Health inspection·November 24, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, observation, and staff interview, the facility failed to provide the physician ordered medication for one, (Resident # 5) of three reviewed for medications. The facility census was 43. Findings Include: Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include of acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease.Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration.Review of facility provided physician orders for Resident #5 revealed an order for Insulin Aspart U-100 (fast acting insulin with onset in five to 10 minutes) Insulin pen 100 units/milliliter (ml) (3ml); 6 units subcutaneous, hold if blood sugar is less than 150 administer before meals at 8:00 A.M., 12:00 P.M. and 5:00 P.M. dated 08/14/25. Further review of Resident #5's physician orders revealed no order for Insulin Lispro.Review of Resident #5's medication administration record (MAR) for November 2025 revealed the facility staff were signing off they were administering Insulin Aspart U-100 Insulin pen; 100 unit/milliliters (three ML); amount to administer: six units; subcutaneous before meals unless the blood sugar was below 150. Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open and used Insulin Lispro (fast acting Insulin with onset in 15 minutes of administration) pen for Resident #5, not an Insulin Aspart pen which was ordered for Resident #5 by the physician. Concurrent interview at the time of the observation with the Assistant Director of Nursing #230 confirmed the Insulin Lispro pen belonged to Resident's #5's and it was opened and had been used to provide insulin to the resident. Event ID: Facility ID: 366196 If continuation sheet Page 2 of 4 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 11/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observation, and interviews, the facility failed to ensure expired medications were not available for use, failed to ensure medications were labeled accurately, and failed to store medications securely. This affected three residents (#5, #10, and #34) and had the potential to affect all residents who may be ordered facility stock medication. The facility census was 43.Findings include:1.Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include but not limited to acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease.Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration.Review of Resident #5's medication administration record (MAR) revealed a physician's order dated 08/14/25 for Insulin Aspart U-100 insulin pen; 100 unit/milliliters (three ML); amount to administer: six units; subcutaneous.Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open and used Insulin Lispro pen for Resident #5 which was undated. Assistant Director of Nursing (ADON) #230 confirmed Resident #5's insulin pen was undated, opened, and used at the time of the observation.2.Review of the medical record for Resident #10 revealed an admission date of 07/01/22 with diagnoses to include but not limited to hypertension, congestive heart failure, Type II Diabetes Mellitus, and chronic kidney disease stage three.Review of Resident #10's MAR revealed an order dated 11/10/25 for Lantus Solostar U-100 insulin (Insulin Glargine) Insulin pen; 100 unit/milliliter (three ML); amount to administer: 16 units; subcutaneous. Additionally, Resident #10 had an order dated 11/06/25 for Insulin Lispro Insulin pen, half-unit; 100 unit/milliliter (mL); amount to administer: per sliding scale; if blood sugar is less than 60, call MD (physician). If blood sugar is 150 to 200, give one unit. If blood sugar is 201 to 250, give two units. If blood sugar is 251 to 300, give three units. If blood sugar is 301 to 350, give four units. If blood sugar is 351 to 400, give five units. If blood sugar is greater than 400, give six units. If blood sugar is greater than 400, call MD.Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open, used, and undated Insulin Lispro pen and an open, used, and undated Lantus pen. ADON #230 verified Resident #10's Insulin pens were open, used, and undated at the time of the observation.3. Review of the medical record for Resident #34 revealed an admission date of 11/14/24 and diagnosis to include but not limited to chronic obstructive pulmonary disease, asthma, irritable bowel syndrome, rheumatoid arthritis, altered mental status, abnormalities of gait, unsteadiness on feet, repeated falls, muscle weakness, hypertension, hypotension, congestive heart failure, Type II Diabetes, osteoarthritis, anxiety disorder, major depressive disorder, and need for personal assistance with personal care.Review of Resident #34's MAR and treatment administration record (TAR) revealed no current orders for Refresh eyedrops (eye lubricant), Tums (antiacid), Ammonium Lactate twelve percent moistening lotion, Diclofenac sodium (non steroidal anti inflammatory) topical gel cream, Bio freeze (menthol topical), and Cytoderm spray. Observation on 11/20/25 at 4:29 P.M. in Resident #34's room revealed Refresh eyedrops, Tums, Ammonium Lactate twelve percent moistening lotion, Diclofenac sodium topical gel cream, Bio freeze, and Cytoderm spray on a dresser in Resident #34's room. The Director of Nursing verified the medications were at the bedside with no orders and removed them from Resident #34's room.4. Observation on 11/20/25 at 9:38 A.M. to 10:14 A.M. of the medication storage room revealed two bottles of unopened four ounce (oz) mL children's Acetaminophen (analgesic antipyretic) bottles of 160 milligrams (mg) per five mL which had expired 10/2025, Aspirin (non steroidal anti inflammatory) 81mg unopened bottle which expired 10/2025, two bottles of tab-a vite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 3 of 4 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 11/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Multivitamins with iron (vitamin supplement) which expired 10/2025, four bottles of Vitamin E 180 mg soft gels which expired 08/2025, 39 Nicotine transdermal step two patches which expired 08/2025, one tuberculin five Tuberculin units per 0.1mL vial opened and undated in the refrigerator, and multiple lancets in a plastic drawer which had no expiration date. The Director of Nursing verified the expired medications and lancets at the time of the observation.Review of the facility policy Medication Storage in the Facility dated 05/2020 under expiration dating (beyond-use dating) stated when the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. (note: the best stickers to affix contain both a date opened and expiration date notation line.) All expired medications will be removed from the active supply, regardless of the amount remaining. The medication may be destroyed at the facility or returned to the provider pharmacy in the usual manner.This violation represents non-compliance investigated under Complaint Number OH002647331. Event ID: Facility ID: 366196 If continuation sheet Page 4 of 4