Health inspection·July 31, 2025

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verify this was completed. Review of concern log dated 04/16/25 revealed a resident concern related to call light issues and staff instructing the resident to stop using the call light. The resident further stated staff were turning off the call light without providing care. Staff education was provided during the all staff meeting with no minutes or sign in sheet provided to verify this was completed. There was also no mention of any call light audits. Review of concerns form undated revealed a concern related to long call light times and late medications. education was provided to staff at the all staff meeting with no minutes and no sign in sheet provided to verify this was completed. There was no mention of call light audits. Review of the concern log dated 04/20/25 revealed a resident concern of being left soiled and on soiled linens for long periods of time. Staff education was provided during the all staff meeting with no minutes or sign in sheet provided to verify completion. Review of the concern log dated 04/28/25 revealed a resident concern revealed being left laying in bowel movement. The concern was not addressed on the form. Staff education was provided during the all staff meeting with no minutes or sign in sheet provided to verify completion. The resident also moved to another room to see if care improves. Review of the concern book revealed no mention of other concerns from Resident Council and no resolutions or evidence of follow up was provided.5. Review of the Resident Council Meeting Minutes dated 05/21/25 revealed concerns of staff not completing tasks and unable to find staff when needed.Review of the concern log dated 05/02/25 revealed a resident concern related to the resident being left saturated with nightgown, mattress and hair saturated from incontinence and found to have old incontinence in brief. Staff education was provided during the all staff meeting with no minutes or sign in sheet provided to verify completion.Review of the concern book revealed no mention of other concerns from Resident Council and no resolutions or evidence of follow up was provided.6. Review of Resident Council Meeting minutes dated 06/18/25 revealed concerns of staff on their phones and not getting tasks done, long waits for call lights, night shift aides hiding in open rooms.Review of concern log dated 06/2025 revealed resident concern were not documented on concern forms and no documentation related to follow up.7. Review of Resident Council Meeting Minutes dated 07/16/25 revealed concerns of staff not doing their tasks, aides being on phones, not making beds, long call light wait times, hiding in rooms instead of caring for residents, signing off medications even though they were not passed, running out of food, not getting the right food, cold food, short on clean linens, and rooms not being cleaned/mopped.Review of concern log dated 07/08/25 revealed a resident concern related to food portion sizes. Staff education was provided related to portion sizes with no sign in sheet provided.Review of concern log dated 07/09/25 revealed a resident concern related to no response to call light for over 20 minutes, when family went to find staff they were hanging out talking at the nurses station. A resident also had the same clothes on during care conferences as she had worn the previous day. Staff education was provided on call lights, changing linens and keeping call light in reach. No mention of not cleaning resident or changing clothes and no education sign in was provided.Review of concern log dated 07/10/25 revealed a resident concern related to not being properly cleaned and room not being cleaned, and not receiving all meals and meal items. Staff education was provided related to cleaning her and her room with no mention of dietary concerns. No education sign in sheet was provided.Review of concern log dated 07/10/25 revealed a resident concern related to call lights not being answered timely. Staff education was provided related to call light response with no sign in sheet provided.Review of a concern log undated revealed resident concerns related to medications due at 7:00 P.M. but were administered at midnight. The. facility found an agency nurse had worked and was unfamiliar with electronic medical record (EMR) system. Thr facility planned to try and use staff familiar with EMR.Review of concern log (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 2 of 18 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 07/31/2025 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dated 07/16/25 revealed a resident concern related to call lights not being answered timely and staff hiding from residents in empty areas. Staff education was provided reminding them to answer call lights with no sign in sheet provided and no mention of follow up related to staff missing on their shifts.Review of concern log dated 07/23/25 revealed a resident concern related to not receiving food on her meal ticket. Resident meal ticket had been written and she had received what was on her ticket. No mention of follow up to ensure accuracy of tickets and what would come on the tray.Interview on 07/28/25 at 8:58 A.M. with Resident #19 revealed the resident was the President of the Resident Council Group. She stated the same concerns got brought up month after month without improvement. The resident stated the facility did not discuss at the meetings what the facility was doing to address the concerns. She verified staff don't pass snacks, don't pass water, call lights take up to 60 minutes to be answered, residents were missing showers and not getting timely incontinence care and brief changes. Residents had also been complaining frequently about medications administered late without improvement.Interviews on 07/29/25 between 11:30 A.M. to 3:00 P.M. with the Administrator confirmed Resident Council Meeting Minutes showed residents were complaining about the same topics month after month. The Administrator revealed several staff had been terminated due to not taking concerns seriously and finding staff that did not want to do the jobs they were hired for (answering call lights, incontinence care etc). She acknowledged concern forms did not address the issues at times and many had multiple concerns with only one addressed on the concern form.Interview on 07/30/25 at 4:40 P.M. with Activity Director #172 revealed she had worked at the facility for about one year and in the past six months or so had been taking notes during Resident Council and informing the Administrator of various complaints. She confirmed the same concepts and issues were brought up month after month.Review of facility policy titled, Resident Grievance, dated 10/2016 revealed the facility shall ensure complaints and grievances were investigated and results reported back in a reasonable time period. After a complaint was made a response shall be provided as well as follow up and complaints shall be logged as part of quality assurance.This deficiency represents non-compliance investigated under Complaint Number1354124. Event ID: Facility ID: 366367 If continuation sheet Page 3 of 18 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 07/31/2025 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 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 observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure falls were investigated thoroughly, appropriate interventions were implemented based on the cause of the falls and ensure interventions were in place per the care plan. This affected three Residents #2, #23, and #63 of three reviewed for falls. Facility census was 58. Findings include 1. Review of the medical record for Resident #2 revealed an admission date of [DATE]. Diagnoses included unspecified dementia, muscle weakness, abnormalities of gait, hypertension, diabetes and dysphagia. Review of the Care Plan dated [DATE] revealed interventions for falls prevention including: observe resident safety by looking in room when passing added [DATE]Physical therapy, occupational therapy and speech therapy added [DATE]Pharmacy and Physician to review medication with resident visits added [DATE]report medication side effects added [DATE]encourage resident to use call light for transfer/ambulation assistance added [DATE] educate resident as able about limitations and safety concerns added [DATE] encourage resident to wear glasses added [DATE]non-skid strips to floor in front of chair next to the bed to ensure traction and safety due to poor safety awareness added [DATE]non-skid footwear to ensure traction and safety due to poor safety awareness added [DATE]encourage use of a reacher to pick up items from the floor due to decreased safety awareness added [DATE] call don't fall sign to bathroom due to poor safety awareness added [DATE]ensure gait belt was in place for all transfers added [DATE]staff to encourage and assist resident with toileting prior to meals added [DATE]non-skid strips in front of toilet in bathroom due to poor safety awareness and check placement each shift added [DATE]Dycem to recliner chair due to poor safety awareness added [DATE]Colorful tape around call don't fall sign for resident to better see it added [DATE] Review of the fall risk assessment dated [DATE] revealed resident scored an eight with note that scores 10 or higher represent a high risk for falls. Review of fall investigation dated [DATE] at 7:10 A.M. revealed resident had an unwitnessed fall in her room while sitting in the chair. Family was notified on 1:30 P.M. and Physician was notified at 2:30 P.M. Neuro checks were initiated and witness statements were initiated. The investigation stated resident was trying to go to the bathroom when the fall occurred and called to alert staff. Dycem was put in place for immediate interventions. The investigation found a witness statements that included interventions of dycem to he recliner and encouraged use of the call light. Report found no evidence neuro checks were completed. Review of fall investigation dated [DATE] at 7:00 P.M. revealed resident had an unwitnessed fall in the bathroom. Family and Physician were notified. Resident sustained an injury of skin tear to right elbow and a raised knot on the back of the head. Witness statements were initiated. The investigation stated resident was noted yelling from her room and was found she was lying on her back in the bathroom. Resident had reported she was leaving the bathroom and fell. Resident was sent to the hospital for evaluation due to head injury. The intervention put in place included non-skid strips in front of the toilet in the bathroom. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of fall investigation dated [DATE] at 9:00 A.M. revealed resident had an unwitnessed fall in her room resulting in injury of a laceration to the eyebrow. Family and Physician were notified and resident was transferred to the hospital. Witness statements were initiated for the investigation. Resident was educated to use the call light. Progress note dated [DATE] revealed around 9:00 A.M. resident was screaming and an aide found resident on the floor. resident stated her head was hurting. Resident stated she was trying to use the bathroom and stated she forgot to use the call light. The investigation stated resident was trying to go to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 4 of 18 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bathroom when the fall occurred and called to alert staff. Resident had a one inch laceration with a small lump. Physician requested transfer to the hospital. Review of fall investigation dated [DATE] at 9:45 A.M. revealed resident had an unwitnessed fall in her room. Family and Physician were notified. Neuro checks were initiated, call don't fall signs in place, fall prevention education was provided, non skid shoes and bright red tape to be put on the call don't fall sign. The investigation documentation found neuro checks were not completed according to the instructions. Progress note dated [DATE] revealed resident was found in her room on the floor by an aide coming in to check on her. Resident stated she was trying to get dressed by herself and fell out of the wheelchair. Resident was confused at baseline and no changes in cognition were identified. Interview and observation on [DATE] at 11:15 A.M. with Resident #2 reported she had several falls and two with injuries in the bathroom she had never recovered from. Resident verified her recliner had no pad (dycem) but wanted to get one so she doesn't get the chair dirty. The call don't fall signs did not did not have colorful tape around them, the dycem was not present on the chair, no call don't fall signs were seen in the bathroom, the reacher was behind the television with linens and towels over it, and resident did not have glasses on or within reach. Interview and observation on [DATE] at 11:38 A.M. with Certified Nursing Aide (CNA) #141 confirmed several fall interventions were not in place. CNA confirmed glasses were not on or in reach, although resident stated she only wears them when reading confirmed a fall intervention to read signage on the walls. CNA also confirmed recliner had no pad (dycem) and stated it was a therapy thing and stated therapy would put in place if staff transferred her into her chair. CNA confirmed the call don't fall signs did not have colorful tape around them and the bathroom sign was not in place. CNA confirmed the reacher was behind the television with linens and towels over it and confirmed it was out of reach for resident. Interviews on [DATE] from 1:55 P.M. to 3:45 P.M. with the Administrator and Regional Nurse (RN) #210 confirmed facility had no evidence neuro checks on [DATE] morning fall were completed and confirmed neuro checks on [DATE] were not completed according to the instructions. RN confirmed falls investigations from [DATE] evening fall and [DATE] fall included no root cause analysis and did not mention the last time resident was toileted or offered assistance with toileting. 2. Review of the medical record for Resident #23 revealed an admission date of [DATE]. Diagnoses included vascular dementia, COVID-19, muscle weakness, abnormalities of gait, atrial fibrillation and failure to thrive. Review of the Care Plan dated [DATE] revealed interventions for falls prevention including:observe resident safety by looking in room when passingPhysical therapy, occupational therapy and speech therapyPharmacy and Physician to review medicationreport medication side effectsencourage resident to use call lighteducate resident as able about limitations and safety concernsencourage resident to wear glasses and hearing aidesnon-skid strips in front of the bednon-skid strips in front of chair non-skid footwear to ensure traction and safetycall don't fall sign to bathroomcall don't fall sign in room bright tape around call lightshoes on or non skid footwear close to bed when not wearing itemsresident to be assisted with all transfers Review of the fall risk assessment dated [DATE] revealed resident scored an eight with note that scores 10 or higher represent a high risk for falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition. Review of fall investigation dated [DATE] at 5:30 A.M. revealed resident had an unwitnessed fall in his room. Family was notified at 11:59 A.M. and Physician was notified at 11:59 A.M. Resident sustained an injury of abrasions to bilateral knees. Witness statements were initiated. Interventions included non-skid footwear and call don't fall signs. No witness statements and no neuro checks were included in the investigation. Progress note dated [DATE] revealed resident was found on the floor and stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 5 of 18 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few slipped out of bed and tried to call back in bed. Review of fall investigation dated [DATE] at 6:00 A.M. revealed resident had an unwitnessed fall with injury in his room. Family and Physician were notified. Resident sustained an injury of a laceration to the top of his head. Witness statements were initiated. Investigation stated facility received call from resident's wife stating resident had fallen. When staff arrived to the room resident was sitting on his chair with a five centimeter laceration to the top of his head with moderate bleeding. Resident stated he got up to take his little pink pills. After he fell he got himself into the chair and contacted his wife. Physician requested resident transfer to the hospital for possible sutures. Medications removed from resident room including Benadryl. Interventions included non-skid strips to be placed in front of resident chair. Review of fall investigation dated [DATE] at 5:45 A.M. revealed resident had an unwitnessed fall in his room. Family was notified and Physician was notified at 3:57 A.M. (prior to the fall). The investigation stated resident was found on the bathroom floor. He stated he felt weak and sat down and pulled the bathroom call light to alert staff. Witness statements and neuro checks were initiated. Interventions included education on needing assistance with transfers and a urine culture and sensitivity was ordered. No neuro checks were included in the investigation. Review of fall investigation dated [DATE] at 4:00 A.M. revealed resident had an witnessed fall in his room. Family and Physician were notified. Resident was attempting to walk to the bathroom and lost his balance. Aides were walking by the room at the time and helped lower resident to the floor. Witness statements were initiated. Interventions included call light education. No witness statements were included in the investigation. Review of fall investigation dated [DATE] at 6:30 P.M. revealed resident had an witnessed fall in his room. Family and Physician were notified. Witness statements were initiated. Interventions included educate on use of the call light and bright tape to call light. No witness statements were included in the investigation. Review of fall investigation dated [DATE] at 6:00 A.M. revealed resident had an witnessed fall in his bathroom. Family and Physician were notified. Witness statements were initiated. Review of progress note dated [DATE] revealed staff heard resident calling out. When they arrived to the room, resident was sitting ion the floor in front of aide in the bathroom. Staff stated when assisting with the walker, he became weak and was lowered to the floor. No changes to interventions were discussed. No witness statements were included in the investigation. Review of fall investigation dated [DATE] at 12:30 P.M. revealed resident had an unwitnessed fall in his room. Family and Physician were notified. Physician completed a medication adjustment due to hypotension and positive orthostatic blood pressures. Witness statements were initiated. No witness statements were included in the investigation. Review of the progress note dated [DATE] revealed resident was observed laying on the floor. Staff reported walking back from bathroom with resident and his legs became weak and resident feel to his knees. The intervention included a medication adjustment. Review of fall investigation dated [DATE] at 8:45 A.M. revealed resident had an unwitnessed fall in his room. Family and Physician were notified. Witness statements were initiated. Interventions were not mentioned. Neuro checks were provided after an unwitnessed fall but did not follow the instructions. Review of progress note dated [DATE] revealed resident was attempting to get up without assistance from the restroom and was looking for his wife when he fell. Resident forgot to use the call light and when he attempted to stand he lost balance and fell to the floor. Resident was educated to use the call light. Review of fall investigation dated [DATE] at 8:15 A.M. revealed resident had an unwitnessed fall in his room. Family was notified at 2:00 P.M. and Physician was notified at 9:00 A.M. Witness statements and neuro checks were initiated. Interventions included resident to be started on a two hour toileting program. Review of progress note dated [DATE] revealed resident was found laying on the floor in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 6 of 18 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few front of the bathroom. Resident reported he was going to the bathroom and lost his balance and fell to his bottom. Review of fall investigation dated [DATE] at 1:00 P.M. revealed resident had an unwitnessed fall in his room. Family and Physician were notified. Witness statements were initiated. Interventions included educate on use of the call light and wait for staff to respond. No witness statements were included in the investigation and neuro checks were not completed according to the instructions. Review of fall investigation dated [DATE] at 5:48 P.M. revealed resident had an unwitnessed fall in his room while trying to wipe up spilled milk. Family was informed at 8:20 P.M. and Physician were notified at 7:45 A.M. Neuro checks started and were not completed according to the instructions and no interventions were documented in related to the fall. Review of the progress note dated [DATE] revealed resident was found on the floor after attempting to wipe up spilled milk. Resident stated he slid down onto his buttock while cleaning. Observation on [DATE] at 9:57 A.M. of Resident #23's room revealed call light had no bright tape and non-skid strips were not in place by the bed. Interview on [DATE] at 11:05 A.M. with Resident #23 revealed he had a fall recently but stated he did not fall frequently. At time of interview Certified Nurse Aide (CNA) #167 confirmed fall interventions were not in place related to the fall care plan including non-skid strips at the bed was not in place and no bright tape was on the call light. CNA confirmed non-skid strips were in place by the chair but were out of reach if resident was getting up from the bed. Interviews on [DATE] from 1:55 P.M. to 3:45 P.M. with the Administrator and Regional Nurse (RN) #206 confirmed witness statements were missing for falls [DATE], [DATE], [DATE] morning and evening falls, [DATE] morning and evening falls, and [DATE]. They also confirmed neuro checks were not completed for falls on [DATE] and [DATE] and neuro checks did not follow instructions for falls on [DATE], [DATE] and [DATE]. RN confirmed interventions did not match the reason for the fall on [DATE] and education was used repeatedly for falls on [DATE] morning and evening, [DATE] and [DATE], and no interventions were mentioned after falls on [DATE] morning and [DATE]. RN also confirmed a delay in notification of the physician and family for fall on [DATE] and [DATE]. 3. Review of the medical record for Resident #63 revealed an admission date of [DATE] and expired on [DATE]. Diagnoses included cachexia, terminal end stage hospice, anorexia, adult failure to thrive, and anxiety. Review of the Care Plan dated [DATE] revealed interventions for falls prevention including:observe resident safety by looking in room when passing added [DATE]Physical therapy, occupational therapy and speech therapy added [DATE]Pharmacy and Physician to review medication with resident visits added [DATE]report medication side effects added [DATE]encourage resident to use call light for transfer/ambulation assistance added [DATE]educate resident as able about limitations and safety concerns added [DATE]encourage resident to wear glasses and hearing aides added [DATE]bilateral 1/2 side rails/assist bars due to weakness and poor safety cognition to assist with greater independence and bed mobility and activities of daily living added [DATE] non-skid footwear as ordered added [DATE]provide resident with a reacher and encourage use to pick up items from the floor added [DATE]non-skid strips in front of toilet in bathroom due to safety and fall prevention added [DATE]Dycem to wheelchair due to poor safety awareness added [DATE] Review of fall investigation dated [DATE] at 6:45 P.M. revealed resident had an unwitnessed fall in her room when reaching. Family and Physician were notified and neuro checks were initiated. The investigation included no evidence neuro checks were completed. The assessment marked no witness statements and the immediate intervention was add dycem to wheelchair. Review of progress note dated [DATE] revealed resident was found sitting on the floor beside the bed. Resident stated they were reaching for the call light on the bed and slid off. Resident sat on the wheelchair prior to falling to the floor. Review of the fall risk assessment dated [DATE] revealed resident scored a 10 with note that scores 10 or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 7 of 18 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete higher represent a high risk for falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition. Review of fall investigation dated [DATE] at 11:08 P.M. revealed resident was found on the floor by staff at 11:00 P.M. Resident was calling for help and stated she slid from her wheelchair as sleep caught up with her while she was in her wheelchair. Resident complained of pain to her right lower calf and posterior left arm and no injury was observed. Family and Physician were notified and neuro checks were initiated. The investigation included evidence neuro checks were completed, but were not completed according to instructions of every 15 minutes for one hour, every 30 minutes for two hours every hour for two hours and every shift for 72 hours. Interviews on [DATE] from 1:55 P.M. to 3:45 P.M. with the Administrator and #204 and Regional Nurse #210 confirmed the interventions added after [DATE] fall for dycem would not be appropriate for a fall from the bed or from reaching for the call light. They confirmed the root cause analysis would be reaching for call light which was not identified in the fall investigation and neuro checks were not completed. For the fall 06/2025 they confirmed the root cause analysis and investigation were not completed and it was an agency nurse who documented on the wrong paperwork and acknowledged the neuro checks were not completed according to the instructions. Review of facility policy titled, Falls dated [DATE] revealed the facility shall provide guidelines for assessing a resident after a fall and assist staff in identifying the cause of the fall. If a fall was unwitnessed or a head injury was observed, neuro checks shall be initiated. The Physician and family shall be notified in a timely manner. A fall investigation shall be initiated including obtaining witness statements, root cause analysis would be completed and fall risk assessment shall be updated if needed. This deficiency represents non-compliance investigated under Complaint Number OH002571615. Event ID: Facility ID: 366367 If continuation sheet Page 8 of 18 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 07/31/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of employee file and policy review, facility failed to ensure residents were free from significant medication error when Narcotics were not given as ordered and documented for Resident #67 and medications were not given as ordered for Resident #66 upon admission. This affected two Residents #66 and #67 of three reviewed for medications. Facility census was 58. Findings include Residents Affected - Few 1. Review of the medical record for Resident #67 revealed an admission date of [DATE] and expired on [DATE]. Diagnoses included unspecified dementia without behaviors, spinal stenosis, muscle weakness, osteoporosis and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of three indicating significant impaired cognition. Review of the Physician orders revealed an order dated [DATE] to [DATE] for Gabapentin capsule 300 MG with instructions to take one capsule twice daily at 6:00 A.M. and 2:00 P.M. A second order dated [DATE] to [DATE] for Gabapentin 300 MG was reviewed with instructions to take three pills once daily 7:30 P.M. to 11:30P.M. for total of 900 MG. Review of the Medication Administration Record (MAR) dated 05/2025 revealed the Gabapentin 300 MG was administered at 6:00 A.M. on all doses ([DATE] to [DATE]). The Gabapentin 300 MG was administered at 2:00 P.M. on all doses ([DATE] to [DATE]). The Gabapentin 900 MG was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]). Review of Narcotic sheets dated 05/2025 revealed Gabapentin 300 MG (one pill) was administered at 6:00 A.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], and [DATE] were not signed off as given. The Gabapentin 300 MG (one pill) was administered at 2:00 P.M. on all doses ([DATE] to [DATE]) except [DATE] and [DATE] were not signed off as given. The Gabapentin 900 MG (three pills) was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]) except [DATE] and [DATE] were signed off as given but only one of the three pills ordered were signed off as given. Review of the care plan dated [DATE] revealed resident received an anticonvulsant medication for pain with interventions to administer according to Physician orders. Review of the MAR dated 06/2026 revealed the Gabapentin 300 MG was administered at 6:00 A.M. on all doses ([DATE] to [DATE]). The Gabapentin 300 MG was administered at 2:00 P.M. on all doses ([DATE] to [DATE]) except on [DATE]. The Gabapentin 900 MG was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]). Review of Narcotic sheets dated 06/2025 revealed Gabapentin 300 MG (one pill) was administered at 6:00 A.M. on all doses ([DATE] to [DATE]) except [DATE] was not signed off as given. Two morning doses were signed off as given on [DATE] (at 5:38 A.M. and 9:00 A.M.), [DATE] (at 12:32 A.M. and 6:00 A.M.), and [DATE] (at 5:50 A.M. and 6:40 A.M.). The Gabapentin 300 MG (one pill) was administered at 2:00 P.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were not signed off as given. The Gabapentin 900 MG (three pills) was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] were signed off as given but only one of the three pills ordered were signed off as given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 9 of 18 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 07/31/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Review of the MAR dated 07/2025 revealed the Gabapentin 300 MG was administered at 6:00 A.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The Gabapentin 300 MG was administered at 2:00 P.M. on all doses ([DATE] to [DATE]) except [DATE]. The Gabapentin 900 MG was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], [DATE] and [DATE]. Residents Affected - Few Review of Narcotic sheets dated 07/2025 revealed Gabapentin 300 MG (one pill) was administered at 6:00 A.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were not signed off as given. The Gabapentin 300 MG (one pill) was administered at 2:00 P.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], and [DATE] were not signed off as given. The Gabapentin 900 MG (three pills) was administered from 7:30 P.M. to 11:30 P.M. on all doses ([DATE] to [DATE]) except [DATE], [DATE], [DATE], and [DATE]. The Gabapentin 900 MG (three pills) were signed off as given on [DATE], [DATE], [DATE], and [DATE] but only one of the three pills ordered were signed off as given. Interviews on [DATE] from 4:50 P.M. to 5:46 P.M. with the Administrator revealed a nurse was terminated after numerous issues with care and documentation. On [DATE] RN #128 had asked a medication aide to pass medications outside their scheduled windows. She was being sent home and the Director of Nursing was taking over the medication cart where it was found medications were documented in the MAR as administered according to physician order, but the packets of pills were found unadministered in the cart for two residents who were away from the facility for appointments/family visits. Additional medications concerns were noted for narcotics documented as administered by RN #128 but were not yet administered and several were not due for several hours. Administrator stated the Director of nursing reviewed medications and found that the two residents with pill packets were out of the building and medications should have been marked refused or unavailable. Four of the five narcotics were identified as no This missing Gabapentin was mentioned in a statement, but was with a resident who doesn't have an order for gabapentin. Interviews on [DATE] from 12:20 P.M. to 3:00 P.M. with the Administrator confirmed additional documentation and narcotic sheets were reviewed. The Administrator confirmed numbers don't match and don't make sense, stated the narcotic forms come from pharmacy and confirmed staff were not filling them out correctly and were mixing up the two different scripts and signing off on the wrong sheets. Interviews on [DATE] from 6:50 A.M. to 7:30 A.M. with Registered Nurse (RN) #79 reviewed documentation of MARs and narcotic sheets and acknowledged medications were signed off on the MAR but not on the narcotic sheet. He reviewed his documentation on the MAR and narcotic sheet and confirmed he had never given three Gabapentin pills in one sitting and confirmed he only gave one and did not properly follow the order on [DATE]. Review of facility policy titled Medication Administration-general guidelines, dated 05/2020, revealed medications shall be administered as prescribed and in accordance with good nursing principles. Residents had the right to the right dose and right time of medication administration. Medications shall be administered within 60 minutes of the scheduled times. The staff who administered the medications shall document directly after the administration was complete. 2. Review of Resident #66's medical record revealed admission date [DATE] and discharge date [DATE] with diagnoses including but not limited to spinal stenosis, weakness, hemiplegia, and congestive heart failure (CHF). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 10 of 18 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 07/31/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #66's physician orders revealed an order dated [DATE] for hypothyroid medication Levothyroxine 25 micrograms (mcg) give one tablet daily, and an order dated [DATE] for diabetes medication Pioglitazone 15 milligrams (mg) give one tablet daily. Review of Resident #66's Medication Administration Record (MAR) dated [DATE] to [DATE] revealed medications Levothyroxine 25 micrograms (mcg) give one tablet daily and Pioglitazone 15 milligrams (mg) give one tablet daily were not administered until [DATE] due to being received from pharmacy until [DATE]. Review of Resident #66's progress notes dated [DATE] to [DATE] revealed no documentation or entries reflecting Residents #66's medications Levothyroxine and Pioglitazone not being administered and there were no entries to reflect the physician was notified on Resident #66 not being notified of the medications not being administered as ordered. Review of the facility's policy titled, Medication Administration dated 05/2020 revealed Medications are to be administered as prescribed in accordance with good nursing principles and practice. An interview on [DATE] at 1:30 P.M. with the Regional Nurse Consultant (RNC) #210 confirmed Resident #66 did not receive the medications Levothyroxine and Pioglitazone until [DATE] and there was no notifications to the physician concerning Resident #66 not receiving those medications. This deficiency represents non-compliance investigated under Complaint Number OH002571615, OH002570084, OH001354126, and OH00135124. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 11 of 18 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 07/31/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, facility failed to ensure menus and spreadsheets were followed and full meals were provided. This affected five Residents #18, #19, #20, #38 and #57 of five reviewed for nutrition. Facility census was 58. Findings include 1. Review of the medical record for Resident #18 revealed an admission date of 03/11/24. Diagnoses included senile degeneration of the brain, dementia and aphasia. Review of physician orders dated 03/13/24 for regular diet with puree texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was not preformed and stated resident was rarely if ever understood, indicating impaired cognition. Observation and interview on 07/28/25 from 12:20 P.M. to 12:30 P.M. during tray line observation with Kitchen staff #102 and #181 and Regional Kitchen Manager (RKM) #206 revealed a meal ticket for Resident #57 stating puree cookies for lunch meal 07/28/25. Resident #57's tray was made with staff not placing any pureed cookie on the meal tray. Kitchen staff #102 and #181 stated it was not needed when asked about the missing pureed item. When asked if the pureed cookies were made, Kitchen staff #102 stated it was not my job. RKM reviewed the menu and spreadsheet with Kitchen staff #102 and verified staff were supposed to make and provide puree cookies. RKM grabbed one package of cookies and made puree cookies for Resident # 57. An additional Resident # 18 was also ordered a pureed diet. 2. Review of the medical record for Resident #57 revealed an admission date of 05/19/23. Diagnoses included sepsis, urinary tract infection, muscle weakness, encephalopathy, diabetes, heart failure and liver cirrhosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 10 indicating moderately impaired cognition. Review of physician orders dated 07/10/25 for no added salt and low concentrated sweets diet with puree texture. Observation and interview on 07/28/25 from 12:20 P.M. to 12:30 P.M. during tray line observation with Kitchen staff #102 and #181 and Regional Kitchen Manager (RKM) #206 revealed a meal ticket for Resident #57 stating puree cookies for lunch meal 07/28/25. Resident #57's tray was made with staff not placing any pureed cookie on the meal tray. Kitchen staff #102 and #181 stated it was not needed when asked about the missing pureed item. When asked if the pureed cookies were made, Kitchen staff #102 stated it was not my job. RKM reviewed the menu and spreadsheet with Kitchen staff #102 and verified staff were supposed to make and provide puree cookies. RKM grabbed one package of cookies and made puree cookies for Resident # 57. An additional Resident # 18 was also ordered a pureed diet. 3. Review of the medical record for Resident #20 revealed an admission date of 10/02/17. Diagnoses included metabolic encephalopathy, Parkinson's, muscle weakness, respiratory failure and unspecified dementia. Review of physician orders dated 01/26/25 for regular diet with mechanical texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Observation and interview on 07/28/25 at 1:20 P.M. revealed Resident #20 was eating with staff assistance from Certified Nurse Aide (CNA) #167. No bowls and no two handled cup was observed on the tray or in the room. Resident #20 and CNA #167 confirmed no bowls and two handled cup was provided. CNA also confirmed it was documented on the meal ticket for lunch 07/28/25 for food to be served in bowls and drinks to be provided in a two handed cup. Observation and interview on 07/29/25 at 9:05 A.M. revealed Resident #20 was eating with staff assistance from Certified Nurse Aide (CNA) #185. No bowls and no two handled cup was observed on the tray or in the room. Resident #20 and CNA #167 confirmed no bowls and two handled cup was provided. CNA also confirmed it was documented and highlighted on the meal ticket for breakfast 07/29/25 for food to be served in bowls and drinks to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 12 of 18 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 07/31/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete provided in a two handed cup. 4. Review of the medical record for Resident #38 revealed an admission date of 03/05/25. Diagnoses included fractured right femur, aftercare of joint replacement surgery, Alzheimer's disease, and anxiety. Review of physician orders dated 03/05/25 for regular diet with mechanical texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was not preformed and stated resident was rarely if ever understood, indicating impaired cognition. Observation and interview on 07/28/25 from 12:20 P.M. to 12:30 P.M. during tray line observation with Kitchen staff #102 and #181 and Regional Kitchen Manager (RKM) #206 revealed a meal ticket for Resident #38 stating mechanical chicken for lunch meal 07/28/25. Observation of staff making up meal trays revealed facility failed to place gravy on the mechanical chicken. Upon surveyor intervention Kitchen staff #102, #181 and RKM #206 rechecked the covered dish on the meal cart and confirmed no gravy was placed on the mechanical chicken. Kitchen staff confirmed gravy should be put on mechanical meat items. 5. Review of the medical record for Resident #19 revealed an admission date of 08/22/24. Diagnoses included obstructive pulmonary disease, muscle weakness, COVID-19, and atrial fibrillation. Review of physician orders dated 06/18/25 for low concentrated sweets and no added salt diet with regular texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition. Observation and interview on 07/29/25 at 8:58 A.M. with Resident #19 coming to the doorway of her room and asking staff where the rest of the meal was. Resident stated she wanted the main items including a breakfast egg, ham, and cheese croissant. Resident informed staff passing trays she only received a bowl of cold cereal. Resident stated staff regularly miss giving items on the menu or meal tickets. Review of the menu for breakfast on 07/29/25 revealed breakfast egg, ham, and cheese croissant, hot/cold cereal, and fruit of the day. Review of the meal ticket dated 07/29/25 revealed a handwritten not for a specific cereal with no items crossed out. Interview on 07/29/25 at 9:06 A.M. with Certified Nurse Aide #185 confirmed kitchen only provided a bowl of cold cereal and did not provide the rest of the breakfast meal items listed on the meal ticket. Interview on 07/29/25 at 9:40 A.M. with Regional Nurse #210 acknowledged all residents should receive full meal. 6. Observation and interview on 07/28/25 from 12:20 P.M. to 12:30 P.M. during tray line observation with Kitchen staff #102 and #181 and Regional Kitchen Manager (RKM) #206 revealed applesauce cups were made up ahead of time with about half with lids facing upward and the other half with lids facing inwards or inverted. The applesauce cups with inverted lids were observed to have about half the serving from the ones with lids facing upwards. Kitchen staff #181 stated they were fine and it did not really matter. RKM #206 observed and confirmed the applesauce containers with inverted lid was a smaller serving size and confirmed they should all be the same. RKM revealed facility had run out of the right size lids and supplemented with a different lid and confirmed all applesauce servings should be of the same serving size. RKM educated Kitchen staff #102 and #181 and informed them to not serve the inverted cups and they would need to re-scoop and serve the correct serving size. This deficiency represents non-compliance investigated under Complaint Number OH002571615 and OH002570084. Event ID: Facility ID: 366367 If continuation sheet Page 13 of 18 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 07/31/2025 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 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 observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure residents were placed in proper isolation type, with appropriate signage. Facility also failed to ensure staff were knowledgeable to isolation status of residents and failed to wear the correct personal protective equipment (PPE). This affected four Residents #19, #20, #23, and #24 of four reviewed for isolation status. Facility also failed to ensure proper sanitization of the glucometer affecting Resident #12 and ensure infection control was maintained during medication administration affecting Resident #68. Facility census was 58. Findings include Residents Affected - Some 1. Review of the medical record for Resident #19 revealed an admission date of 08/22/24. Diagnoses included obstructive pulmonary disease, muscle weakness, COVID-19, and atrial fibrillation. Review of progress note dated 07/16/25 revealed resident tested positive for COVID-19, resident family contacted. Progress note dated 07/28/25 at 1:54 P.M. revealed staff discussed transmission based precautions with physician and was approved to discontinue precautions. Review of physician order dated 07/16/25 and 07/26/25 revealed resident should be in airbourne isolation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition. Observation on 07/28/25 at 1:05 P.M. revealed Resident #19 had a contact precautions sign posted from the Center of Disease control (CDC) which provided information on what Personal protective information was to be worn. It stated a gown and gloves should be worn at entrance to the room. Observation on 07/28/25 from 1:11 P.M. to 1:14 P.M. found only gowns and N-95 masks could be found. Eye protection was found after checking five PPE boxes and no gloves could be found. Interview and observation on 07/28/25 at 1:14 PM with housekeeper #173 confirmed the PPE boxes did not have gloves but stated they should be in the resident rooms. Housekeeper #173 walked into resident # 19's room past the contact isolation sign on the door without wearing any PPE. She confirmed she did not wear any PPE and confirmed the sign said to wear gown and gloves. Housekeeper #173 confirmed staff should be wearing the required PPE upon entrance to the room. Observation at 07/28/25 at 4:00 P.M. revealed several signs had been removed or changed including removing signs for Resident #20 isolation status. 2. Review of the medical record for Resident #20 revealed an admission date of 10/02/17. Diagnoses included metabolic encephalopathy, Parkinson's, muscle weakness, respiratory failure and unspecified dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Progress note dated 07/16/25, 07/21/25 and 07/30/25 revealed Resident refused COVID testing, Physician and family aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 14 of 18 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 07/31/2025 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 0880 Record review found no documentation was found or provided on why resident was in isolation status. Level of Harm - Minimal harm or potential for actual harm Observation on 07/28/25 at 1:05 P.M. revealed Resident #20 had a piece of computer paper with only the words contact precautions typed on it. It gave no description or instructions. Residents Affected - Some Interview and observation on 07/28/25 at 1:11 P.M. with Licensed Practical Nurse (LPN) #110 confirmed Resident #20 was in isolation for COIVD. LPN confirmed the sign on the door just stated contact precautions with no instructions or description. LPN was asked what personal protective equipment (PPE) should be worn when going in the room and LPN stated I am not sure. LPN also stated she was unsure what to wear for contact precautions and was unsure why the signage was different from one contact precaution sign with details to another without. Observation on 07/28/25 from 1:11 P.M. to 1:14 P.M. found only gowns and N-95 masks could be found. Eye protection was found after checking five PPE boxes and no gloves could be found. Interview and observation on 07/28/25 at 1:20 P.M. with Certified Nurse Aide (CNA) #167 was assisting with feeding Resident #20. CNA was only wearing a surgical mask and no other PPE. CNA confirmed she was wearing only a surgical mask and confirmed she saw the sign for contact precautions on the door to residents room. She acknowledged she was unsure what she should be wearing when entering residents room for COVID-19 isolation. Interview on 07/28/25 at 1:26 P.M. with Regional VP #204 confirmed signage for COVID-19 positive should not just be contact precautions and also confirmed she was unsure why residents did not have the proper signage and only a printout of contact precautions typed on it. Observation at 07/28/25 at 4:00 P.M. revealed several signs had been removed or changed including removing signs for #20 isolation status. Interview on 07/28/25 at 4:33 P.M. with Regional Nurse #210 and Regional VP #204 revealed the contact precautions typed signs were for COVID positive residents. The Regional Nurse was not aware of the handmade signs but clarified those residents were in covid isolation until the physician cleared them this date 07/28/25 in the afternoon. He also revealed residents should have the official sign on the door with PPE available and staff should know what to wear and when and staff should be wearing correct PPE. 3. Review of the medical record for Resident #23 revealed an admission date of 03/12/25. Diagnoses included vascular dementia, COVID-19, muscle weakness, abnormalities of gait, atrial fibrillation and failure to thrive. Review of physician orders dated 05/31/25 to 07/30/25 revealed orders to cleanse laceration to the back of the head with soap and water once daily and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition. Progress note dated 07/16/25 revealed resident tested positive for COVID-19. Physician and family notified and resident placed in isolation. Progress note dated 07/28/25 at 2:05 P.M. revealed staff discussed transmission based precautions with physician and was approved to discontinue precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 15 of 18 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 07/31/2025 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 0880 Review of physician order dated 07/16/25 and 07/26/25 revealed resident should be in airbourne isolation. Level of Harm - Minimal harm or potential for actual harm Observation on 07/28/25 at 1:05 P.M. revealed Resident #22 had a piece of computer paper with only the words contact precautions typed on it. It gave no description or instructions. Residents Affected - Some Interview on 07/28/25 at 1:26 P.M. with Regional VP #204 confirmed signage for COVID-19 positive should not just be contact precautions and also confirmed she was unsure why residents did not have the proper signage and only a printout of contact precautions typed on it. Observation at 07/28/25 at 4:00 P.M. revealed several signs had been changed including changing Resident #23's sign from contact precautions to enhanced barrier precautions. Interview on 07/28/25 at 4:33 P.M. with Regional Nurse #210 and Regional VP #204 revealed the contact precautions typed signs were for COVID positive residents. The Regional Nurse was not aware of the handmade signs but clarified those residents were in covid isolation until the physician cleared them this date 07/28/25 in the afternoon. He also revealed residents should have the official sign on the door with PPE available and staff should know what to wear and when and staff should be wearing correct PPE. Interview on 07/29/25 at 9:40 A.M. with Corporate nurse #210 confirmed Resident #23 was in enhanced barrier isolation due to a laceration to the head that was receiving wound treatments. 4. Review of the medical record for Resident #24 revealed an admission date of 04/30/25. Diagnoses included hemiplegia and hemiparesis, diabetes, muscle weakness, cognitive communication deficit, and dysphagia. Review of physician orders dated 05/01/25 revealed orders for wound care to cleanse right ischium with soap and water. Review of physician order found an order for enhanced barrier precautions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition. Observation on 07/28/25 at 1:05 P.M. revealed Resident #24 had no isolation signage outside the door. Observation at 07/28/25 at 4:00 P.M. revealed several signs had been changed including an added isolation signage for Resident #24. Interview on 07/28/25 at 4:33 P.M. with Regional Nurse #210 and Regional VP #204 revealed residents should have the official sign on the door with PPE available and staff should know what to wear and when and staff should be wearing correct PPE. Interview on 07/29/25 at 9:40 A.M. with Corporate nurse #210 confirmed Resident #24 was in enhanced barrier precautions due to wounds, catheter and tube feeding. Interview and observation on 07/29/25 at 4:18 P.M. to 4:39 P.M. with LPN #110 revealed she administered medication and tube feeding solution through a feeding tube for Resident #24. Outside Resident #24's door was a sign for enhanced barrier precautions stating to wear gown and gloves and handling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 16 of 18 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 07/31/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some close contact items such as a tube feed. LPN wore gloves only while handing the tube feed. LPN confirmed she did not wear a gown and when asked about understanding of enhanced barrier precautions, LPN verified no knowledge of this type of isolation. Review of the signage for Enhanced Barrier Precautions stated provider and staff must wear gown and gloves for the following activities: device care or use (feeding tube). Review of the contact precaution signage stated gown and gloves shall be used when entering and upon leaving the room. Review of facility policy titled, Isolation-Transmission Based Precautions, dated 07/01/25 revealed appropriate precautions shall be used for individuals confirmed or suspected to have infections. Airbourne Precautions shall be used for COVID-19 infections. Signage shall be used to alert staff of the precautions and wear appropriate personal protective equipment prior to entering resident rooms. Contact precautions were not used for COVID-19 but gown and gloves shall be worn. Enhanced Barrier Precautions include wearing gowns and gloves during high contact activities for select residents. Review of facility policy titled, Coronavirus, dated 11/19/24 revealed Residents shall be placed in isolation for 10 days and appropriate personal protective equipment shall be used. 5. Review of Resident #12's medical record revealed admission [DATE] with diagnoses including but not limited to nasal fracture, type two diabetes, and high blood pressure. Resident #12 was cognitively intact and required limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #12's physician orders revealed an order dated 07/25/25 to obtain accuchecks (blood sugar readings using a glucometer) three times a day (TID) before meals to monitor type two diabetes. An observation on 07/30/25 at 9:35 A.M. revealed Licensed Practical Nurse (LPN) #110 preparing to obtain Resident #12's blood sugar reading. LPN #110 removed the glucometer from the chest pocket of her scrub top and placed it on the medication cart without cleaning the glucometer. LPN #110 gathered the test strips bottle, a lancet, and alcohol wipe from the medication cart and proceeded to enter Resident #12's room. LPN #110 placed the glucometer, bottle of test strips, lancet, and the alcohol wipe on the bed covering at the foot of Resident #12's bed, there was no barrier used. LPN #110 obtained Resident #12's blood sugar reading and continued to place the equipment and supplies on the bed covering without using a barrier. LPN #110 then exited the room, replaced the bottle of test strips in the medication cart drawer, disposed of the used test strip and lancet, and placed the glucometer on the medication cart without a barrier. LPN #110 did not clean the glucometer after use with Resident #12. LPN #110 sanitized her hands and began preparing medication for administration for the next resident. A review of the facility's policy titled, Fingerstick Glucose Level dated 05/01/25 revealed, Prepare a field on the bedside stand or over the bed table by placing a clean towel or paper towels down to create a clean barrier. Clean reusable equipment according to the manufacturer's instructions (single use bleach wipe). Set equipment on a clean barrier and allow appropriate drying time. An interview on 07/30/25 at 9:55 A.M. with LPN #110 confirmed the glucometer was not cleaned prior to and after use with Resident #12, and there was no clean barrier used for the supplies and equipment when obtaining Resident #12's blood sugar reading. LPN #110 stated the glucometer is usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 17 of 18 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 07/31/2025 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 0880 cleaned at the end of the shift. Level of Harm - Minimal harm or potential for actual harm 6. Review of the medical record for Resident #68 revealed readmission date 07/28/25 with diagnoses including but not limited to arthritis, high blood pressure, and type two diabetes. Residents Affected - Some Review of Resident #68's physician orders revealed an order dated 06/25/25 for supplement Vitamin D3 20 micrograms (mcg) give daily by mouth, and order dated 06/25/25 for high blood pressure medication Lorsartan 100-12.5 milligrams (mg) give daily by mouth, and order dated 06/25/25 for a supplement Oyster Shell with Calcium 500 mg daily by mouth. An observation on 07/30/25 at 10:10 A.M. revealed LPN #110 preparing morning medication administration for Resident #68. LPN #110 donned gloves without washing or sanitizing hands prior to glove use. LPN #110 removed the individual tablets from the packaging by popping them out of the medication cards and/or pouring them out of the bottles into her gloved hand and then placing them into the medication cup. LPN #110 had been touching the medication cart and lap top computer with the gloved hands prior to handling the medications. Review of the facility's policy titled, Preparation and General Guidelines – Medication Administration dated 05/2020 revealed, Hands are washed before putting on examination gloves. An interview on 07/30/25 at 10:30 A.M. with LPN #110 confirmed her hands were not washed or sanitized prior to donning gloves, and medications were dispensed form their packaging by popping and/our pouring the individual tablets into a gloved hand and then placed into the medication cup by LPN #110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366367 If continuation sheet Page 18 of 18