Health inspection·January 21, 2025

F 0697 non-medication relief measures such as repositioning, pillows, pad, support, diversion, if indicated and remind resident that reporting pain early may improve effectiveness of pain medication. Level of Harm - Actual harm Residents Affected - Few Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #87 was cognitively intact for daily decision-making and had received as needed pain medications and non-pharmacological interventions. The resident stated his pain was almost constant with an intensity of a 10 out of 10 that frequently affected his sleep and day-to-day activities. The resident had one unstageable pressure ulcer, diabetic foot ulcers and an infection of the foot. Review of the electronic physician orders revealed Resident #87 was ordered the following scheduled medications for pain management: OxyContin (opioid to treat moderate to severe pain) 10 mg extended release every 12 hours at 10:00 A.M. and 10:00 P.M. and Diclofenac cream (nonsteroidal anti-inflammatory) to affected joints as ordered every six hours. The last dose of Oxycontin was administered on [DATE] at 10:00 P.M. and the last dose of Diclofenac cream on [DATE] at 6:00 A.M. Further review of the resident's current electronic physician orders, dated [DATE], revealed Resident #87 had the following as needed (PRN) medications for pain management: acetaminophen (Tylenol) every six hours prn for complaints of pain rated 1-10 on a 0-10 pain rating scale and Oxycodone-acetaminophen (opioid) 5/325 mg one tablet every four hours prn for complaints of pain rated 1-10. The resident received one dose of Oxycodone on [DATE] at 5:21 P.M. Pain assessments were ordered to be completed once a shift and with the administration of PRN medications. Review of the Wound Management assessment dated [DATE] revealed Resident #87 had six diabetic ulcers, a sacrum and a penile pressure ulcer. On [DATE] at 9:12 A.M. Registered Nurse (RN) #202 was observed to administer scheduled morning medications to Resident #87. At that time, a pain assessment was completed and the resident denied complaints of pain. The medications administered to Resident #87 did not include his scheduled Oxycontin. No additional information was provided from RN #202 during the investigation. On [DATE] at 11:30 A.M., while the surveyor was making observations on Resident #87's unit, a loud moaning sound could be heard and got louder when the surveyor walked toward Resident #87's room. Resident #87 was observed, lying in his bed, with his right hand pressed against his forehead with facial grimacing. He was moving his head side to side and moaning. Resident #87 complained of severe pain described as a radiating, constant, burning/aching/throbbing pain of both legs (the right was worse than the left leg), sacrum and feet. Resident #87 rated his pain a 10 out of 10 and stated he receives routine pain medicine because he has a lot of pain from his wounds but was not sure when he last received the medication. On [DATE] at 11:35 A.M. the surveyor reported to RN #201 that Resident #87 had complaints of severe pain and asked if the resident had received his scheduled 10:00 A.M. dose of Oxycontin. RN #201 reviewed the electronic Medication Administration Record (eMAR) and the controlled drug record for Resident #87 and verified the resident had not received his scheduled 10:00 A.M. dose of Oxycontin. RN #201 stated she arrived to work around 10:00 A.M. and was assigned to Unit 300 (Resident #87s unit) and began her assignment, which consisted of medication administration, around 10:10 A.M. RN #201 verified the resident had not received his Oxycontin because she was administering medications to other residents who had not received medications and they were late too (over an hour past the scheduled medication administration time and were indicated by red color coding in the computer system). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 2 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0697 Level of Harm - Actual harm Residents Affected - Few Further observation at 11:39 A.M. revealed RN #201 dispensed OxyContin 10 mg into a medication cup, locked the medication cart and walked to Resident #87's room. Upon entrance to Resident #87's room, the resident was observed with facial grimacing and RN #201 asked the resident how he was doing. Resident #87 stated I am hurting and RN #201 replied good thing I brought this and handed the resident the medication cup containing the OxyContin 10 mg and a four-ounce glass of water. The resident took the medication and moaned. RN #201 told Resident #87 it would take 35 to 45 minutes for the pain medication to take effect, asked him if he wanted to keep the rest of the water provided with the medication and then exited his room. RN #201 did not assess the resident's pain and did not offer to reposition the resident or provide any non-pharmacological interventions to alleviate the resident's pain. Review of the electronic Medication Administration Record (eMAR) dated [DATE] revealed RN #201 documented Resident #87's 10:00 A.M. dose of OxyContin 10 mg was administered at 11:39 A.M. with comments including late administration: charted late with comment res (resident) care. On [DATE] at 12:07 P.M., observation of Resident #87 revealed he was in bed with his eyes closed. No moaning was heard coming from his room and he opened his eyes after obtaining permission to enter his room. Resident #87 stated that his pain lasts, once it starts, until the pain medicine starts to work. Resident #87 stated he still had pain in his legs, rated a six out of 10 and hoped the nurse would be returning to do the treatments to his legs. Review of the progress note dated [DATE] at 12:09 P.M. revealed pain medication administered at 11:35 A.M. and signed out at 11:39 A.M. Nurse Practitioner #200 notified of the late administration due to resident care. Interview with RN #201 on [DATE] at 4:15 P.M. for clarification as to why she documented 'charted late' when the medication administration was observed to be administered at 11:39 A.M. RN #201 stated that 'charted late' was just one option they have to document under. The RN verified Resident #87's OxyContin was administered greater than one hour after the scheduled administration time (considered late) and documented res care because she was providing care to other residents during the scheduled administration time (not that Resident #87 was receiving resident care to cause the late administration). The RN verified the resident did not receive his Oxycontin as scheduled, resulting in the resident moaning and complaining of severe pain. Review of the medical record revealed no evidence a comprehensive pain assessment was completed on [DATE] related to the late dose of scheduled pain medication. 2. Closed medical record review revealed Resident #74 was admitted on [DATE] with diagnoses including generalized osteoarthritis, spinal stenosis, lumbar region without neurogenic claudication, wedge compression fracture of T9-T10 vertebra, sequela-chronic T9 fracture, chronic pain syndrome, difficulty in walking, abnormal posture, need for assistance with personal care, displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, congestive heart failure and peripheral vascular disease. Review of the care plan: Pain (dated [DATE]) revealed potential for pain related to odontoid fracture, right ankle fracture, osteoarthritis, lumbar spinal stenosis, chronic T9 fracture, chronic pain syndrome, muscle spasms, and restless leg syndrome. Interventions included to administer pain medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 3 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0697 Level of Harm - Actual harm Residents Affected - Few Review of the care plan: Hospice (dated [DATE]) revealed Resident #74 was receiving hospice benefits for diagnoses including end stage congestive heart failure, pain, respiratory, dying process and coping/lifestyle/grieving. Goals included to promote comfort with care and daily routine. Pain was to be assessed for location and intensity, medicate per physician order and coordinate with hospice for pain control measures and consult with hospice for changes in resident's pain. Review of the significant change MDS 3.0 assessment (dated [DATE]) revealed Resident #74 was moderately impaired for daily decision-making, required assistance from staff at various levels to complete self-care, received scheduled, PRN (as needed) and non-pharmacological interventions for pain, complained of frequent pain that occasionally interfered with sleep and activities of daily living, described his pain as severe rated an eight out of 10 and had a life expectancy of less than six months. Review of Registered Nurse (RN) #205's hospice Progress Note dated [DATE] revealed Resident #74 was lying in bed upon arrival (between 9:05 A.M. and 10:00 A.M.) and was noted to be moving their arms/legs, grimacing and voiced pain to legs when asked. Nursing was notified and it was noted that Resident #74 had not received any PRN morphine since RN #205's visit on [DATE] but had received scheduled morphine. RN #205 documented concern for pain that was not being reported or recognized by staff, the resident has voiced pain to this nurse yesterday and today with visits. Morphine 10 mg every four hours schedule and prn to be ordered if family agrees. Nursing was encouraged to monitor closely for signs and symptoms of pain. Review of RN #205's hospice Progress Note dated [DATE] revealed (between 9:00 A.M. and 10:00 A.M.) Resident #74 was lying in bed with eyes closed, noted to be moving arms and legs frequently, moaning and moving mouth as if trying to speak, and appeared to be grimacing. Care coordinated with facility nurse who stated the resident had received two PRN doses of morphine in addition to his scheduled morphine in the last 24 hours. RN #205 updated family who stated Resident #74 was not comfortable when he was visited the previous night and would like morphine increased. Nurse Practitioner #206 was notified and agreed to increase morphine to 10 mg every four hours scheduled and to continue the PRN morphine dose as well. Review of the hospice RN #207 Progress Note dated [DATE] revealed (between 12:24 P.M. and 1:19 P.M.) facility nurse stated resident has been comfortable and family at bedside felt he was comfortable with current medications at this time. Resident #74 was unresponsive at the visit. Review of the Controlled Drug Receipt/Proof of Use/Disposition Form (dated [DATE] through [DATE]) and the Medication Administration Record dated [DATE] revealed the morphine sulfate was not administered as ordered at 8:00 P.M. on [DATE]. Review of Resident #74's progress notes date [DATE] at 10:00 P.M. [Recorded as Late Entry on [DATE] at 5:34 A.M.] revealed the resident was not breathing when the nurse walked into the room and the resident was without a pulse or heart rhythm. Review of LPN #204's Personnel Action Form and attached written Director of Nursing (DON) Statement dated [DATE] revealed the LPN #204 was issued a Disciplinary addressing non-compliance related to failure to comply with facility written policies & procedures and failure of time management techniques to complete assignments. Efficiently & effectively exhibits competent ability to perform job duties according to department specific job description. This violation was labeled as a medication error on [DATE] and was LPN #204's second offense. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 4 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0697 Level of Harm - Actual harm Residents Affected - Few Review of the typed DON Statement revealed she interviewed LPN #204 via telephone on [DATE] regarding Resident #74's medication administration on [DATE]. LPN #204 stated that she was in a resident's room that required her attention early in the shift, after completing count and report. The outgoing nurse stated Resident #74 was stable and had been resting comfortably. LPN #204 was pulled over to another unit to help a charge nurse with an enteral feeding tube and when she returned, continued her medication pass. At that time, she was summoned to Resident #74's room, and he had expired. Attempts were made during the onsite survey to reach LPN #204 however; no return calls were provided. On [DATE] at 3:21 P.M., the Administrator verified Resident #74's dose of morphine sulfate was not given as scheduled on [DATE] at 8:00 P.M. Review of the policy: IIA2: Medication Administration-General Guidelines (dated [DATE]) revealed medications were administered within 60 minutes of scheduled time, except before, with, or after meal orders, which are administered based on standard, facility mealtimes. The individual who administered the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. Review of the undated policy: Pain Medication Administration revealed it was the facility's policy to provide guidelines for assessing the resident's level of pain prior to administering non-narcotic or narcotic analgesics. General guidelines the resident's experience of pain is highly individual and subjective. Pain was whatever the resident said it was. Intense pain could result from even minor procedures or surgery. Residents were not at risk for addiction to narcotic analgesics if used as prescribed for moderate to severe pain. Be familiar with the physiologic and behavioral signs of pain. (Note: Visible physiologic and/or behavioral signs of pain do not always accompany the experience of pain.) Residents may be reluctant to report pain due to the belief that pain is a normal part of the aging process or because of a reluctance to bother busy staff members. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. The pain assessment consists of gathering both subjective and objective data. Pain assessment tools, as indicated per facility protocol included the use of a one to 10-point pain intensity scale with word modifiers. Procedures included to provide resident privacy, explain the purpose of the assessment to the resident, and obtain subjective information from the resident including the following: a. Location. Ask the resident to point to the site(s) of pain. Utilize a drawing of a human body to assist in identifying the location(s) of pain. Pain Intensity. Provide the resident with 1-10-point Pain Intensity Scale and ask the resident to choose the best description of his/her pain experience. Use the Wong-Baker FACES Pain Rating Scale with residents who are cognitively impaired, non-verbal, or who do not speak English. Encourage the resident to use adjectives to describe the quality of pain (sharp, piercing, dull, aching, shooting, burning, intense, agonizing, unbearable, etc.). Onset and Duration. Ask the resident about the time of onset and periods of relief {if any). Ask the resident if there are circumstances or activities that make the pain worse. Ask the resident if there are circumstances or activities that help reduce the pain. Ask the resident if there are accompanying symptoms such as nausea, vomiting, and sensitivity to light and sounds. Obtain objective information through assessment including behavioral responses to (acute) pain included facial wrinkling/grimacing and crying or moaning; evidence of depression, anxiety, fear or hopelessness; effect of pain on activities of daily living; and/or the condition of the site of pain, if appropriate. Evaluate the effectiveness of non-pharmacologic interventions (e.g., repositioning, warm or cold compresses, etc.), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 5 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0697 Level of Harm - Actual harm administer pain medications as ordered and place the call light within easy reach of the resident. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Follow documentation guidelines in the procedure entitled Documentation of Medication Administration. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00161035. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 6 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, controlled drug receipt review, policy review, and interview, the facility failed to ensure controlled medications were documented accurately to account for all controlled drugs. This affected two residents (#74, #87) of three residents reviewed for pain management. The census was 94. Findings include: 1. Closed medical record review revealed Resident #74 was admitted on [DATE] with diagnoses including congestive heart failure, wedge compression fracture of T9-T10 vertebra, displaced bimalleolar fracture of right lower leg, and subsequent encounter for closed fracture with routine healing. Resident #74 expired at the facility on [DATE]. Review of the care plan: Hospice (dated [DATE]) revealed Resident #74 was receiving hospice benefits for diagnoses including end stage congestive heart failure, pain, respiratory, dying process and coping/lifestyle/grieving. Goals included to promote comfort with care and daily routine. Interventions included to medicate per physician order, assess pain for location and intensity, and consult for changes with pain. Review of the significant change MDS 3.0 assessment (dated [DATE]) revealed Resident #74 was moderately impaired for daily decision-making, received scheduled, PRN (as needed) and non-pharmacological interventions for pain, complained of frequent pain that occasionally interfered with sleep and activities of daily living, described his pain as severe rated an eight out of 10, was receiving hospice services and had a life expectancy of less than six months. Review of Resident #74's Physician Order dated [DATE] revealed to administer hydrocodone acetaminophen (APAP) 5/325 milligrams (mg) every eight hours at 12:00 A.M., 8:00 A.M. and 4:00 P.M Review of Resident #74's electronic Medication Administration Record (dated [DATE] and [DATE]) and Resident #74's Controlled Drug Receipt/Proof-Of-Use/Disposition (Controlled Drug Form) labeled Hydrocodone/APAP 5-325 (mg) one tablet every eight hours (dated [DATE] through [DATE]) revealed the following: a. On [DATE], the electronic Medication Administration Record (eMAR) revealed one hydrocodone 5/325 tablet was administered at 4:00 P.M.;however, the entry on the Controlled Drug Form dated [DATE] did not reflect a dose of hydrocodone 5/325 (mg) was removed from the controlled drug card and administered at 4:00 P.M Further review of the Controlled Drug Forms revealed no documentation a dose was removed from the Controlled Drug card and given on [DATE] at 4:00 P.M. and the amount left in the drug card remained the same amount between the [DATE] dose at 8:00 A.M. and the next dose administered at 8:11 P.M b. On [DATE], the eMAR revealed one hydrocodone was administered at 12:00 A.M.; however, the entry on the Controlled Drug Form dated [DATE] at 12:00 A.M. entry was struck through and initialed by the nurse as an error. Further review of the Controlled Drug Forms revealed the drug count remained the same between the dose administered on [DATE] at 10:10 P.M. and the next dose given on [DATE] at 5:53 A.M (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 7 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0755 Level of Harm - Minimal harm or potential for actual harm c. On [DATE], the eMAR revealed one hydrocodone was administered at 4:00 P.M.; however, the entry on the Controlled Drug Form dated [DATE] did not reflect a dose of hydrocodone 5/325 (mg) was removed from the controlled drug card and administered at 4:00 P.M Further review of the Controlled Drug Forms revealed the drug count remained the same between the dose administered on [DATE] at 2:00 P.M. and the next dose administered at 4:00 P.M. on [DATE]. Residents Affected - Few On [DATE] at 2:54 P.M. an electronic request was made to the Administrator and Director of Nursing (DON) for any additional information regarding the above controlled drug administration and documentation. On [DATE] at 4:08 P.M., an electronic interview with the Administrator referred to a performance improvement plan (dated [DATE]) for a relative facility-identified issue regarding Resident #74 not receiving pain medication as scheduled on [DATE] for an 8:00 P.M. dose and implemented this QAPI to correct. On [DATE] at 4:11 P.M., a second electronic request was sent to the Administrator and the DON to clarify the questions requested regarding the administration of oxycodone and the discrepancies found between documentation on the eMAR and the Controlled Drug Forms. On [DATE] at 4:22 P.M., the Administrator responded to the request stating the performance improvement plan encompassed the facility's previous failure to administer scheduled dose of pain medication as ordered, not any one specific pain medication. An education on timed medication administration and 5 rights to medication administration was initiated on [DATE] as part of this. The education included documentation of medication administration. As of [DATE] at 5:01 P.M., there was no additional information provided regarding the accuracy of the Controlled Drug Forms and documentation on the eMAR for the above examples found in Resident #74's medical record. 2. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including end stage renal disease, paroxysmal atrial fibrillation, non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle, neoplasm of unspecified behavior of bone, soft tissue and skin, dependence on renal dialysis, type 2 diabetes mellitus without complications, and Hodgkin lymphoma. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #87 was cognitively intact for daily decision-making, received as needed pain medications and non-pharmacological interventions. The resident stated his pain was almost constant with an intensity of a 10 out of 10 that frequently affected his sleep and day-to-day activities. The resident had one unstageable pressure ulcer, diabetic foot ulcers and an infection of the foot. Review of the electronic Physician Orders (dated [DATE]) revealed Resident #87 was ordered OxyContin (opioid to treat moderate to severe pain) 10 milligrams (mg) extended release every 12 hours at 10:00 A.M. and 10:00 P.M On [DATE] at 11:39 A.M., observation revealed Registered Nurse (RN) #201 dispensed OxyContin 10 (mg) into a medication cup, locked the medication cart and started walking to the opposite side of the 300 unit to deliver the pain medication to Resident #87. The resident took the OxyContin at 11:41 A.M. RN #201 was not observed signing the Controlled Drug Form at the time the medication was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 8 of 9 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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 0755 dispensed or immediately after administration. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 11:48 A.M., observation of Resident #87's OxyContin 10 (mg) Controlled Drug Form with RN #202 verified RN #201 had not documented the removal of the OxyContin or administration of the medication. (RN #201 was administering medications to another resident during this observation). RN #202 verified controlled substances were to be signed out at the time dispensed on both the eMAR and the Controlled Drug Sheets. Residents Affected - Few On [DATE] at 12:07 P.M., interview with RN #201 verified she had not documented the OxyContin on the Controlled Drug Form at the time of administration, stating she forgot. This deficiency represents non-compliance investigated under Complaint Number OH00161035. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366429 If continuation sheet Page 9 of 9