Inspection·November 2, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/02/23 at 2:30 P.M. with Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON) #600, verified there were no Medication Regimen reviews or Pharmacy Recommendations provided for Resident #13 for 09/23 or 10/23. 4. Review of the medical record for Resident #30 revealed an admission date of 09/30/23. Diagnoses included localized edema, insomnia, glaucoma, gastro-esophageal reflux disease (GERD), muscle weakness, and type II diabetes mellitus. Review of the consultant pharmacist's medication regimen review for Resident #30, dated 10/02/23, revealed to please add an ICD-10 diagnosis to the diagnosis tab of the electronic medication administration record (eMAR) to support the use of the following medications: amitriptyline (antidepressant), Eliquis (anticoagulant), furosemide (diuretic), Januvia (antidiabetic), Lumigan (antiglaucoma), melatonin, insulin degludec (antidiabetic), and pantoprazole (reduces levels of stomach acid). Further review of the consultant pharmacist's recommendation form revealed nothing documented under the area titled Follow Through indicating the recommendation was addressed. Review of the eMAR for October 2023 revealed a blank space under the diagnosis tab for amitriptyline, Eliquis, furosemide, Januvia, Lumigan, melatonin, insulin degludec, and pantoprazole. Interview on 11/02/23 at 8:56 A.M. with Minimum Data Set (MDS) Nurse #608 verified there was diagnosis added to the diagnosis tab of the eMAR for each medication identified. Review of the facility policy titled Medication Regimen Review, dated May 2020 revealed findings and recommendations were to be reported to the Director of Nursing (DON), the attending prescriber, the Medical Director, and if appropriate, the Administrator. Responses were to be made readily available to he consultant pharmacist for follow-up. Under item G: The consultant pharmacist medication regimen review (MRR) and Nursing Documentation Review reports were to be processed as follows and were to be provided in a written or electronic format: 1) Medication Regimen Review Recommendations to Prescriber a.) the consultant pharmacist or facility was to provide the report to the responsible prescriber and DON within seven working days of the review. b.) A copy of the report was to be kept by the facility until the prescriber's signed response was returned. c.) The prescriber was to accept and act upon recommendations or reject and provide an explanation for disagreeing. d.) The facility was to maintain copies of signed reports and make them readily available for the consultant pharmacist for follow-up. 2) Nursing Documentation Review a.) The report was to be provided by the consultant pharmacist within seven working days of the review. b.) A copy of the report was to be kept by the facility until the nurse's response was returned. 2. Review of the medical record for Resident #33 revealed an admission date of 06/15/22 and diagnoses included diabetes, major depression, hypertension, gout, and dementia with behavioral disturbance. Review of lab work in the medical record revealed there was no evidence of a Hemoglobin AIC (HGAIC) (a blood test that reflects an average blood glucose level) or an uric acid level (blood test to check the level of uric acid which often causes gout). Review of pharmacy recommendation dated 11/02/22 revealed Consultant Pharmacist #606 recommended a uric acid level and HGAIC with the next lab draw and repeat both labs in six months. The recommendation had a check mark by the recommendation that Primary Care Physician (PCP) #608 was in agreement with the recommendation but with no date. Review of pharmacy recommendation dated 01/03/23 revealed Consultant Pharmacist #606 recommended (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 2 of 7 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #33's sliding scale be discontinued and to obtain a HGAIC on the next available lab date and repeat the HGAIC in three months. The Interim Director of Nursing (DON) placed a X by the recommendation, check blood sugar twice a day times one week and call if blood sugar below 70 and/or above 250. There was no date on the form. Review of pharmacy recommendation dated 03/07/23 revealed Consultant Pharmacist #606 recommended Resident #33 to have a trial dose reduction of duloxetine (anti-depressant) 20 milligram (mg) by mouth everyday and monitor for symptoms. Nurse Practitioner (NP) #607 checked that he agreed to the trial and signed and dated the recommendation for 09/07/23 (six months after the recommendation was made by the pharmacist). Review of pharmacy recommendation dated 07/03/23 revealed Consultant Pharmacist #606 recommended Resident #33's sliding insulin be discontinued and obtain HGAIC next available lab date and repeat HGAIC in three months. The recommendation had a check mark by the recommendation and was signed by PCP #608 without a date. Review of physician order completed by PCP #608 dated 09/08/23 revealed Resident #33's duloxetine was decreased to 20 mg once a day (per pharmacy recommendation). Interview on 11/01/23 at 2:52 P.M. with the Interim Director of Nursing verified there was no evidence Resident #33 had received an HGAIC or uric acid level despite pharmacy recommendations dated 11/02/22, 01/03/23, and 07/03/23. She also verified Resident #33's pharmacy recommendation dated 03/07/23 for the duloxetine dose reduction was not addressed until 09/07/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 3 of 7 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, medical record review and policy review the facility did not ensure Resident #48 was free of a significant medication error. This affected one resident (Resident #48) out of one resident reviewed for insulin administration. This had the potential to affect eight residents (Resident #6, #10, #20, #18, #30, #33, #47, and #48) that had orders for insulin. Residents Affected - Few Findings include: Review of medical record for Resident #48 revealed an admission date of 10/13/23 and diagnoses included diabetes, hypertension, and chronic kidney disease. Review of care plan dated 10/16/23 revealed Resident #48 had an alteration in blood glucose metabolism related to her diagnosis of diabetes. Interventions included to administer diabetic medications per physician orders and observe for signs of hypoglycemia/ hyperglycemia. Review of November 2023 physician orders for Resident #48 revealed she had an order for lispro (a rapid acting insulin) insulin pen to administer three units subcutaneously (SQ) with meals scheduled at 7:30 A.M. and an order for insulin lispro insulin pen to be administered SQ per sliding scale including if blood sugar was 301 to 350 to administer eight units of insulin before meals and at bedtime (the morning dose was scheduled for 7:30 A.M.) Observation on 11/01/23 at 9:02 A.M. revealed Resident #48 was lying in bed when Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #600 entered her room to take her blood sugar and administer her insulin. Resident #48 did not have a breakfast tray in her room. Resident #48 stated to LPN/ADON #600 that she was upset as she did not understand why LPN/ADON #600 was taking her blood sugar so late as she had already eaten her breakfast. LPN/ADON #600 took her blood sugar, and it was 306 and LPN/ADON #600 stated that Resident #48 would require sliding scale insulin coverage with her routine insulin because the blood sugar was elevated. Resident #48 stated to LPN/ADON #600 that her blood sugar would be high since she ate almost an hour ago and stated that she should not have to get coverage just because the nurse was late on checking her blood sugar. Observation on 11/01/23 at 9:17 A.M. revealed LPN/ADON #600 administered Resident #48 her routine lispro insulin three units and eight units sliding scale lispro insulin to equal 11 units to her left deltoid (arm). Interview on 11/01/23 at 9:40 A.M. with LPN/ADON #600 verified Resident #48's routine insulin was scheduled for 7:30 A.M. and her routine lispro insulin was to be administered with meals and her sliding scale lispro insulin was also scheduled for 7:30 A.M. before breakfast. She verified she obtained her blood glucose level and administered her insulin at 9:17 A.M. after she had already eaten her breakfast. Interview on 11/01/23 at 9:55 A.M. with State Tested Nursing Assistant (STNA) #601 revealed breakfast trays arrived to Resident #48's hall approximately between 7:40 A.M. and 7:50 A.M. everyday. STNA #601 passed Resident #48's breakfast tray between 7:40 A.M. to 8:00 A.M. today, 11/01/23. Interview on 11/01/23 at 10:10 A.M. with Resident #48 revealed when she was at home, she always used to take her blood sugar and administer her insulin right before she ate her meal. She revealed she was upset as frequently the nurses did not check her blood glucose level and/or give her insulin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 4 of 7 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few until after she ate. She revealed on 11/01/23 she had received her breakfast tray at approximately 8:00 A.M. and ate Cheerios and a breakfast croissant sandwich before LPN/ADON #600, had come in to check her blood sugar and administer her insulin which was after 9:00 A.M. Review of the undated facility policy labeled; Insulin Administration revealed it was the facility's policy to provide guidelines for safe administration of insulin to residents with diabetes. The policy revealed to check the blood glucose per physician order. Review of facility policy labeled, Medication Administration- General Guidelines dated May 2020 revealed medications were administered in accordance with orders of the prescriber. The nurse was to follow the five rights including right time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 5 of 7 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on record review and interview, the facility failed to ensure staffing data was submitted appropriately to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents in the facility. The census was 36. Findings include: Review of the CMS staffing data report for quarter three of the 2023 fiscal year (from April 1 to June 30 2023) revealed the facility did not submit staffing data for the affected quarter. Interview with the Administrator on 10/31/23 at 8:37 A.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 6 of 7 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0947 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview, record review and review of facility policy the facility did not ensure State Tested Nursing Assistant (STNA) #602 received 12 hours of formal in service education within the last year. This affected one STNA out of three STNAs (#602, #604, and #605) whose personnel files were reviewed for formal education/training. This had the potential to affect 36 residents. Findings include: Review of the personnel file for STNA #602 revealed a hire date of 07/15/03. Review of STNA #602's education transcript revealed in the last 12 months STNA #604 had 0.75 total hours of training. Interview on 11/02/23 at 12:20 P.M. with Regional Staff Coordinator #603 verified STNA #602 had only completed 0.75 hours of training in the last 12 months. Review of facility policy labeled, Inservice Training dated April 2013 revealed employees must complete all assigned course work and attend mandatory in-services. The policy revealed each STNA annually must complete at least 12 hours of formal in-service education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 7 of 7