Altercare Thornville Inc.

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

third and fourth toe diabetic ulcer wounds to be cleansed with normal saline and to pack wounds with betadine-soaked gauze and apply a dressing daily. Review of the active physician order for Resident #100, dated 06/24/25, entered by the Facility Wound Nurse #33, with a discontinued date of 06/26/25 by the Director of Nursing (DON), revealed the right foot-leave dressing in place until next wound clinic appointment. Do not get wet. Cover for showers.Review of the TAR for Resident #100 revealed from 06/24/25 through 06/25/25, no dressing change was completed for the right second, third and fourth toe diabetic ulcer wounds.Interview on 08/05/25 at 10:25 A.M. with the Facility Wound Nurse #33 verified there was no documentation in Resident #100's medical record for the incident on 06/02/25 regarding the trauma to the right foot third and fourth toe. She interviewed the resident, and she could not remember how it happened. They concluded it must have happened when the resident accidentally dragged her right foot over a non-skid strip. Also verified she did not document the fourth right toe on 06/02/25 and should have as that was when it was discovered and should have been documented for description and measurements.Continued interview on 08/05/25 at 10:31 A.M. with the Facility Wound Nurse #33 verified for Resident #100, the order placed on 06/02/25 through 06/04 25 was a treatment for the right foot second and third toe when the second toe was not a concern, it was the fourth toe and it did not get any treatment for those days. Review of the daily weights in vital signs results for Resident #100 revealed since admission

on [DATE REDACTED], no daily weights were obtained on 03/03/25, 03/10/25, 03/11/25, 03/18/25, 05/13/25 and 06/25/25.2.Review of the medical record for Resident #400, revealed an admission date of 03/27/25.

Diagnoses included but were not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, altered mental status and general weakness.Review of the active care plan for Resident #400 dated 03/27/25 revealed a cardiac impairment related to congestive heart failure.Review of

the active physician order for Resident #400 dated 03/28/25 revealed a daily weight once in the morning due to congestive heart failure.Review of the daily weights in the vital signs results for Resident #400 revealed since admission on [DATE REDACTED], no daily weights were obtained on 03/28/25, 04/29/25 and 06/10/25.3.

Review of the medical record for Resident #500, revealed an admission date of 02/28/25. Diagnoses included but were not limited to muscle weakness, dementia and pulmonary embolism.Review of the active care plan for Resident #500 dated 02/28/25 revealed a risk of fluid imbalance/complications related to edema and diuretic use with no interventions including daily weights.Review of the active physician order for Resident #500 dated 03/04/25 revealed a daily weight once in the morning.Review of the daily weights

in the vital sign results for Resident #500 since 03/04/25 revealed no daily weights were obtained on 03/04/25, 04/20/25 and 05/05/25.Interview on 08/05/25 at 3:13 P.M. with the Director of Nursing verified Residents #100, #400 and #800 had missing weights and were not due to refusals, but due to them not being obtained as no documentation could be produced for the dates for the reason they were missed.This deficiency represents non-compliance investigated under Complaint Number 1385838.

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

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Thornville Inc.

14100 Zion Road Thornville, OH 43076

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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

treatments as ordered and continue with prevention care plan measures to prevent further skin breakdown.

The care plan interventions were not implemented until 07/21/25. Review of the wound grid documentation for Resident #800, dated 07/15/25 at 11:24 P.M. by FWN #33, revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/17/25 at 10:18 A.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/22/25 at 1:12 P.M. by the FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7 cm by 6.2 cm by .8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the Wound Physician notes dated 07/24/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.4 cm by 6.6 cm by 1.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125 mm/HG, use black sponge throughout and apply three times a week. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish

the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the Wound Physician visit notes dated 07/31/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.2 cm by 5.6 cm by 1.2 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125mm/HG, use black sponge throughout and apply three tim

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

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Thornville Inc.

14100 Zion Road Thornville, OH 43076

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

also assessed to have a pressure ulcer injury.Review of the care plan dated 04/18/25 for Resident #800 revealed actual alteration in comfort, pain related to pressure ulcers with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician's orders dated 04/21/25 for Resident #800 revealed the pain medication of hydrocodone-acetaminophen 5-325mg tablet, one tablet every six hours as needed for severe pain of 6-10.Further review of the orders also revealed for this resident dated 04/23/25, acetaminophen 325 mg tablet, one tablet every 6 hours for mild pain rating 1-5.Further review revealed in the progress notes, starting on 04/22/25 and ending on 05/13/25, a wound review: weekly

review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33 were not completed weekly for pain assessment. Further review revealed The dates with pain scales and treatment as medications were: 05/13/25 pain rating of a 5, 05/20/25 pain rating of a 5, 06/03/25 pain rating of a 6, 06/10/25 pain rating of a 6, 06/12/25 pain rating of a 6, 06/17/25 pain rating of a 5, 06/19/25 pain rating of a 5, 06/24/25 pain rating of a 5, 07/15/25 pain rating of a 6, 07/17/25 pain rating of a 5, 07/22/25 pain rating of a 6, 07/24/25 pain rating of a 6, and 07/31/25 pain rating of a 6. Review of the MAR for Resident #800 for the dates of wound pain assessment, no as needed pain medication as administered. Interview on 08/07/25 at 2:30 P.M. with Assistant Director of Nursing (ADON) verified no medications were given prior to wound care treatments for pain which is the documentation in the progress notes that the ADON was documenting on for Resident #300 and #100, Resident 300 does not even have anything ordered as needed for pain. Reviewed dates of all wound review templates with medication interventions not completed and no follow up after the wound treatment was completed if still in pain, the floor nurses do a pain scale every shift, but wound nurse does not follow up after and if non pharm does not work, there were two dates for interventions that included repositioning, no follow up was documented that

it helped and if other treatment such as medication was needed.Interview on 08/08/25 at 11:40 A.M. with

the Facility Wound Nurse #33 verified for Resident #800, there should have been wound pain assessments completed weekly from 04/22/25 through 05/13/25 and she did not verify if the resident received pain medication. Also verified no as needed pain medication was given to this resident from 05/13/25 through 07/31/25 when the resident was assessed to have wound pain.Review of the facility policy titled Pain Assessment and Management updated 05/01/25 revealed it is the facilities policy to assess, monitor, treat and evaluate pain to ensure effective pain management is provided.This was an incidental finding discovered during the course of this complaint investigation.

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

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Thornville Inc.

14100 Zion Road Thornville, OH 43076

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 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review, policy review and interview, the facility failed to ensure the facility medication administration error rate was not more than five percent. This affected one resident (#42) of eight residents observed for medication administration with four errors out of 25 opportunities resulting in

an error rate of 16%. The census was 47. Findings include: Medical record review revealed Resident #42 was admitted on [DATE REDACTED] with diagnoses including wedge compression thoracic vertebra fractures, depression, anxiety, atherosclerotic heart disease and constipation. Review of the admission Minimum Data Set assessment dated [DATE REDACTED] revealed Resident #42 was moderately impaired for daily decision-making.

Review of the electronic Physician Orders dated 09/25/25 revealed medications to be administered included chewable aspirin 81 milligrams (mg) for prophylaxis, buspirone 10 (mg) for sadness/anxiety, I-vite (vitamin and mineral) for supplement and senna plus 8.6-50,mg for bowel regimen, bupropion SR 150 (mg), celexa 40 (mg), culturelle 15 billion cell, lactulose 10 grams, aspercreme lidocaine patch, lisinopril 10mg, OsCal 500 (mg) with Vit D3, Miralax 17 gm, and Vitamin C 500 (mg). On 09/25/25 between 8:00 A.M. and 8:14 A.M., observation revealed Registered Nurse (RN) #200 prepared and administered Resident #42's morning medications including enteric coated aspirin 81 (mg), buspirone 5 (mg), and senna 8.5 (mg) and I-vite was not dispensed or administered during the observation. RN #200 was observed leaving her medication administration record open upon entering the resident's room and the electronic MAR was positioned across from the nursing station and not within eye sight of the nurse. RN #200 also left the sealed Aspercreme lidocaine patch on top of the medication cart unsupervised when she went to the resident's room to administer the other medications. At the time of the observation, RN #200 verified she left the Aspercreme lidocaine patch unattended on the top of the medication cart. On 09/25/25 at 2:46 P.M.,

interview with RN #200 verified she documented she had administered I-Vite to the resident; however she did not administer the medication. RN #200 verified she administered enteric coated ASA and senna to Resident #42 because that was the only form of the medications available to administer in her medication cart, and the buspirone order had been changed from 5 (mg) to 10 (mg) and the old bubble pack containing

the 5 (mg) dose was left in the medication cart without a label indicating directions had been changed. RN #200 verified she had not given the ordered dose. RN #200 was observed removing the buspirone 5 (mg) bubble pack from the medication cart, closed the cart drawer, did not lock the medication cart, walked to the medication/storage room beside the nursing station with the bubble pack, unlocked the door and entered

the medication/storage room with the door closing behind her. No staff were noted to be within the vicinity of the medication cart and the cart remained unlocked. RN #200 verified the cart was unlocked when she came back out of the medication/storage room. Review of the policy: Specific Medication Administration Procedures dated May 2020 revealed medications were to be administered in a safe and effective manner, all medication storage areas including carts were to be locked at all times unless in use and under the direct observation of approved facility or pharmacy personnel. If medication instructions are changed during

the course of therapy, it was the nurse's responsibility to add a direction change notation/sticker directly on

the product to indicate as such.

Residents Affected - Few

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

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

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Thornville Inc.

14100 Zion Road Thornville, OH 43076

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain an up to date and complete medical record for three residents (#100, #300 and #800) of three residents reviewed for receiving wound care from an outside wound consultant group. The facility census was 47. Findings include:1.Review of the medical

record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady

on feet, muscle weakness, heart failure, chronic kidney disease stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25 and sepsis 06/10/25.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed resident had intact cognition with a Brief

Interview for Mental Status (BIMS) of 15 out of 15. Review of the medical record for Resident #100 revealed

a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed no Wound Physician visits in her closed record to review.Interview on 08/04/25 at 12:02 P.M. with

the Director of Nursing (DON) revealed Resident #100 saw the Wound Physician group a few times during her stay and will get the visit notes from the Facility Wound Nurse #33 as they were not in her chart. 2.

Review of the medical record for Resident #300, revealed an admission date of 05/20/25. Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE REDACTED] revealed resident had intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #300 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the record to review.Interview on 08/06/25 at 11:09 A.M. with the Facility Wound Nurse #33 verified Resident #300 did not have any of her Wound Physician visits in her current medical record and should be uploaded after each visit.3. Review of the medical record for Resident #800, revealed an admission date of 04/18/25. Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.Review of the most recent MDS 3.0 assessment dated [DATE REDACTED] revealed resident with intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #800 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the medical record to review.Interview on 08/06/25 at 1:50 P.M. with Regional Nurse #68 verified Resident #800 did not have the Wound Physician Consultant notes uploaded into their charts and had to access them on the consultant's server, but it is the expectation that the Facility Wound Nurse #33 be uploaded after each visit to keep the residents' chart up to date and current for care.This was an incidental finding discovered during the course of this complaint investigation.

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

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altercare Thornville Inc.

14100 Zion Road Thornville, OH 43076

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

Based on observation, interview and facility policy reviews, the facility failed to ensure proper hand hygiene and medical equipment was sanitized before and after resident use. This affected two residents (#701 and #802), but has the potential to affect all 47 residents residing in the facility. Findings include:Observation on 08/05/25 at 8:35 A.M. with Registered Nurse (RN) #27 revealed her to be preparing medications for Resident #701. She put on a glove to her right hand and proceeded to touch the cart, the residents' medications and the computer all with the same glove on. Once the medications were in the cup, she removed the glove, did not sanitize her hands after locking the cart and entering Resident #701's room. She took Resident #701's blood pressure and pulse ox with a machine she brought into the room. She then administered the residents' medications and proceeded to leave the room without sanitizing her hands and cleaning off the equipment. She returned to the cart at 8:48 A.M. and proceeded to prepare Resident #802's medications following the same steps. She put on a glove to her right hand, proceeded to touch the cart, medications and computer with the same glove, then removed her glove, locked the cart and did not sanitize her hands before entering Resident #802's room to administer medications. She took Resident #802's blood pressure and pulse ox with the same machine she carried into the rooms and did not sanitize them before or after use. She administered Resident #802's medications and left the room without sanitizing her hands.Interview on 08/05/25 at 9:00 A.M. with Registered Nurse #27 verified she should have changed her glove once she touched anything other than Resident #701 and #802's medications, she should have sanitized her hands before and after entering the resident's rooms and she verified she never cleaned the blood pressure and pulse ox equipment before and after each resident.Review of the facility policy titled Hand Washing-Hygiene no date, revealed it is the facility's policy for employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious diseases.

Alcohol/Antimicrobial hand rub may be used in the following situations: before donning gloves, after removing gloves and before preparing or handling medications.Review of the facility policy titled Cleaning of Equipment no date revealed the facility will utilize general disinfecting procedures to prevent and control infection.This was an incidental finding discovered during the investigation for Complaint Number 1385838.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet