Altercare Thornville: Missing Wound Care Records - OH
The resident, identified in inspection records only as Resident 100, was admitted to Altercare Thornville Inc. on February 26, 2025. She was cognitively intact, scoring a perfect 15 out of 15 on a standard mental status assessment. Her diagnoses included heart failure, chronic kidney disease, and muscle weakness. The foot wound appeared on June 2. By June 10, she had sepsis. She was discharged home on July 3.
When inspectors reviewed her closed chart, they found no record of a single visit from the outside wound consultant group the facility had been using.
The Director of Nursing, interviewed on August 4, acknowledged that Resident 100 had seen the wound physician group several times during her stay. She said she would get the visit notes from the facility's wound nurse, identified in records as Wound Nurse 33, because they were not in the chart.
The problem was not limited to one resident.
Resident 300 was admitted May 20, 2025, with a skin alteration documented on arrival. Her diagnoses included metabolic encephalopathy, altered mental status, muscle weakness, and a history of cerebral infarction. She too scored near-perfect on cognitive testing. Her wound physician visit notes were also missing entirely from her medical record.
The facility's own wound nurse confirmed it on August 6. Wound Nurse 33 told inspectors that Resident 300 did not have any wound physician visit notes in her current chart and that the notes should be uploaded after each visit.
Resident 800, admitted April 18, 2025, with diagnoses including type 2 diabetes, atrial fibrillation, chronic kidney disease, and a history of cerebral infarction, had the same gap. No wound physician consultant notes appeared anywhere in the medical record.
A regional nurse, interviewed the same day, acknowledged that Resident 800's wound consultant notes had not been uploaded and that staff had to go directly to the consultant's own server to find them. The regional nurse described it as the expectation that Wound Nurse 33 upload the notes after each visit to keep charts current.
The expectation had not been met for any of the three residents inspectors reviewed.
All three were receiving care from the same outside wound consultant group. All three had skin alterations documented in the facility's wound tracking records. And in all three cases, the only way to know what the wound physician had found, recommended, or changed would have been to leave the patient's chart entirely and search elsewhere.
Inspectors rated the violation at the minimal harm level. The facility's census at the time of the inspection was 47 residents.
The finding emerged as an incidental discovery during a complaint investigation at the facility, which sits on Zion Road in Thornville, a small community in Perry County in central Ohio. The inspection was completed September 2, 2025.
Medical records exist so that anyone caring for a patient, at any hour, can know what has happened and what has been decided. A wound that progresses from a skin alteration to sepsis in eight days is a wound that demands close tracking. Whether the missing consultant notes would have changed anything for Resident 100 is a question the record, as it stands, cannot answer. The notes were never there to read.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
ALTERCARE THORNVILLE INC. in THORNVILLE, OH was cited for violations during a health inspection on September 2, 2025.
The resident, identified in inspection records only as Resident 100, was admitted to Altercare Thornville Inc.
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.