Health inspection·May 27, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #317 was admitted on Monday 05/16/22 with medical diagnosis including stroke, hemiplegia, diabetes, and muscle weakness. Residents Affected - Some Resident #317's nursing assessment dated [DATE] revealed Resident #317 was alert and oriented and able to make her needs known. The assessment identified Resident #317 was dependent on staff for bathing. Review of the facility shower schedule for the 300 hallway revealed the schedule was set by room number. Resident #317's shower days were listed for Wednesdays and Sundays. Observation of Resident #317 on 05/23/22 at 2:25 P.M. revealed Resident #317's fingernails were very long and had black substance under them. Resident #317 was asked about bathing and identified today was the first shower she has had since admission to the facility (6 days ago). Resident #317 confirmed no one has offered to cut her nails or ask if she liked them long. Resident #317 confirmed she does not like the nail long and is unable to cut them herself. Interview with Registered Nurse (RN) #189 on 05/24/22 at 10:51 A.M. confirmed Resident #317's fingernails were long, dirty and she had not been notified of the resident's nail condition. RN #189 confirmed STNA's are not permitted to cut Resident #317's fingernails because she is a diabetic. RN #189 identified she would clean and cut Resident #317's fingernails. 4. Resident #322 was admitted on [DATE] with medical diagnosis including cerebral palsy, pneumonia, high blood pressure, morbid obesity, depression and asthma. Review of Resident #322's admission assessment dated [DATE] revealed Resident #322 was alert and oriented and totally dependent on staff for bathing. Review of the shower schedule revealed Resident #322's showers were listed for Mondays and Thursdays on the 3:00 P.M. to 11:00 P.M. shift. Interview with Resident #322 on 05/23/22 at 11:26 A.M. revealed she has had only one shower since she arrived at the facility. Resident #322 lifted up her hair and showed it was greasy and needed washed. Resident #322 identified she asked the staff everyday for a shower and hair wash and was told if they have time. Resident #322 revealed they do not have enough nursing assistants to complete the bathing. Review of the Shower Sheets written by staff when a shower was completed with the facility Director of Nursing (DON) on 05/25/22 at 9:42 A.M. revealed Resident #322 was listed for a bed bath on 05/13/22, 05/16/22, 05/19/22, and 05/23/22. DON confirmed the resident had not been provided a shower or had her hair washed since admission on [DATE]. Interviews were completed with three facility staff members, who wished to remain anonymous on 05/26/22. The staff revealed they have been frequently short of staff and showers are not completed. Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to perform oral hygiene for Resident #4 and #9, shaving assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 2 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Resident #9, showers, and nail care for Resident #317 and #322. This affected four residents (Resident #4, #9, #317, and #322) of seven residents reviewed for activities of daily living (ADL's). Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/07/22 wit diagnoses including type 2 diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of Resident #4's physician orders revealed an order dated 02/10/22 for limited assistance of one staff member for oral hygiene. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/14/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of one to two or more staff members for all Activities of daily Living (ADL's) except eating which she was independent after being set up. Review of the care plan started on 02/17/22 revealed the resident needed therapy services due to a decline in prior function of ADL's/mobility due to the resident history of COVID-19, anemia, weakness, dysphasia, impaired ability to perform ADL/s, difficulty walking, and impaired wheelchair mobility/seating. Interventions included allowing as much independence with ADL's as possible while still maintaining safety, providing encouragement as needed to participate with ADL's daily, offering praise for resident efforts, and providing assistance as needed with ADL's. Observation and interview on 05/23/22 at 12:29 P.M. with Resident #4 revealed her teeth were not brushed daily. Her teeth was observed to have plaque and residue coating them. Interview on 05/23/22 at 12:40 P.M. with State Tested Nursing Assistant (STNA) #124 revealed residents teeth were brushed daily, at a minimum, and at the residents preferred time. Interview on 05/26/22 at 8:44 A.M. with Licensed Practical Nurse (LPN) #147 revealed the facility was short staffed, she had difficulty getting her job duties completed prior to the end of her shift, and she confirmed the STNA's reported having difficulty getting ADL care completed on their shift. Interview on 05/26/22 at 8:47 A.M. with STNA #152 and STNA #155 confirmed the facility was short staffed, they found it difficult to get job duties done, and resident ADL care lacked as as result of short staffing. Interview on 05/26/22 at 8:54 A.M. with Resident #4 revealed her teeth were last brushed the day before yesterday (05/24/22). She stated when she was set up with the needed items to brush her teeth she could do it herself. Interview on 05/26/22 at 11:09 A.M. with Resident #4 revealed her teeth still had not been brushed. Her teeth appeared coated with plaque and her lips had pink/red residue on them. 2. Review of the medical record for Resident #9 revealed an admission date of 09/22/2015 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 3 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses including but not limited to vascular dementia, communication deficit, psychological disorders including schizoaffective disorder (D/O), obsessive-compulsive D/O, depression, psychosis, mood affective D/O, CVA with hemiplegia and aphasia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment). The resident required limited to extensive assistance of one to two staff members for all Activities of daily Living (ADL's) except eating which he required set up only. Review of the plan of care dated 03/07/22 revealed the resident displayed rejection of care by refusing meals at times, refusing oral supplements, refusing to use wheelchair cushion, refusing outings, refusing ace wraps, refusing right hand splint, refusing weights and being combative at times. There was no mentioning of refusing oral care or shaving. Further review of the care plan revealed the resident had an impaired ability to perform or participate in daily ADL care related to his diagnosis of vascular dementia, communication deficit, psychological disorders including schizoaffective disorder (D/O), obsessive-compulsive D/O, depression, psychosis, mood affective D/O, CVA with hemiplegia and aphasia, and HTN. Interventions included assistance with all ADL care and mobility as needed, anticipate resident needs as able, encourage the resident to participate with care as tolerated, assist with A.M. and P.M. care, encourage resident to participate with hygiene as tolerated, assist with and/or shave facial hairs every day and as needed (prn) or per resident preference. Review of Resident #9's medical record revealed no evidence oral care or personal hygiene was documented. Observation and interview on 05/23/22 at 9:30 A.M. with Resident #9 revealed staff was not brushing his natural teeth and he could not recall the last time his teeth were brushed. He also stated he was not being assisted with shaving, he liked to be clean shaven, but had facial hair. The residents teeth were observed to be coated with a yellowish white substance. Interview on 05/23/22 at 12:40 P.M. with STNA #124 revealed residents teeth were brushed daily, at a minimum, and at the residents preferred time. Interview on 05/26/22 at 8:44 A.M. with LPN #147 revealed the facility was short staffed, she had difficulty getting her job duties completed prior to the end of her shift, and she confirmed the STNA's reported having difficulty getting ADL care completed on their shift. Interview on 05/26/22 at 8:47 A.M. with STNA #152 and STNA #155 confirmed the facility was short staffed, they found it difficult to get job duties done, and resident ADL care lacked as as result of short staffing. Interview and observation 05/26/22 at 8:56 A.M. with Resident #9 revealed he had not been shaven, had his teeth brushed, or been offered either service all week. He confirmed he would like his teeth brushed and his face shaven. His facial hair was still visible and he teeth remained coated with a yellowish white film like substance. Interview on 05/26/22 09:05 A.M. with STNA #187 revealed she got Resident #9 up, dressed, applied deodorant, and will provide the remainder of his morning care after breakfast. Interview on 05/26/22 at 10:51 A.M. with STNA #125 revealed Resident #9 has his teeth brushed after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 4 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0677 Level of Harm - Minimal harm or potential for actual harm lunch, she sets him up at the sink, with the most recent time being 05/25/22. STNA #125 revealed the resident receives showers on second shift. She confirmed the resident had facial hair. Interview on 05/26/22 at 10:58 A.M. with STNA #187 revealed Resident #9 was set up and brushed his teeth. Residents Affected - Some Interview on 05/26/22 at 10:59 A.M. with Resident #9 confirmed his teeth were brushed 05/26/22 but had not been brushed all week prior. Review of the facility policy titled, Mouth Care, undated, revealed mouth care was completed to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Further review of the policy revealed the date and time mouth care was provided, the name and title of the individual providing the mouth care, assessment of the resident's mouth, if the resident refused the treatment, the reason why and the intervention taken was to be documented in the resident's medical record. Review of the facility policy titled, Shaving the Resident, undated, revealed the date and time shaving assistance was provided, the name and title of the individual providing the care, assessment of the resident's mouth, if the resident refused the treatment, the reason why and the intervention taken was to be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 5 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, medical record review, and facility policy review, the facility failed to identify and treat Resident #4's stage III pressure ulcer. This affected one resident (Resident #4) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed the resident was admitted on [DATE] with diagnoses including type two diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/14/22, revealed the resident had (intact/ impaired) cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of one to two or more staff members for all activities of daily living (ADL's) except eating which she was independent after being set up. Further review of the MDS revealed the resident was at risk for pressure ulcers but did not have a pressure ulcer. Review of the plan of care dated 02/17/22 revealed the resident was at risk for skin breakdown related to impaired mobility, PVD, diabetes, urinary incontinence, bowel incontinence, renal disease, poor nutritional intake, friction, poor sensory, anemia, shearing, and history of impaired skin integrity. Interventions included ted hose to bilateral lower extremities as ordered, check placement, and skin integrity every shift, elbow protectors to bilateral elbows to promote healthy skin integrity, prafo boots to bilaterally heels while in bed to promote health skin integrity due to poor mobility, apply skin prep to bilateral heels as ordered for prevention of skin injury, encourage/assist the resident to float the heels as tolerated, and observe/report any noncompliance with preventative skin care and notify physician as needed. Review of Resident #4's May 2022 physician orders revealed active orders for skin prep to bilateral heels, every shift for preventative measures, bilateral ted hose to legs every day with special instructions for skin integrity and placement checks every shift, and prafo boots (pressure relieving boots) to bilateral heels while in bed to promote healthy skin integrity due to poor mobility with special instructions to check placement and skin integrity every shift. Review of the progress notes from 02/07/22 through 05/23/22 at 7:56 A.M. revealed no progress notes regarding the resident's refusal of skin prep or prafo boots. Observation on 05/23/22 at 12:18 PM of Resident #4 revealed she had an undated, meplix (bordered foam dressing), on her right heel, that was falling off. The resident stated the wound had not been changed recently and was painful. This observation was confirmed on 05/23/22 at 12:19 P.M. by LPN #103 who confirmed the area appeared to be an open, pressure ulcer, on the resident's heel, where her heel was resting on the bed. She also confirmed the dressing was undated and she was unsure when it was applied or changed. Review of Resident #4's medical record revealed no evidence the facility identified the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 6 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0686 had a pressure ulcer or an order for a wound dressing prior to the above observation. Level of Harm - Minimal harm or potential for actual harm Review of the Wound Grid Documentation dated 05/23/22 at 3:22 P.M. by the Director of Nursing (DON) revealed the resident had an in-house, stage III (Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) were often present. Slough and/or eschar may be visible. The depth of tissue damage varied by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone were not exposed. The resident had a pressure ulcer to her right heel. The wound bed was described as pink with scant exudate, ten percent (%) slough (yellow, stringy, tissue), without eschar or odor. Residents Affected - Few Interview on 05/24/22 at 11:53 A.M. with the Administrator confirmed Resident #4 was found to have a stage III on her right heel that was not identified prior to surveyor intervention. Interview on 05/26/22 at 8:44 A.M. by LPN #147 revealed the facility was short staffed, she had difficulties getting her required job duties completed and state tested nursing assistants (STNA's) had difficulty turning/repositioning residents timely. Interview on 05/26/22 at 8:47 A.M. with STNA #152 and STNA #155 revealed the facility was short staffed and they found it difficult to get their job duties done. They revealed residents are not turned or repositioned as a result. Review of the facility policy titled, Pressure Injuries: Assessment, Prevention, & Treatment, undated, revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. Further review of the policy revealed the skin would be assessed routinely for the presence of developing pressure injuries and provide care for existing pressure injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 7 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 Based on staff interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and #46 oxygen (O2) equipment was stored properly and Resident #4's oxygen orders were documented accurately. This affected two Residents (#4 and #46) of three residents reviewed for respiratory care. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 02/19/22 with diagnoses including chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, chronic combined systolic (congestive) and diastolic (congestive) heart failure, acute respiratory failure with hypoxia, obstructive sleep apnea (OSA), other nonspecific abnormal finding of lung field, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/28/22, revealed Resident #46 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of eight out of 15 (moderate impairment). The resident required limited to extensive assistance of one to two or more staff members for all activities of daily living (ADL's). Further review of the MDS revealed the resident used a non-invasive mechanical ventilator (BiPAP/CPAP) and oxygen therapy. Review of the plan of care dated 04/28/22 revealed the resident had the potential for alteration in respiratory function related to COPD, asthma, and the use of supplemental oxygen. Interventions included administration of respiratory treatments as ordered and administration of medications as ordered. Further review of the care plan revealed the resident had the potential for fluid imbalance/complications related to edema, diuretic use, and renal disease. Interventions included medications per physician orders, observe, and report any shortness of breath. Review of Resident #46's physician orders for May 2022 identified an order for continuous oxygen (O2) at two liters (L) per nasal cannula with special instructions to check placement and O2 saturation (O2 sat) every shift (7:30 A.M. to 7:30 P.M. and 7:30 P.M. to 7:30 A.M.). Observation on 05/23/22 at 9:49 A.M. with Licensed Practical Nurse (LPN) #147 and State Tested Nursing Assistant (STNA) #124, revealed the resident was on 1.5 L of O2 via an undated nasal cannula tubing. STNA #124 confirmed the observation. Additional observations on 05/23/22 at 12:32 P.M. revealed the resident remained on 1.5 L of O2 via undated nasal cannula. 2. Review of the medical record for Resident #4 revealed an admission date of 02/07/22 with diagnoses including cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/14/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of one to two or more staff members for all activities of daily living (ADL's) except eating which she was independent after being set up. Further review of the MDS revealed the resident did not receive Oxygen (O2) therapy. Review of Resident #4's physician orders for May 2022 revealed an order dated 05/22/22 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 8 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continuous oxygen at two to three Liters (L) per nasal cannula with special instructions to check placement and record oxygen saturation (O2 sat) every shift (twice per day). Review of Resident #4's progress note dated 05/22/22 at 5:53 P.M. by LPN #147 revealed the resident complained of feeling short of breath (SOB), had diminished lung sounds bilaterally, with O2 sat of 87% on room air (RA). The provider was notified and new orders for an immediate (stat) chest x ray, as needed (PRN) respiratory nebulizers, one time dose of Torsesmide (diuretic) due to edema in the residents bilaterally lower extremities (BLE), and oxygen per nasal cannula two to four liters to maintain sats above 90%. Review of Resident #4's Electronic Treatment Administration Record (ETAR) for 05/22/22 revealed the order for continuous oxygen at two to four L was transcribed incorrectly. The order read O2 and two to three L per nasal cannula with special instructions to check placement and record oxygen saturation (O2 sat) every shift (twice per day). Review of the plan of care dated 05/23/22 revealed the resident had the potential for alteration in respiratory function related to shortness of breath (SOB). Interventions included administration of respiratory treatments as ordered and administer oxygen as ordered. Observation on 05/23/22 at 9:14 A.M. revealed Resident #4's O2 in place at four Liters (L) via undated nasal cannula tubing. Further review of the nebulizer tubing, laying on nightstand, revealed the mask and tubing were undated. The observation was confirmed on 05/23/22 at 12:19 P.M. by LPN #103 who revealed O2 was to be administered per physician orders, via dated tubing, and respiratory tubing was to be stored in a bag when not in use. Review of the facility policy titled, O2 Administration undated, revealed when not in use the oxygen cannula/mask and tubing was to be stored in a plastic bag. Further review of the facility policy revealed the physician's orders were to be followed for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 9 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, and facility policy review, the facility failed to sufficiently staff the facility to provide activities of daily living assistant for Resident #4, #9, #317, and #322. This affected four residents (Resident #4, Resident #9, Resident #317, and Resident #322) of eight residents reviewed for sufficient staffing. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/07/22 wit diagnoses including type 2 diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of Resident #4's physician orders revealed an order dated 02/10/22 for limited assistance of one staff member for oral hygiene. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/14/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of one to two or more staff members for all activities of daily living (ADL's) except eating which she was independent after being set up. Review of the care plan started on 02/17/22 revealed the resident needed therapy services due to a decline in prior function of ADL's/mobility due to the resident history of COVID-19, anemia, weakness, dysphasia, impaired ability to perform ADL/s, difficulty walking, and impaired wheelchair mobility/seating. Interventions included allowing as much independence with ADL's as possible while still maintaining safety, providing encouragement as needed to participate with ADL's daily, offering praise for resident efforts, and providing assistance as needed with ADL's. Observation and interview on 05/23/22 at 12:29 P.M. with Resident #4 revealed her teeth were not brushed daily. Her teeth was observed to have plaque and residue coating them. Interview on 05/23/22 at 12:40 P.M. with State Tested Nursing Assistant (STNA) #124 revealed residents teeth were brushed daily, at a minimum, and at the residents preferred time. Interview on 05/26/22 at 8:44 A.M. with Licensed Practical Nurse (LPN) #147 revealed the facility was short staffed, she had difficulty getting her job duties completed prior to the end of her shift, and she confirmed the STNA's reported having difficulty getting ADL care completed on their shift. Interview on 05/26/22 at 8:47 A.M. with STNA #152 and STNA #155 confirmed the facility was short staffed, they found it difficult to get job duties done, and resident ADL care lacked as as result of short staffing. Interview on 05/26/22 at 8:54 A.M. with Resident #4 revealed her teeth were last brushed the day before yesterday (05/24/22). She stated when she was set up with the needed items to brush her teeth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 10 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0725 she could do it herself. Level of Harm - Minimal harm or potential for actual harm Interview on 05/26/22 at 11:09 A.M. with Resident #4 revealed her teeth still had not been brushed. Her teeth appeared coated with plaque and her lips had pink/red residue on them. Residents Affected - Some 2. Review of the medical record for Resident #9 revealed an admission date of 09/22/2015 and diagnoses including but not limited to vascular dementia, communication deficit, psychological disorders including schizoaffective disorder (D/O), obsessive-compulsive D/O, depression, psychosis, mood affective D/O, CVA with hemiplegia and aphasia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment). The resident required limited to extensive assistance of one to two staff members for all Activities of daily Living (ADL's) except eating which he required set up only. Review of the plan of care dated 03/07/22 revealed the resident displayed rejection of care by refusing meals at times, refusing oral supplements, refusing to use wheelchair cushion, refusing outings, refusing ace wraps, refusing right hand splint, refusing weights and being combative at times. There was no mentioning of refusing oral care or shaving. Further review of the care plan revealed the resident had an impaired ability to perform or participate in daily ADL care related to his diagnosis of vascular dementia, communication deficit, psychological disorders including schizoaffective disorder (D/O), obsessive-compulsive D/O, depression, psychosis, mood affective D/O, CVA with hemiplegia and aphasia, and HTN. Interventions included assistance with all ADL care and mobility as needed, anticipate resident needs as able, encourage the resident to participate with care as tolerated, assist with A.M. and P.M. care, encourage resident to participate with hygiene as tolerated, assist with and/or shave facial hairs every day and as needed (prn) or per resident preference. Review of Resident #9's medical record revealed no evidence oral care or personal hygiene was documented. Observation and interview on 05/23/22 at 9:30 A.M. with Resident #9 revealed staff was not brushing his natural teeth and he could not recall the last time his teeth were brushed. He also stated he was not being assisted with shaving, he liked to be clean shaven, but had facial hair. The residents teeth were observed to be coated with a yellowish white substance. Interview on 05/23/22 at 12:40 P.M. with STNA #124 revealed residents teeth were brushed daily, at a minimum, and at the residents preferred time. Interview on 05/26/22 at 8:44 A.M. with LPN #147 revealed the facility was short staffed, she had difficulty getting her job duties completed prior to the end of her shift, and she confirmed the STNA's reported having difficulty getting ADL care completed on their shift. Interview on 05/26/22 at 8:47 A.M. with STNA #152 and STNA #155 confirmed the facility was short staffed, they found it difficult to get job duties done, and resident ADL care lacked as as result of short staffing. Interview and observation 05/26/22 at 8:56 A.M. with Resident #9 revealed he had not been shaven, had his teeth brushed, or been offered either service all week. He confirmed he would like his teeth brushed and his face shaven. His facial hair was still visible and he teeth remained coated with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 11 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0725 yellowish white film like substance. Level of Harm - Minimal harm or potential for actual harm Interview on 05/26/22 09:05 A.M. with STNA #187 revealed she got Resident #9 up, dressed, applied deodorant, and will provide the remainder of his morning care after breakfast. Residents Affected - Some Interview on 05/26/22 at 10:51 A.M. with STNA #125 revealed Resident #9 has his teeth brushed after lunch, she sets him up at the sink, with the most recent time being 05/25/22. STNA #125 revealed the resident receives showers on second shift. She confirmed the resident had facial hair. Interview on 05/26/22 at 10:58 A.M. with STNA #187 revealed Resident #9 was set up and brushed his teeth. Interview on 05/26/22 at 10:59 A.M. with Resident #9 confirmed his teeth were brushed 05/26/22 but had not been brushed all week prior. Review of the facility policy titled, Mouth Care, undated, revealed mouth care was completed to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Further review of the policy revealed the date and time mouth care was provided, the name and title of the individual providing the mouth care, assessment of the resident's mouth, if the resident refused the treatment, the reason why and the intervention taken was to be documented in the resident's medical record. Review of the facility policy titled, Shaving the Resident, undated, revealed the date and time shaving assistance was provided, the name and title of the individual providing the care, assessment of the resident's mouth, if the resident refused the treatment, the reason why and the intervention taken was to be documented in the resident's medical record. 3. Resident #317 was admitted on Monday 05/16/22 with medical diagnosis including stroke, hemiplegia, diabetes, and muscle weakness. Resident #317's nursing assessment dated [DATE] revealed Resident #317 was alert and oriented and able to make her needs known. The assessment identified Resident #317 was dependent on staff for bathing. Review of the facility shower schedule for the 300 hallway revealed the schedule was set by room number. Resident #317's shower days were listed for Wednesdays and Sundays. Observation of Resident #317 on 05/23/22 at 2:25 P.M. revealed Resident #317's fingernails were very long and had black substance under them. Resident #317 was asked about bathing and identified today was the first shower she has had since admission to the facility (6 days ago). Resident #317 confirmed no one has offered to cut her nails or ask if she liked them long. Resident #317 confirmed she does not like the nail long and is unable to cut them herself. Interview with Registered Nurse (RN) #189 on 05/24/22 at 10:51 A.M. confirmed Resident #317's fingernails were long, dirty and she had not been notified of the resident's nail condition. RN #189 confirmed STNA's are not permitted to cut Resident #317's fingernails because she is a diabetic. RN #189 identified she would clean and cut Resident #317's fingernails. 4. Resident #322 was admitted on [DATE] with medical diagnosis including cerebral palsy, pneumonia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 12 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0725 high blood pressure, morbid obesity, depression and asthma. Level of Harm - Minimal harm or potential for actual harm Review of Resident #322's admission assessment dated [DATE] revealed Resident #322 was alert and oriented and totally dependent on staff for bathing. Residents Affected - Some Review of the shower schedule revealed Resident #322's showers were listed for Mondays and Thursdays on the 3:00 P.M. to 11:00 P.M. shift. Interview with Resident #322 on 05/23/22 at 11:26 A.M. revealed she has had only one shower since she arrived at the facility. Resident #322 lifted up her hair and showed it was greasy and needed washed. Resident #322 identified she asked the staff everyday for a shower and hair wash and was told if they have time. Resident #322 revealed they do not have enough nursing assistants to complete the bathing. Review of the Shower Sheets written by staff when a shower was completed with the facility Director of Nursing (DON) on 05/25/22 at 9:42 A.M. revealed Resident #322 was listed for a bed bath on 05/13/22, 05/16/22, 05/19/22, and 05/23/22. DON confirmed the resident had not been provided a shower or had her hair washed since admission on [DATE]. Interviews were completed with three facility staff members, who wished to remain anonymous on 05/26/22. The staff revealed they have been frequently short of staff and showers are not completed. Review of the facility policy titled, Staffing Plan, undated, revealed facility staffing was based on resident population and acuity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 13 of 14 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 366367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interviews, the facility failed to provide Resident #8 social services to obtain sufficient clothing. This affected one resident (Resident #8) of one resident reviewed for social services. Residents Affected - Few Findings include: Resident #8's was admitted on [DATE] with medical diagnosis including anxiety, depression, cognition, pain, wheezing, UTI, glaucoma, restless leg syndrome and depression. Resident #8's medical record revealed she did not have family and she had a lawyer for power of attorney. The record identified Resident #8 resided in an apartment prior to falling, going to the hospital and then being admitted at the facility. Review of Resident #8's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she was cognitively intact, with periods of confusion. The MDS indicated it was very important for Resident #8 to take care of belongings. Observation of Resident #8 on 05/23/22 at 12:21 P.M. revealed the resident had a pair of jeans and shirt sitting on her bed, while sitting in a chair with her pajamas on. Resident #8 was asking for undergarments so she could get dressed for the day. Observation of Resident #8's closet and drawers identified no undergarments and only two outfits located in her closet. Observation of Resident #8 on 05/24/22 at 10:38 A.M. revealed she had pajamas on, that had christmas decorations. Interview with Resident #8 at this time revealed she was in need of her clothing from her apartment so she can get dressed. Resident #8 identified she can dress herself as she stood up and went to her closet to show one outfit was in the closet. Resident #8 revealed she had been at the facility for a long time and needed her clothing. Review of the medical record revealed no evidence of any attempts from the facility to contact her lawyer, her power of attorney, to obtain her personal items. The record additionally identified no evidence of meetings to identify her discharge plan. Interview with Director of Nursing (DON) on 05/25/22 at 9:14 A.M. revealed she was acting as the facility social services person at this time as the facility did not have one. DON confirmed Resident #8 does not have enough clothes here and they contacted someone on this date. DON revealed the facility determined Resident #8 resided in independent living apartment prior to admission. DON confirmed the facility needed to make arrangements to get Resident #8 some clothing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 14 of 14