Altercare Thornville: 16% Medication Error Rate - OH
Federal inspectors found Altercare Thornville's medication error rate hit 16 percent in September — more than triple the federal safety limit of 5 percent. The violations affected one of eight residents observed during medication administration, with four errors documented out of 25 opportunities.
The 47-bed facility's problems centered on Registered Nurse #200's handling of medications for Resident #42, who was admitted with spinal fractures, depression, anxiety, heart disease and constipation. The resident was moderately impaired for daily decision-making, according to assessment records.
On September 25 between 8:00 and 8:14 a.m., inspectors watched RN #200 prepare morning medications for the resident. She was supposed to give chewable aspirin, buspirone for anxiety, vitamins, and senna for constipation, among other drugs.
Instead, the nurse gave enteric coated aspirin rather than the prescribed chewable form. She administered 5 milligrams of buspirone instead of the ordered 10 milligrams. She gave regular senna instead of the prescribed senna plus formula.
The nurse never gave the resident I-vite vitamins at all.
But she documented giving all the medications anyway, including the vitamins she skipped entirely. When interviewed at 2:46 p.m. that day, RN #200 admitted she had falsely recorded administering the I-vite supplement.
The nurse told inspectors she gave whatever medications were available in her cart, regardless of whether they matched the doctor's orders. The buspirone dose had been changed from 5 to 10 milligrams, but old bubble packs containing the lower dose remained in her medication cart without any label indicating the change.
Facility policy required nurses to add direction change stickers directly on medication products when orders changed. RN #200 had not done this.
Inspectors documented multiple security violations during the medication administration. RN #200 left her electronic medication record open and positioned it across from the nursing station, out of her line of sight while she entered the resident's room.
She left a sealed Aspercreme lidocaine patch sitting unattended on top of the medication cart while administering other drugs to the resident. When questioned, the nurse confirmed she had left the controlled substance patch unsupervised.
The security breaches continued when RN #200 removed the incorrect buspirone bubble pack from her cart. She closed the cart drawer but failed to lock it before walking to the medication storage room next to the nursing station.
No staff were visible near the unlocked medication cart during her absence. When the nurse returned from the storage room, she confirmed to inspectors that the cart had remained unlocked the entire time.
Facility policy from May 2020 required all medication storage areas including carts to remain locked at all times unless in use and under direct observation of approved personnel. The policy also mandated medications be administered in a safe and effective manner.
The violations occurred during a complaint investigation at the facility. Resident #42's case represented the only resident observed for medication administration errors, but inspectors found problems in four out of 25 medication administration opportunities.
The 16 percent error rate far exceeded federal safety standards designed to protect nursing home residents from medication mistakes that can cause serious harm or death. Research shows medication errors in nursing homes can lead to hospitalization, permanent injury, and fatal complications, particularly among elderly residents with multiple chronic conditions.
For Resident #42, who was already dealing with spinal fractures and mental health conditions requiring careful medication management, the wrong doses and missed vitamins represented a breakdown in basic nursing care. The resident's moderate cognitive impairment made them unable to advocate for proper treatment or notice when medications were skipped entirely.
The nurse's admission that she routinely gave whatever medications were available rather than following physician orders suggests the problems extended beyond a single incident. Her failure to properly label changed medications and secure controlled substances indicated systemic issues with medication management protocols.
The inspection found the facility failed to ensure its medication error rate stayed below the federal threshold designed to protect vulnerable residents from preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare Thornville Inc. from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALTERCARE THORNVILLE INC. in THORNVILLE, OH was cited for violations during a health inspection on September 2, 2025.
Federal inspectors found Altercare Thornville's medication error rate hit 16 percent in September — more than triple the federal safety limit of 5 percent.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.