable to move arm without pain and was transported to hospital where a closed displaced fracture of acromial end of left clavicle was diagnosed. Further review of Resident #14's medical record revealed on 08/24/23 at 12:33 A.M. that Resident #14 slid off the footrest of her chair on to her buttocks and on 08/27/23 at 6:35 A.M. she was found sitting on floor beside her bed. Plan of care dated 12/30/22 for Resident #14 was silent for usage of sling/immobilizer device for left arm. Further review of plan of care for incidents on 08/24/23 and 08/27/23 and was found to be silent for new or reevaluated of previous interventions for both incidents. Interview and subsequent observation with Resident #14 on 09/05/23 at 10:34 am, stated she had fallen a few weeks ago while walking in her room causing an arm fracture and had to wear a sling on her arm since the fall and that she had fallen a few times after her fracture. Observation of Resident # 14, sitting in chair and left arm in sling/immobilizer device. Interview 09/07/23 with Regional Director #131, verified that no plan of care was implemented at the time of the device application nor was new or updated fall interventions placed on plan of care for the 08/24/23 and 08/27/23 incidents. Review of facility non-dated policy, Care Plan-Use Of, states the care plan shall be used in developing the residents daily care routines. Review of facility non-dated policy, Falls and Fall Risk, Managing, states, if falling recurs despite initial interventions, staff will implement additional or different interventions or indicated why the current approach remains relevant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 4 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to ensure Resident #18 was provided proper podiatry care and services. This affected one resident (Resident #18) out of one resident reviewed for podiatry care and services. This had the potential to affect 35 residents residing at the facility. Residents Affected - Few Findings included: Review of the medical record revealed Resident #18 was admitted [DATE]. Resident #18's diagnoses include type two diabetes mellitus, diabetic neuropathy, chronic kidney disease stage three, surgical care following volvulus, major depressive disorder, anxiety disorder, and asthma. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was cognitively intact and required extensive assistance with personal hygiene and bed mobility. Review of care plan with last review dated 08/06/23 revealed Resident #18 had an alteration in blood glucose metabolism related diagnoses of diabetes mellitus. Intervention included observe feet for potential ulcers. Resident #18 needs therapy services related to decline in prior function of activities of daily living (ADL)'s and mobility. Interventions included allow as much independence as possible and provide rest periods as needed to help minimize fatigue. There was no mention of foot care or need for podiatry services in the care plan. Review of Current orders for September 2023 revealed no orders for Podiatry services. Review of records for Resident #18 revealed there is no documentation of foot care or podiatry services since admission [DATE]. Resident #18 did sign consent for consulting services including podiatry dated 03/30/23. On 09/05/23 at 10:03 A.M., interview with Resident #18 revealed toenails are bothering him and need cut. Resident #18 states he has told several staff they bother him, but no one has done anything yet. Observed Resident #18's toenails to be long and yellowed, there is also a bruise on the top of the right foot. On 09/06/23 at 3:55 P.M., interview with Director of Nursing and Administrator verified the podiatrist only comes every couple of months. The podiatrist is the only person who can trim toenails for a resident with diabetes mellitus. The podiatrist is scheduled to come this month (September 2023) and Resident #18 is on the list to be seen by the podiatrist this month. On 09/07/23 at 8:10 A.M., further interview with Resident #18 revealed he has not seen a podiatrist since admission, he did not know that was an option and did not know he could request to see the podiatrist. Observed the toenails on both feet to be long and yellowed. Resident #18 states the toenails rub on the sheet and blanket and it hurts. It feels like the blanket is too heavy on my toenails. On 09/07/23 at 8:15 A.M., interview with State Tested Nursing Assistant (STNA) #118 revealed if the STNA notices long toenails during care it is reported to the nurse. If the resident is not a diabetic the STNA may cut the nails if the resident wishes. If the resident is a diabetic, the nurse will assess the situation and get the resident put on the list to see the podiatrist. STNA #118 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 5 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #18 has had dry feet and STNA #118 has rubbed lotion on Resident #18's dry feet and noted the toenails to be thick and yellow but not excessively long. On 09/07/23 at 8:25 A.M., interview with Licensed Practical Nurse (LPN) # 120 revealed if a STNA comes to the nurse with a concern about toenails the nurse assesses the resident for herself. If the toenails are long, the nurse then contacts the doctor and gets the resident on the list to see the podiatrist. The nurse contacts the social worker who maintains the list to see the consult services including the podiatrist. On 09/07/23 at 9:02 A.M., interview with Administrator confirmed Resident #18 signed a consent for consult services that includes podiatry on 03/30/23. Resident #18 was not seen on the regular visit day 06/27/23 and is now on the list to be seen 09/20/23 as a new patient visit. The administrator stated they do not have a policy for providing consult services like podiatry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 6 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to adequately monitor and provide oversight for resident's nutritional status. This affected one (Resident #141) of three residents reviewed for nutrition. The census was 35. Residents Affected - Few Findings Include: Resident #141 was admitted to the facility on [DATE]. His diagnoses were fracture of unspecified part of neck of right femur, muscle weakness, dysphagia, chronic obstructive pulmonary disease, end stage renal disease, atherosclerosis, chronic kidney disease, hypokalemia, hypoosmolality and hyponatremia, hypertension, cardiac murmur, osteoarthritis, bacterial pneumonia, anemia, hyperlipidemia, metabolic encephalopathy, vertigo, melena, shortness of breath, and alcohol abuse. Review of Resident #141 weights, dated 08/18/23 to 08/28/23, revealed the following weights: 08/19/23 (105.4 pounds), 08/21/23 (105.2 pounds), and 08/28/23 (115 pounds). Review of Resident #141 Dialysis Transfer Information Forms, dated 08/21/23 to 08/30/23, revealed the pre-weights varied between 51.2 kilograms (kg) and 52.3 kg (112.64 pounds to 115.06 pounds) and the post weights varied between 49.7 kg and 52.1 kg (109.34 pounds and 114.62 pounds). None of the weights (pre or post) were near the facility documented weights of 105 pounds. Review of Resident #141 progress notes, dated 08/28/23 to 08/29/23, revealed Dietitian #301 documented that there was a significant weight increase from 08/21/23 to 08/28/23, but she did not have any new orders or recommendations at that time. But, on 08/29/23, Dietitian #301 documented that a new recommendation/order was provided to the physician, and it was agreed upon/sign; although there was nothing specifically detailed in the progress note. Review of Resident #141 Dietary Recommendation, dated 08/28/23, revealed, Description of Condition Needing Intervention: significant weight gain in 7 days (9.3%), beneficial, supplement in place, and dialysis. The suggested intervention was to add a house supplement. The physician signed it on 08/29/23. Review of Resident #141 medical records since admission found no evidence that Dietitian #301 reviewed Resident #141 dietary records to compare the weights with the facility acquired weights. There was no evidence to support Resident #141 had an actual significant weight gain, yet she documented and assessed Resident #141 nutritional status based on a perceived weight gain, which included adding four ounce house nutritional supplement due to in part a significant weight gain (according to the Dietary Recommendation documentation). Interview with Director of Nursing (DON) and Regional Director #131 on 09/06/23 at 3:51 P.M. confirmed the facility weights on 08/18/24 and 08/21/23 were significantly different than the weights taken by the dialysis center. They confirmed there could have been two different weighing mechanisms used (hoyer versus traditional scale) from 08/18/23 to 08/28/23, and that could have contributed to the significant increase in documented weight. They confirmed there was no documentation to support Dietitian #301 reviewed the dialysis notes and weights to compare with the facility weights and determine if there was an actual significant increase. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 7 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with Company Dietitian #300 on 09/07/23 at 11:09 A.M. revealed she is not the dietitian for this facility, but is filling in for dietary needs while Dietitian #301 was on vacation. She confirmed a dietitian should look at dialysis notes and weights, and compare them with facility documentation to determine if there are weight errors, or if there nutritional orders should be put in place. She stated she looked at Resident #141 weights from the facility and from the dialysis center, and she would concur that the weights the facility took on 08/18/23 and 08/21/23 were most likely incorrect. But again, she confirmed the facility dietitian should be comparing weights across all areas of the resident's health/status. Event ID: Facility ID: 366196 If continuation sheet Page 8 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of facility policies the facility failed to ensure physician's orders were in place prior to oxygen administration and failed to ensure oxygen tubing was dated for Resident #19. This affected one resident (#19) of one resident reviewed for respiratory care. The facility census was 35. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 07/24/23 with diagnoses including cachexia, dysphagia, malignant neoplasm of colon, hypertension, depression, chronic systolic heart failure, anxiety disorder, and actinic keratosis. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition. Observation on 09/05/23 at 10:02 A.M. revealed Resident #19 had an oxygen concentrator in use. There was no date observed on the tubing. Interview on 09/05/23 at 10:05 A.M. with the Director of Nursing (DON) verified the oxygen tubing was undated and should have been. Observation on 09/05/23 at 10:30 AM revealed no physician order for oxygen. Review of the plan of care created 09/05/23 at 1:04 P.M. revealed Resident #19 was nonadherent with care and services as he removed oxygen and fiddled or played with the date tape on the date tape, removing it at times. Interventions included actively involving the resident in care, allowing resident to choose options when able, encouraging to express feelings, notifying physician of escalated or new behavior, and reiterating purpose and advantages of treatment for the resident. Interview on 09/05/23 at 5:09 P.M. with the DON verified the oxygen order had not been in place. She additionally reported she had not put in the care plan, however, Resident #19 fiddling with the date tape was not a real concern as it could have been put closer to the concentrator and out of his reach. Review of the policy Oxygen Administration undated, revealed staff was to verify there was a physician's order for the procedure. After completing oxygen set up the following information was to be recorded in the resident's medical record: date and time it was administered, rate of oxygen flow, route, and rationale, frequency and duration of the treatment, reason for as needed administration, how the resident tolerated the treatment, if the procedure was refused, and the signature and title of the person recording the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 9 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 medical record review, staff interview, and facility policy review, the facility failed to provide proper parameters for as needed pain medications and did not attempt non-pharmacological interventions prior to the administration of as needed pain medications. This affected three (Residents #136, #143, and #185) of six residents reviewed for unnecessary medications. The census was 35. Residents Affected - Few Findings include: 1. Resident #136 was admitted to the facility on [DATE]. His diagnoses were metabolic encephalopathy, lobar pneumonia, altered mental status, retention of urine, dysphagia, urinary tract infection, atherosclerotic heart disease, hypertension, hypoosmolality and hyponatremia. His Minimum Data Set (MDS) assessment had not been completed to determine his cognitive status. Review of Resident #136 physician orders revealed an order for acetaminophen 500 milligrams, amount one to two tablets every four hours as needed for pain. There was no parameters or instructions on when the nurse was to administer one or two tablets when the resident expressed pain. Review of Resident #136 Medication Administration Record (MAR), dated September 2023, revealed he was administered acetaminophen on 09/04/23, but there was no documentation to support if non-pharmacological interventions were attempted prior to administration nor were there any instructions/documentation as to how many tablets were administered. Interview with Regional Director #131 and Director of Nursing (DON) on 09/06/23 at 3:24 P.M. both confirmed there were no documented parameters as to when the facility should administer one or two tablets; they confirmed it should be defined. Also, non-pharmacological interventions should be documented in the notes section of the MAR, and confirmed there were none documented for the administration of acetaminophen on 09/04/23. 2. Resident #143 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, pneumonia, urinary tract infection, osteoarthritis, hypothyroidism, type II diabetes, hyperlipidemia, major depressive disorder, hypoosmolality and hyponatremia, hypertension, insomnia, anxiety disorder, atherosclerosis of aorta, chronic kidney disease, and muscle weakness. Her Minimum Data Set (MDS) assessment had not been completed to determine her cognitive status. Review of Resident #143 physician orders revealed an order for Gabapentin 100 mg every eight hours as needed for moderate pain. There was no documentation to clarify what moderate pain would be defined as. Also, Resident #143 was ordered Oxycodone 10-325 mg every six hours as needed for severe pain. There was no documentation to clarify what severe pain would be defined as. Review of Resident #143 MAR, dated September 2023, revealed no documentation to support non-pharmacological interventions were attempted prior to any administrations of Gabapentin or Oxycodone. Interview with Regional Director #131 and Director of Nursing (DON) on 09/06/23 at 3:24 P.M. both confirmed there were no policies or procedures to define what moderate pain or severe pain would be. They both agreed that moderate and severe pain could be different for each person. Also, non-pharmacological interventions should be documented in the notes section of the MAR and they were not for each of these administrations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 10 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 3. Review of the medical record for Resident #185 revealed an admission date of 08/11/23 with diagnoses including dysthymic disorder, developmental disorder of scholastic skills, unspecified mood disorder, pain in left leg, headache, and abdominal distension. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #185 had intact cognition. She experienced almost constant pain over the last five days that made it hard for her to sleep and limited her day-to day activities. Her worst pain over the last five days was a ten. Review of the physician order dated 08/18/23 revealed an order for Acetaminophen 500 milligrams (mg), 1000 mg to be given for a pain of one to ten as needed. Nonpharmacological interventions were to be offered prior to administration. Review of the physician order dated 08/18/23 revealed an order for Acetaminophen 500 mg, 500 mg to be given for a pain of one to ten as needed. Nonpharmacological interventions were to be offered prior to administration. Review of the Medication Administration Record (MAR) for August and September 2023 revealed Acetaminophen 500 mg was administered on 08/18/23, 08/19/23, 08/21/23, 08/22/23, 08/27/23, 08/29/23, 08/31/23, 09/01/23, 09/02/23, and twice on 09/04/23 at 5:24 A M and 10:14 P.M. Review of the administration comments revealed pain was never rated on a scale of one to ten, and the description of pain was only given on 08/19/23, 08/31/23, and 09/02/23. No nonpharmacological interventions were documented. Review of the MAR for August and September 2023 revealed Acetaminophen 1000 mg was administered on 08/20/23 for a pain of six, on 08/23/23 for a pain of seven, twice on 08/26/23 for a pain of five and a pain of eight, 08/27/23 for a pain of eight, 08/29/23 for a pain of six, and 08/30/23 for a pain of five. No nonpharmacological interventions were documented. Review of the plan of care dated 08/31/23 revealed Resident #185 had pain related to headaches. Interventions included administering pain medications, coordinating with therapy, observing for episodes of breakthrough pain, offering additional non-pharmacological interventions, and remind resident to report pain early. Review of the plan of care dated 09/01/23 revealed Resident #185 had the potential for alteration in comfort related to pain in left leg, abdominal bloating, and cramping. Interventions included assessing pain for cause, location, and duration, assisting resident to maintain most comfortable position, attempt alternate relief measures, encourage resident to rate pain, encourage resident to report pain early, medicate per order for resident pain, and observing for nonverbal signs of pain. Interview on 09/06/23 at 10:45 A.M. with the Director of Nursing (DON) verified all pain medications had parameters of a pain for one to ten. She reported the nurse and the resident decided which medication was more appropriate at each instance. The DON verified non-pharmacological interventions were not documented for either dosage of Acetaminophen and should have been. She additionally verified the pain rating and location of pain should have been documented for each administration. Review of the policy Pain Assessment and Management Protocol undated revealed orders for 'as needed' medications were to note the pain intensity using a numeric pain scale or the pain assessment in advanced dementia scale. Non-pharmacological interventions were to be attempted before administering 'as needed' medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 11 of 12 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to obtain proper justification for the use of antibiotic medications. This affected two (Residents #136 and #143) of three residents reviewed for infections. The census was 35. Residents Affected - Few Findings Include: 1. Resident #136 was admitted to the facility on [DATE]. His diagnoses were metabolic encephalopathy, lobar pneumonia, altered mental status, retention of urine, dysphagia, urinary tract infection, atherosclerotic heart disease, hypertension, hypoosmolality and hyponatremia. His Minimum Data Set (MDS) assessment had not been completed to determine his cognitive status. Review of Resident #136 physician orders revealed he was ordered the medication Amoxicillin 875-125 milligrams, one tablet twice daily. But review of the physician orders and medication administration records (MAR) confirmed there was no justification for this medication. Review of Resident #136 McGeer's Criteria assessments, dated 09/02/23, revealed one was completed for both encephalopathy secondary to a urinary tract infection, and one for bilateral lower lobe pneumonia. There was no documentation to support which infection the amoxicillin was prescribed for. Interview with Regional Director #131 and Director of Nursing (DON) on 09/06/23 at 3:24 P.M. confirmed there was no documented justification for the use of amoxicillin. They both confirmed McGeer's criteria was completed for both infections (UTI and pneumonia), but there was no documented justification as to which infection the amoxicillin was prescribed for. 2. Resident #143 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, pneumonia, urinary tract infection, osteoarthritis, hypothyroidism, type II diabetes, hyperlipidemia, major depressive disorder, hypoosmolality and hyponatremia, hypertension, insomnia, anxiety disorder, atherosclerosis of aorta, chronic kidney disease, and muscle weakness. Her Minimum Data Set (MDS) assessment had not been completed to determine her cognitive status. Review of Resident #143 physician orders revealed she was ordered the medication ceftriaxone two grams via intravenous (IV). But review of the physician orders and medication administration records (MAR) confirmed there was no justification for this medication. Interview with Regional Director #131 and Director of Nursing (DON) on 09/06/23 at 3:24 P.M. both confirmed there was no documented justification for the use of ceftriaxone. Review of facility Communication of Resident Condition and Treatment with Antimicrobial Orders policy, dated November 2019, revealed antimicrobials will be used only for as long as needed to treat infections, minimized the risk of relapse, or control active risk to others. If the resident's condition warrants antimicrobial use, the physician/prescribers will provide antimicrobial orders, which should include the following elements: name of medication, dose, route of administration, duration of therapy and indication of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 12 of 12