Health inspection·October 5, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Review of the medical record identified no documentation of a notification of the fall with injury to Resident #56's representative. Review of the coroner's office investigation, dated [DATE] at 9:50 A.M., revealed the coroner's office staff arrived at the facility on [DATE] at 10:25 A.M. Residents Affected - Few On [DATE] at 1:36 P.M., interview with the DON and Administrator verified they did not notify Resident #56's family of the fall with injury until [DATE] after the coroner's staff left and they could not specify where the notification was documented. This deficiency represents non-compliance investigated under Complaint Number OH00147023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 2 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure baseline care plans were completed for two (Residents #162 and #265) of 25 residents whose records were reviewed during the annual survey. The facility census was 59. Findings include: 1. Review of the medical record for Resident #162 revealed an original date of admission of 09/09/23 and a readmission date of 09/30/23. Diagnoses included infection following a procedure, other surgical site, subsequent encounter, altered mental status, unspecified, need for assistance with personal care, enterostomy malfunction, bacteremia, parastomal hernia, anal fistula, unspecified intestinal obstruction, retention of urine, personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus, encounter for surgical aftercare following surgery on the digestive system, unspecified cystostomy status, sepsis, unspecified organism, urinary tract infection, site not specified, and malignant neoplasm of lateral wall of bladder. Review of Clinical Documentation of admission Assessments dated 09/09/23 and 09/30/23 revealed both assessments were incomplete, had status listed as in progress, and had no accompanying baseline care plan for either admission. On 10/04/23 at 12:15 P.M., interview with Minimum Data Set (MDS) Registered Nurse (RN) #579 verified there was no baseline care plan completed for Resident #162 for the admission on [DATE] or the readmission on [DATE]. 2. Review of the medical record for Resident #265 revealed an admission date of 09/23/23 with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, generalized muscle weakness (generalized), need for assistance with personal care, abnormalities of gait and mobility, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, alcohol dependence, nicotine dependence, schizophrenia, anxiety disorder, seizures, idiopathic peripheral autonomic neuropathy, unspecified primary angle-closure glaucoma, major depressive disorder, vertigo, and history of falling. Review of Resident #265's medical record revealed no evidence of a baseline care plan. On 10/05/23 at 10:22 A.M., interview with Regional RN #603 confirmed Resident #265 did not have a baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 3 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 interview, record review, review of the facility investigation, review of the coroner's investigation, and review of facility policy, the facility failed to timely assess for injury of Resident #56 after he was found deceased on the floor, failed to timely notify the coroner of a potential head injury for Resident #56 which resulted in a delay of post-mortem evaluation, and failed to ensure a thorough investigation was completed for Resident #56's fall and death. This affected one (#56) of three residents reviewed for falls and one (#56) of three residents reviewed for death. In addition, the facility failed to ensure transfers were performed according to physician orders, which affected one (#28) of seven residents reviewed for accidents. The census was 59. Findings include: 1. Review of the closed medical record for Resident #56 revealed an admission date of [DATE] with diagnoses including inclusion body myositis, acute respiratory failure with hypercapnia, anemia, depression, hypertension, pneumonia, constipation, vitamin D deficiency, age related physical debility, anxiety disorder, gastrostomy status, altered mental status, and diabetes mellitus. The resident expired on [DATE]. Review of the assessment titled Clinical admission Documentation 0419, dated [DATE], revealed Resident #56 was not at high risk for falls. The assessment also indicated there was no baseline care plan for falls. Review of the nurse note dated [DATE] at 9:56 P.M. revealed Resident #56 was found lying on the floor next to his bed, unresponsive to his name, absent of breath sounds, and absent of vital signs. Resident #56's death was verified by two nurses. On [DATE] at 6:24 P.M., the nurses note dated [DATE] at 9:56 P.M. was edited by Registered Nurse (RN) #600 to include that Resident #56 had trauma to the occipital region of his head with a moderate amount of blood present and bruising present to the left upper extremity. Prior to this edit, there was no mention in the medical record of any injury related to his fall or death. Review of the nurse note dated [DATE] at 10:11 P.M. revealed RN #600 notified the Director of Nursing (DON) that Resident #56 was deceased . Review of the nurse note dated [DATE] at 10:50 P.M. revealed the coroner's office and Medical Director #605 had released the body, Resident #56's body could be placed back in bed, and post mortem care could be provided. Review of the nurse note dated [DATE] at 11:03 P.M. revealed RN #600 notified the hospice agency that Resident #56 was deceased . Review of the nurse note dated [DATE] at 11:49 P.M. revealed Resident #56's body was carefully placed back in bed via a mechanical hoyer lift and post mortem care was performed. The note did not include any injuries or blood identified at the time of moving Resident #56's body. Review of a text message from RN #600, dated [DATE] at 6:03 A.M., revealed she informed the DON and Regional RN #603 that there was trauma and blood from the back of Resident #56's head identified at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 4 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 the time of moving his body into the bed. Level of Harm - Minimal harm or potential for actual harm Review of the facility's incident investigation, dated [DATE], revealed on [DATE] at approximately 10:00 P.M., RN #600 was notified by an aide that Resident #56 was on the floor next to the bed. At that time, Resident #56's continuous bi-pap mask was not on him, it was laying across the bed. RN #600 evaluated Resident #56 and found him unresponsive to his name, absent of breath sounds, and absent of vital signs. Hospice, the Director of Nursing (DON), and Regional RN #603 were notified of Resident #56's death. At the time of the death notification, no injuries were reported. The Coroner indicated this incident would not be a coroner's case and the body was picked up by the funeral home in the early hours on [DATE]. On [DATE] at approximately 6:30 A.M., RN #600 sent a text message to the DON and Regional RN #603 stating she forgot to tell them Resident #56 had a potential laceration to the head and blood was noted when they lifted him back into bed via hoyer lift. On [DATE] at approximately 10:20 A.M., the hospice agency contacted the Administrator and DON regarding concerns of Resident #56's alleged head injury and notified the facility that the hospice agency had contacted the coroner's office with their concerns. On [DATE] at approximately 10:25 A.M., a forensic investigator from the coroner's office arrived to the facility and informed the Administrator and DON that the coroner's office was never notified of a potential head injury for Resident #56. The summary of events included: the nurse aide notified RN #600 of Resident #56's fall out of bed on [DATE], RN #600 notified the DON and hospice nurse on [DATE], the DON notified Regional Nurse #603 of the fall on [DATE], Regional Nurse #603 notified the coroner's office of the fall and death on [DATE], the coroner did not take on Resident #56 as a case and cleared the body to be released to the funeral home on [DATE], the hospice nurse contacted the funeral home to arrange pickup on [DATE] at approximately 11:51 P.M., the hospice nurse notified Resident #56's family of his passing on [DATE], the coroner's forensic investigator arrived at the facility on [DATE], the Administrator and DON notified the family of the fall with potential head injury on [DATE], witness statements were gathered on [DATE], verbal permission was given to release medical records to the coroner's office on [DATE], and the requested medical records were provided to the coroner's office on [DATE]. The family reported no concerns about the fall or the potential head injury. The investigation documentation also included the face sheet, do not resuscitate (DNR) order, physician's notes, vital signs history, progress notes, hospice agency information, hospice aide and nurse notes, and witness statements from State Tested Nurse Aide (STNA) #610 and Non-STNA #537. There was no witness statement for RN #600 or Licensed Practical Nurse (LPN) #607, who verified Resident #56 was deceased on [DATE]. Residents Affected - Few Review of the coroner's office investigation, dated [DATE] at 9:50 A.M., revealed the facility had notified the coroner's office of Resident #56's death on [DATE] at 10:28 P.M. The coroner's office received a call on [DATE] at 9:50 A.M. from the hospice agency notifying them that there was blood on the floor, blood on the pillow, and a gash on the back of Resident #56's head. When asked why they did not report the injury at the time it was discovered, the hospice agency informed the coroner's office that the facility told them the coroner's office had already been notified and released the body. The funeral home performed embalming and noted a good size hole to the left side of the occiput parallel to the shoulders at the level of the top of the ear to the posterior aspect and it was leaking embalming fluid. The coroner's office staff arrived at the facility on [DATE] at 10:25 A.M. The coroner's office staff reported to the facility the issue with not having the discovery of a wound to the head relayed properly. Upon inspection of Resident #56's room, the head of the bed was away from the wall, there was a blanket with some visible blood in a linear mark about eight inches in length, some drops and smears of a reddish substance on the floor, and the bed in the lowest position measured 21 inches from the floor. The coroner's office staff arrived at the funeral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 5 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 home on [DATE] at 1:42 P.M. and took pictures of Resident #56's body. The wound to the back of the head had swelling around it about the size of a silver dollar in diameter and extending outward from the skull approximately one inch. The cause of death was an accident with probable closed head injury, fall from bed, and combined muscular dystrophy with hypercapneic respiratory audosis. On [DATE] at 11:53 A.M., interview with the Administrator confirmed Resident #56 was found on the floor and the nurse reported there were no injuries at the time of discovery. She stated the coroner's office and Medical Director #605 were notified and they released the body. She said the hospice nurse arrived around 11:50 P.M. and noted some blood on the pillow under his head. The Administrator stated that the following morning, [DATE], she received a call from the hospice agency around 10:00 A.M. with concerns regarding Resident #56's injury, reporting the hospice nurse did not assess Resident #56 for injury and only noticed blood on the pillow. On [DATE] at 12:27 P.M., interview with the DON stated she received a phone call from RN #600 regarding Resident #56 being found deceased on the floor. She stated both the coroner's office and Medical Director #605 had released the body because RN #600 had reported there were no injuries. She said RN #600 sent a text message to the DON on [DATE] around 6:00 A.M. to report there was blood and a head injury when they moved his body into bed. On [DATE] at 12:44 P.M., interview with RN #600 stated she notified the DON and of the fall and death. She stated that she did not touch the body further or assess for injury at that time because she was waiting for approval from the physician. RN #600 said the body was released by the coroner's office and the physician about an hour after he was discovered, so staff put him back in bed. She stated when staff moved Resident #56's body, she noticed blood on the floor under his head and observed a crack leaking blood on the back of his head. RN #600 said she waited until around 6:00 A.M. the following morning ([DATE]) to notify the DON about the injury because she had 25 other residents and other responsibilities to attend to. On [DATE] at 12:58 P.M., interview with Coroner's Staff #601 stated their office was initially notified of Resident #56's death on [DATE] at 10:28 P.M. by Regional RN #603. She said she was informed Resident #56 had rolled out of bed, his oxygen mask had come off, the bed was in the lowest position, and there was no injury. Coroner's Staff #601 informed Regional RN #603 that if there was no injury, there was no need for a coroner's investigation. Coroner's Staff #601 stated their office received a call on [DATE] around 10:00 A.M. from the hospice agency notifying them that Resident #56 had a head injury and there was blood on his bed. She stated she went to the facility and observed Resident #56's room, the bed was 20 inches from the floor, there were rails near the head of the bed, the bed was away from the wall, there were small drops of a red-brown substance on the floor, and there was a dark linear line of a substance that appeared to be blood on a blanket. She went to the funeral home to take pictures of the decedent, noting a linear wound to the back of the head with associated hematoma (bruising) that was leaking embalming fluid. She stated an investigation was opened and the cause of death was an accident with a probable closed head injury. On [DATE] at 1:20 P.M., interview with Hospice RN #602 stated when the hospice nurse arrived at the facility, she observed blood on Resident #56's pillow. That was when the facility notified hospice of the fall and stated the body had already been released. She stated there was blood on the pillow and on the back of Resident #56's head, and she confirmed the hospice nurse did not assess the wound or take measurements. On [DATE] at 2:26 P.M., interview with Coroner #604 stated there was no relay from the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 6 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 regarding Resident #56's injury from falling out of bed and it was a struggle to get the medical records from the facility. He stated there was a laceration to the back of the scalp. He stated if they had been made aware of the injury, they would have brought Resident #56 in for an in-depth evaluation to see if it contributed to his death. He said he could not determine if the actual fall caused Resident #56's death or laying on the ground for an extended period of time. Residents Affected - Few On [DATE] at 2:57 P.M., interview with Medical Director #605 stated he could not remember the specific details about Resident #56 and could not remember if the facility informed him of the injury after the fall. On [DATE] at 9:26 A.M., interview with LPN #607 stated she was working on another unit when Resident #56 fell. She said an aide told her the other nurse needed help because a resident had died and was on the floor. She said no staff moved the body at the time of discovery because they were waiting to see if he was a coroner's case. She said once he was cleared, the staff moved him back onto his bed. LPN #607 stated there was blood on the floor and on the back of his head due to trauma to the back of his head. She said she was not aware of RN #600 assessing Resident #56's injury to determine the extent. She also could not remember giving a statement at the time of the incident but stated the DON had called her on [DATE] to obtain her statement. On [DATE] at 9:39 A.M., interview with Funeral Home Director #608 stated he picked up Resident #56 at the facility, took him to the funeral home, began unwrapping his body and observed padding to the back of his head. He stated when he removed the padding, he observed a quarter sized hole on his head with a two inch hematoma surrounding it. He said he proceeded with embalming Resident #56. Funeral Home Director #608 stated the coroner's office called him on [DATE] to begin an investigation. On [DATE] at 10:07 A.M., interview with the DON stated all witness statements obtained were included in the file provided, verifying that there were no statements included from the nurses on duty at the time of the incident. Review of facility policy titled Falls - Clinical Protocol, not dated, revealed the facility would determine a resident's fall risk during the initial assessment. Staff would document falls that occurred while the individual was in the facility including when and where it happened, any observations of the event, determining the cause of the fall, and whether it was witnessed or unwitnessed. Review of facility policy titled Death of a Resident, not dated, revealed that appropriate documentation would be made in the clinical record concerning the death of a resident, to include: o Date and time of death o The name and title of the individual pronouncing the resident's death o Physician would document cause of death in the progress notes within 24 hours (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 7 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 o Level of Harm - Minimal harm or potential for actual harm Notification to the family by the nurse supervisor o Residents Affected - Few Notification to the mortician by the nurse supervisor o The name of the mortician and the person removing the deceased resident o A signed release of the body2. Review of the medical record for Resident #28 revealed an admission date of [DATE] with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of left leg above the knee, generalized muscle weakness, atherosclerotic heart disease, abnormalities of gait and mobility, generalized anxiety disorder, end stage renal disease (ESRD), difficulty in walking, peripheral vascular disease (PVD), dependence on renal dialysis, depression, Type 2 diabetes mellitus (DM2) with diabetic neuropathy, obesity, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and required extensive assistance and two staff for transfers. Review of the care plan dated [DATE] revealed Resident #28 had an impaired ability to perform or participate in activities of daily living (ADL) care secondary to diagnoses including DM2 with neuropathy, ESRD, fibromyalgia, CHF, COPD, respiratory distress syndrome, PVD, and depression. Interventions included assistance with all ADL care and mobility as needed. Review of the physician orders revealed an order dated [DATE] for a mechanical lift with a two person assist for all chair and bed transfers. Interview on [DATE] at 09:34 A.M. with Resident #34 revealed two staff members typically transfer her with the Hoyer lift (manual hydraulic lift). Resident #34 also confirmed there are times when only one staff member moves her with the Hoyer lift when no other staff are available and out of necessity. Observation on [DATE] from 01:10 P.M. to 01:12 P.M. identified STNA #513 backing out of a resident room with a Hoyer lift. Further observation revealed resident #28 in a sling suspended from a Hoyer lift just inside the doorway of her room. There was no bed or chair beneath the resident. STNA #513 abruptly stopped moving the Hoyer lift upon looking down the hallway. There were no other staff in the resident's room or in the hall at the time of the observation. After confirming the surveyor could not assist with the transfer, STNA #513 turned and started walking away with Resident #28 in the Hoyer unattended, raised in the air, and with no bed or chair beneath the resident. After approximately five to eight steps, STNA # 513 stopped and turned back toward the resident's room and contemplated out loud whether she should put the resident back down before searching for another staff member to provide assistance. STNA #513 then guided the Hoyer lift further into the room and lowed Resident #513 into her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 8 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 Interview on [DATE] at 01:10 P.M. with STNA #513 confirmed she was the only staff member transferring Resident #28 in the Hoyer lift when she stated, where is my helper and proceeded to ask if the surveyor was allowed to spot her during the resident's transfer. Interview on [DATE] at 01:12 P.M. with Resident #28 revealed there was another staff member present when the transfer process first started and confirmed only STNA #513 was present when she was being moved in the lift. Interview on [DATE] at 02:18 P.M. with STNA #513 confirmed STNA #570 was initially with her during the Hoyer transfer on [DATE] at 1:10 P.M. but left after lifting Resident #28 up in air because another resident in the 600 hall was yelling for assistance. STNA #513 confirmed she knew STNA #570 was leaving during the transfer. STNA #513 confirmed Resident #28 was being transferred from her chair to her bed but then added she was just backing out of room to reposition the Hoyer so she could place Resident #28 in her wheelchair to wait for assistance putting Resident #28 in bed. Interview on [DATE] at 08:25 AM with STNA #570 confirmed she was initially present for the Hoyer transfer of Resident #28 on the afternoon of 10//02/23 when she heard a resident yelling for help in the 600 hallway and left to check on that resident. STNA #570 confirmed Resident #28 was still in her chair when she left the resident's room. STNA #570 further clarified that Resident #28 was in the sling, the sling was hooked to the Hoyer, and Resident #28's arms were crossed over her chest in preparation for the lift, but her butt was still in the chair when she left the resident's room and the lift had not begun. Review of the facility's undated policy titled Hoyer Lift Guidelines revealed two staff members were always required when using the Hoyer lift. This deficiency represents non-compliance investigated under Complaint Number OH00147023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 9 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 0698 Provide safe, appropriate dialysis care/services 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 record review and interview, the facility failed to ensure pre and post dialysis assessments were completed per the facility policy. This finding affected two (Residents #5 and #28) of two residents investigated for dialysis services. Residents Affected - Few Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, mixed hyperlipidemia and diabetes. Review of Resident #5's physician orders revealed an order dated 07/20/23 for dialysis on Tuesday, Thursday and Saturday with pick up time of 10:45 A.M. and chair time of 11:00 A.M. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #5's medical record from 09/01/23 to 10/04/23 did not reveal evidence the resident was assessed on 09/05/23 before or after dialysis, on 09/07/23 after dialysis, on 09/09/23 before or after dialysis, on 09/12/23 before or after dialysis which included a blood pressure, on 09/14/23 before or after dialysis which included a blood pressure, on 09/16/23 after dialysis which included a blood pressure, on 09/19/23 before or after dialysis which included a blood pressure, on 09/21/23 after dialysis which included a blood pressure, on 09/26/23 after dialysis which included a blood pressure and on 09/30/23 before or after dialysis which included a blood pressure. Interview on 10/04/23 at 10:30 A.M. with Regional Registered Nurse (RN) #603 indicated the nursing staff were required to complete pre dialysis assessments including the time of exit from the facility as well as vital signs and post dialysis assessments including the return date and time, mental status and vital signs. The staff nurse was also required to assess the resident's dialysis site for any complications including bleeding. Regional RN #603 confirmed Resident #5's pre and post dialysis assessments were not completed consistently prior to and following Resident #5's dialysis services for end stage renal disease. 2. Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, type two diabetes, chronic respiratory failure, and dependence on renal dialysis. Review of Resident #28's physician orders revealed an order dated for dialysis on Monday, Wednesday, and Friday with pick up time of 4:30 A.M. and chair time of 5:00 A.M. Review of Resident #28's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #28 Care Plan dated 12/26/22 revealed Resident #28 received Resident receives hemodialysis related end stage renal disease. Interventions included Resident #28 to go to Dialysis Center three days per week, on the following days: Monday, Wednesday, and Friday; encourage dialysis, . Facility to communicate any resident concerns to Dialysis Center; obtain vital signs as ordered; inform dialysis of any abnormal labs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 10 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #28's medical record from 09/01/23 to 10/04/23 did not reveal evidence the resident was assessed on 09/01/23 after dialysis which included a blood pressure, on 09/08/23 after dialysis, on 09/11/23 before dialysis which included a blood pressure, on 09/15/23 after dialysis which included a blood pressure, on 09/27/23 before dialysis which included a blood pressure, on 10/02/23 after dialysis which included a blood pressure, on 10/02/23 before dialysis which included a blood pressure, on 10/03/23 before dialysis which included a blood pressure, on 10/04/23 before dialysis which included a blood pressure. Interview on 10/05/23 at 11:05 A.M. with Regional RN #603 confirmed Resident #28's pre and post dialysis assessments were not completed consistently prior to and following Resident #28's dialysis services for end stage renal disease. Review of the undated Dialysis Care Planning Policy revealed the facility shall initiate and maintain a professional relationship with the dialysis center for any resident admitted requiring renal dialysis. Prior to any transfer out of the facility, the nurse would complete the illustrated skin sheet. Upon return to the facility from dialysis, the nurse would perform a complete body check, observe the dialysis site for complication and report the concerns to the dialysis center immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 11 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff followed appropriate procedures following the fall and subsequent death of Resident #56. This affected one (#56) of three residents reviewed for death. The census was 59. Findings include: Review of the closed medical record for Resident #56 revealed an admission date of [DATE] with diagnoses including inclusion body myositis, acute respiratory failure with hypercapnia, anemia, depression, hypertension, pneumonia, constipation, vitamin D deficiency, age related physical debility, anxiety disorder, gastrostomy status, altered mental status, and diabetes mellitus. The resident expired on [DATE]. There was no comprehensive Minimum Data Set (MDS) Assessment because Resident #56 was only in the facility for six days prior to his expiration. Review of the assessment titled Clinical admission Documentation 0419, dated [DATE], revealed Resident #56 was not at high risk for falls. The assessment also indicated there was no baseline care plan for falls. Review of the nurse note dated [DATE] at 9:56 P.M. revealed Resident #56 was found lying on the floor next to his bed, unresponsive to his name, absent of breath sounds, and absent of vital signs. Resident #56's death was verified by two nurses. On [DATE] at 6:24 P.M., the nurses note dated [DATE] at 9:56 P.M. was edited by Registered Nurse (RN) #600 to include that Resident #56 had trauma to the occipital region of his head with a moderate amount of blood present and bruising present to the left upper extremity. Prior to this edit, there was no mention in the medical record of any injury related to his fall or death. Review of the nurse note dated [DATE] at 10:11 P.M. revealed RN #600 notified the Director of Nursing (DON) that Resident #56 was deceased . Review of the nurse note dated [DATE] at 10:50 P.M. revealed the coroner's office and Medical Director #605 had released the body, Resident #56's body could be placed back in bed, and post mortem care could be provided. Review of the nurse note dated [DATE] at 11:03 P.M. revealed RN #600 notified the hospice agency that Resident #56 was deceased . Review of the nurse note dated [DATE] at 11:49 P.M. revealed Resident #56's body was carefully placed back in bed via a mechanical hoyer lift and post mortem care was performed. The note did not include any injuries or blood identified at the time of moving Resident #56's body. Review of a text message from RN #600, dated [DATE] at 6:03 A.M., revealed she informed the DON and Regional RN #603 that there was trauma and blood from the back of Resident #56's head identified at the time of moving his body into the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 12 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's incident investigation, dated [DATE], revealed on [DATE] at approximately 10:00 P.M., RN #600 was notified by an aide that Resident #56 was on the floor next to the bed. At that time, Resident #56's continuous bi-pap mask was not on him, it was laying across the bed. RN #600 evaluated Resident #56 and found him unresponsive to his name, absent of breath sounds, and absent of vital signs. Hospice, the Director of Nursing (DON), and Regional RN #603 were notified of Resident #56's death. At the time of the death notification, no injuries were reported. The Coroner indicated this incident would not be a coroner's case and the body was picked up by the funeral home in the early hours on [DATE]. On [DATE] at approximately 6:30 A.M., RN #600 sent a text message to the DON and Regional RN #603 stating she forgot to tell them Resident #56 had a potential laceration to the head and blood was noted when they lifted him back into bed via hoyer lift. On [DATE] at 12:27 P.M., interview with the DON stated she received a phone call from RN #600 regarding Resident #56 being found deceased on the floor. She stated both the coroner's office and Medical Director #605 had released the body because RN #600 had reported there were no injuries. The DON verified RN #600 sent a text message to the DON on [DATE] around 6:00 A.M., approximately eight hours after his body was discovered on the floor, to report there was blood and a head injury when they moved his body into bed. On [DATE] at 12:44 P.M., interview with RN #600 verified she waited until around 6:00 A.M. the following morning ([DATE]) to notify the DON about the injury because she had 25 other residents and other responsibilities to attend to. On [DATE] at 9:26 A.M., interview with LPN #607 stated she was not aware of RN #600 assessing Resident #56's injury to determine the extent. This deficiency represents non-compliance investigated under Complaint Number OH00147023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 13 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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, record review and interview, the facility failed to ensure the multi-use glucometer testing (BGT) machine was disinfected and sanitized after use per the facility policy and manufacturer's directions to prevent the risk of cross-contamination of blood-borne pathogens, failed to ensure respiratory equipment was stored effectively to prevent the potential for cross contamination of airborne pathogens and failed to ensure appropriate infection control was maintained during Resident #261's tracheostomy care This finding affected one resident (Resident #161) of two residents reviewed for blood glucose monitoring, one resident (Residents #13) of four residents investigated for respiratory care and one resident (Resident #261) of one resident investigated for tracheostomy care. Residents Affected - Few Findings include: 1. Review of Resident #161's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, anxiety disorder and essential hypertension. Review of Resident #161's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #161's physician orders revealed an order dated 09/13/23 to administer Lispro sliding scale insulin if the blood sugar was 151 to 200 administer two units, 201 to 250 administer four units, 251 to 300 administer six units, 301 to 350 administer eight units, 351 to 400 administer 10 units, 401 to 450 administer 15 units before meals and at bedtime due at 7:00 A.M., 11:00 A.M., 4:00 P.M. and 8:00 P.M. Do not give over 60 units per day; and an order dated 09/13/23 for contact precautions per facility policy three times a day for methicillin-resistant staphylococcus aureus (MRSA which was a bacterial infection) and Carbapenem-Resistant Enterobacteriaceae (CRE which was antibiotic resistant bacterial infection). Review of Resident #161's physician orders revealed an order dated 09/13/23 indicated the resident was in contact precautions per the facility policy. Observation on 10/02/23 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #606 walked to the medication administration cart, picked up a FreeStyle Libre BGT system (a blood glucose monitor that doesn't require blood samples or finger sticks. The readings are based on a sensor on your arm continuously for up to 14 days at a time), walked to Resident #161's room, donned an isolation gown and gloves and went into Resident #161's room with the BGT machine. Observation on 10/02/23 at 9:35 A.M. with LPN #606 revealed the nurse removed her protective isolation gown and mask before leaving Resident #161's resident room, donned a new mask and walked to the medication cart. She then placed the BGT machine on the top of the medication cart and cleaned the BGT machine with an alcohol wipe. Interview on 10/02/23 at 9:42 A.M. with LPN #606 confirmed she did not have the appropriate BGT sanitizer wipes to clean and disinfect her BGT machine to prevent potential cross contamination of blood borne pathogens in her medication administration cart. LPN #606 stated she used an alcohol wipe because the alcohol wipe was what was available on her medication cart. Interview on 10/05/23 at 10:47 A.M. with RN Regional #603 indicated the facility used Super (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 14 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 Sani-Cloth Germicidal Disposable Wipes to sanitize and disinfect the BGT machine. Level of Harm - Minimal harm or potential for actual harm Review of the Disinfection of Equipment, Patient Care Areas and Common Areas policy updated 04/20 revealed an approved disinfectant based on the manufacturer guidelines would be utilized to disinfect equipment, patient care areas and common areas to prevent the transmission of spores, bacteria and virus. Reusable equipment would be disinfected after every patient use and stored in a clean area. Residents Affected - Few Review of the Assure Prism Multi BGT Monitoring System manufacturer directions indicated the approved disinfection wipes for the BGT machine including Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipes and CaviWipes. 2. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and emphysema. Review of Resident #13's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #13's physician orders revealed an order dated 06/01/23 for Ipratropium/Albuterol solution for nebulization 0.5 mg (milligrams)-3 mg/3 ml administer 2.5 mg inhalation every six hours at 11:00 P.M., 05:00 A.M., 11:00 A.M. and 5:00 P.M. Review of Resident #13's medication administration records (MARS) from 10/01/23 to 10/05/23 revealed the resident was administered the nebulization treatments as ordered. Observation on 10/02/23 at 2:29 P.M. revealed Resident #13's respiratory treatment mask and tubing were lying on top of the resident's nightstand beside the respiratory treatment machine and was not placed in a protective bag to prevent possible cross-contamination and spread of airborne pathogens. An additional observation on 10/04/23 at 09:40 A.M. with Assistant Director of Nursing (ADON) #528 revealed Resident #13's respiratory treatment mask and tubing were lying on the top of the respiratory treatment machine and was not placed in a bag to prevent potential cross contamination. Review of the undated Nebulizer Hand Held Treatment policy indicated to store the hand held nebulizer setup in a resident labeled plastic bag between treatments.3. Review of the medical record for Resident #261 revealed an admission date of 09/22/23 with diagnoses including cerebral infarction, muscle weakness (generalized), abnormalities of gait and mobility, aphasia, thrombocytosis, anxiety disorder, chronic systolic (congestive) heart failure, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, dissection of carotid artery, dysphagia, encounter for attention to gastrostomy, encounter for surgical aftercare following surgery on the nervous system, and tracheostomy status. Review of the care plan dated revealed Resident #261 had a potential for complications related to the tracheostomy. Interventions included to observe and record color, amount, and consistency of sputum, keep room cool and free of irritants, assure Shiley Flex trach size 6CN75H trach tube and inner cannula Shiley size 6IC75 is in place, assure that trach ties are secure, and provide tracheostomy care every day. Review of the physician orders revealed tracheostomy orders dated 09/23/23, including trach type: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 15 of 16 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 366298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Nobles Pond, Inc 7006 Fulton Drive, NW Canton, OH 44718 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 Residents Affected - Few Shiley Flex, trach size: 6CN75H, inner cannula Shiley 6IC75; change trach ties once daily, as needed, and after showers; remove Passy Muir Valve at 8:00 P.M. and place back on at 8:00 A.M.; change disposable inner cannula once a day; change suction machine tubing every week; change Trach collar weekly and as needed. Observation on 10/04/23 at 03:08 PM of Registered Nurse (RN) #563 performing tracheostomy care for Resident #261 revealed she donned a surgical face mask, a gown, and gloves to begin the procedure but did not put on goggles or a face shield. Equipment gathered included a sterile trach care kit and a non-sterile bottle containing sterile water. Once the sterile field was in place, RN #563 removed the soiled non-sterile gloves, applied sterile gloves, and poured a sterile packet of hydrogen peroxide into one compartment of the trach care tray. RN #563 then picked up the non-sterile bottle containing sterile water with her right sterile-gloved hand, opened the cap with her left sterile-gloved hand, and poured the solution into the designated compartments of the sterile trach care tray. RN #563 proceeded to clean around the tracheostomy stoma with gauze soaked in the sterile peroxide mixture, followed by gauze soaked in sterile water to rinse the area around the tracheostomy tube. The gloves used to handle the non-sterile bottle containing sterile water were not changed prior to performing trach care with the sterile solution. Interview on 10/04/23 at 03:32 P.M. with Regional RN Consultant #603 confirmed the outside of the bottle containing sterile water was not sterile and RN #563 broke sterile procedure when she picked up the bottle and poured the solution into the trach care tray using sterile gloves and did not change gloves before proceeding with tracheostomy care. Review of the undated Tracheostomy Care policy revealed staff were supposed to put on gown, mask, goggles, face shield, and non-sterile gloves prior to preparing the tracheostomy care kit. The policy also revealed a solution of half normal saline, and half peroxide should be used to cleanse the trach and the solution should be prepared prior to donning sterile gloves and cleansing the trach stoma. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366298 If continuation sheet Page 16 of 16