Altercare Newark South Inc.

F 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, and interviews, the facility failed to ensure timely assistance was provided to complete activities of daily living. This affected one resident (Resident #34) of seven residents reviewed for activities of daily living. The facility census was 43.Findings Include:Review of the medical record for Resident #34 revealed an admission date of 11/14/24 with diagnoses that included chronic obstructive pulmonary disease, asthma, irritable bowel syndrome, rheumatoid arthritis, altered mental status, abnormalities of gait, unsteadiness on feet, repeated falls, muscle weakness, hypertension, hypotension, congestive heart failure, Type II Diabetes, osteoarthritis, anxiety disorder, major depressive disorder, and need for personal assistance with personal care.Review of Resident #34's care plan revealed the resident required supervision or touching assistance with a shower, dressing upper and lower body, putting on and off footwear, and personal hygiene.Review of the shower sheet dated 11/12/25 revealed Resident #34 wanted a shower Friday morning before her appointment. Resident #34 was scheduled for an appointment Friday 11/14/25 for a colonoscopy. There was no shower sheet noted for Resident #34 dated 11/14/25 or a progress note which indicated Resident #34 received a shower on 11/14/25.Interview on 11/20/25 at 2:31 P.M. with Resident #34 revealed she asked for a shower before her appointment on 11/14/25 and the staff refused to give her a shower.Interview on 11/24/25 at 10:30 A.M. with Certified Nursing Assistant (CNA) #370 revealed facility residents received scheduled showers twice a week unless they had an appointment or requested an extra shower. CNA #370 stated the expectation was to give the resident a shower before

an appointment or if the resident requested an extra shower.The Director of Nursing (DON) in an interview

on 11/24/25 at 1:37 P.M. stated I'm not going to lie. There is no documentation that Resident #34 received a shower on 11/14/25 before her procedure.Review of the facility policy Shower-Tub Bath updated 05/01/25 stated it is the facility's policy to promote resident hygiene by offering and assisting residents with bathing per their plan of care.This violation represents non-compliance investigated under Complaint Number OH002673953.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Newark South Inc.

17 Forry Street Newark, OH 43055

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on record review, observation, and staff interview, the facility failed to provide the physician ordered medication for one, (Resident # 5) of three reviewed for medications. The facility census was 43. Findings Include: Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include of acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease.Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration.Review of facility provided physician orders for Resident #5 revealed an order for Insulin Aspart U-100 (fast acting insulin with onset in five to 10 minutes) Insulin pen 100 units/milliliter (ml) (3ml); 6 units subcutaneous, hold if blood sugar is less than 150 administer before meals at 8:00 A.M., 12:00 P.M. and 5:00 P.M. dated 08/14/25. Further review of Resident #5's physician orders revealed no order for Insulin Lispro.Review of Resident #5's medication administration record (MAR) for November 2025 revealed the facility staff were signing off they were administering Insulin Aspart U-100 Insulin pen; 100 unit/milliliters (three ML); amount to administer: six units; subcutaneous before meals unless the blood sugar was below 150. Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open and used Insulin Lispro (fast acting Insulin with onset in 15 minutes of administration) pen for Resident #5, not an Insulin Aspart pen which was ordered for Resident #5 by the physician. Concurrent interview at the time of the observation with the Assistant Director of Nursing #230 confirmed the Insulin Lispro pen belonged to Resident's #5's and it was opened and had been used to provide insulin to the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Newark South Inc.

17 Forry Street Newark, OH 43055

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Multivitamins with iron (vitamin supplement) which expired 10/2025, four bottles of Vitamin E 180 mg soft gels which expired 08/2025, 39 Nicotine transdermal step two patches which expired 08/2025, one tuberculin five Tuberculin units per 0.1mL vial opened and undated in the refrigerator, and multiple lancets

in a plastic drawer which had no expiration date. The Director of Nursing verified the expired medications and lancets at the time of the observation.Review of the facility policy Medication Storage in the Facility dated 05/2020 under expiration dating (beyond-use dating) stated when the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. (note: the best stickers to affix contain both a date opened and expiration date notation line.) All expired medications will be removed from the active supply, regardless of the amount remaining. The medication may be destroyed at the facility or returned to the provider pharmacy in the usual manner.This violation represents non-compliance investigated under Complaint Number OH002647331.

Event ID:

Facility ID:

If continuation sheet