Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure Resident #35 was treated in a dignified
manner when a notice was posted in the resident's room in plain view that provided information regarding
her care. This affected one resident (#35) of two residents reviewed for dignity.
Findings include:
A review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her
diagnoses included dementia, senile degeneration of the brain, above knee amputations of the bilateral
lower extremities, and overactive bladder.
A review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment, an assessment tool used
by the facility to identify a resident's level of care for reimbursement purposes, dated 11/21/19 revealed the
resident's cognition was severely impaired. The assessment revealed the resident was totally dependent on
two staff for transfers and was always incontinent of her bowel and bladder.
On 01/06/20 at 1:45 P.M., an observation of Resident #35 revealed she was lying in bed in a supine
position. Above her bed posted on the wall was a sign that read Bedtime- if Hoyer pad was not soiled,
please fold up and leave in her room. Please do not send to the laundry if it was clean. Some mornings
unable to get up due to Hoyer pad being wet.
On 01/07/20 at 3:25 P.M., an interview with State Tested Nursing Assistant (STNA) #26 revealed Resident
#35 required the use of a Hoyer lift (a mechanical lift that had a hydraulic pump and a sling to move a
resident from one surface to another) to transfer and was incontinent of both her bladder and bowel. He
verified the resident had a sign posted on her wall above her bed that gave out personal care information
and could be viewed by anyone in the room. He confirmed by reading the sign it could be concluded the
resident required the use of a mechanical lift for transfers and she was incontinent as it instructed them on
when they should and should not send her Hoyer lift pad to laundry based on whether or not it had been
soiled. He stated there were other locations the information could have been posted that was not in a visible
location that could be seen by any visitors that came for either of the two residents that resided in that
room.
On 01/07/20 at 3:32 P.M., an interview with the Director of Nursing (DON) confirmed it could be determined
Resident #35 required the use of a Hoyer lift and was incontinent based on the information provided on the
notice that was posted above her bed on the wall. She stated they should not have posted any notices like
that on the wall in plain view that identified a resident's care needs or gave out any personal care
information to those that did not need to know that information. She
(continued on next page)
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
Page 1 of 20
Event ID:
365481
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
acknowledged any visitors for either of the two residents who resided in that room would know Resident
#35 was incontinent and used a Hoyer lift for transfers by reading that information included in the notice.
She stated, if a notice regarding a resident's care was needed, she would have had them post it in a
location that was not conspicuous for all to see. She removed the sign and denied she had any knowledge
it had been posted there or who may have posted it. During the interview, the DON revealed the facility did
not have any policies that were specific to the posting of medical information or resident care needs in the
residents' rooms.
Event ID:
Facility ID:
365481
If continuation sheet
Page 2 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure Resident #12's call light was within
reach and accessible for the resident to use. This affected one resident (#12) of 20 residents whose care
plans were reviewed.
Residents Affected - Few
Findings include:
A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Her
diagnoses included muscle weakness, lack of coordination, unsteadiness on her feet, and repeated falls.
A review of Resident #12's quarterly MDS 3.0 assessment dated [DATE] revealed the resident did not have
any communication issues. She was able to make herself understood and was able to understand others.
Her cognition was moderately impaired. She was not known to have any behaviors nor was she known to
reject care. She required supervision with set up help for transfers, walking in her room and toilet use.
Balance issues were noted with surface to surface transfers, moving from a seated to standing position,
walking, turning around and with moving on and off a toilet. She had the use of a walker as a mobility
device.
A review of Resident #12's care plans revealed she was at risk for falls related to an impaired gait stability,
incontinence, and the use of medications that predisposed her to falls. Her interventions included
encouraging the resident to use a call light for transfer and ambulation assistance.
On 01/06/20 at 3:50 P.M., an observation of Resident #12 revealed she was sitting in her room in her
recliner. She was asked to push her call light to verify it was working. The resident was not able to locate
her call light as it was clipped to a recliner cover that was on her chair in the back of the chair out of her
reach. She stated she did use her call light when she needed something.
On 01/13/20 at 12:33 P.M., a follow up observation of Resident #12 again observed her in her recliner. She
was asked where her call light was and indicated she did not know. Her call light was observed to be
clipped to the privacy curtain between the two beds in that room. It was clipped high up on the privacy
curtain and out of the resident's reach. The resident commented she could not reach it where her call light
had been clipped to the privacy curtain. Findings were verified by Maintenance Employee #61.
On 01/13/20 at 1:25 P.M., an interview with STNA #63 revealed Resident #12 was capable of using her call
light for assistance if she needed to. She denied knowing the resident to do so but stated she could if the
need arose. She acknowledged the resident was at risk for falls and part of her fall prevention intervention
was to encourage the use of her call light for transfer and ambulation assistance. She confirmed the
resident's call light should be kept in reach at all times in the event she needed it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 3 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0575
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy
groups and a statement that the resident may file a complaint with the State Survey Agency.
Based on observation, required state/local information posting review and interview the facility failed to
ensure required postings included all required contact information including local and state agency
information. This affected three resident (#9, #17 and #25) of three residents who participated in resident
council and had the potential to affect all 68 residents residing in the facility.
Finding include:
On 01/07/20 between 3:16 P.M. and 3:49 P.M., interview with Resident #9, #17 and #25 revealed they were
unaware of where the Ombudsman contact information was posted or what the role of the Ombudsman
was. The residents also stated they were not aware they had the right to formally complain to the State
agency regarding care they were receiving.
On 01/07/20 at 3:50 P.M., observation revealed the surveyor was unable to locate the posting of the state
Ombudsman information, local or state contact information, or the posting on how to file a complaint to the
State agency on the 100 hall or secured unit.
On 01/07/20 between 3:55 P.M. and 4:10 P.M., observation revealed the surveyor was unable to find the
required postings and asked the Director of Nursing (DON) the location of the postings. The DON stated
they were outside her office in the corner by the storage room. A plexiglas cabinet was observed against
the wall across from the nursing station that could only be seen if you were facing the east hall corridor and
looking towards the far right. The postings were not visible from the entrance or main lobby. Observation of
the postings in the cabinet revealed an eight by 12 inch sheet of paper with typed information regarding
state/local agencies and information about how to contact them. The print was small and a glare was noted
on the plexiglass from the above lights. At the time of the observation, Resident #17 was shown the posting
and stated she was unable to read the posting due to the small print.
On 01/07/20 at 4:14 P.M. and 4:27 P.M., interview with Administrator #24 verified the required postings were
not readily accessible, there were no postings on the secured unit, the print was small and difficult to read,
and residents who were visually impaired would have difficulty seeing the posting. Administrator #24 also
verified there was no description of how to file a grievance with the facility and no statement regarding filing
a complaint with the Ohio Department of Health.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 4 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical
record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including
unspecified dementia with behavioral disturbance, schizoaffective disorder and major depressive disorder.
Review of the electronic physician progress note, dated 01/30/19 revealed a new delusional disorder
diagnosis for Resident #56.
Review of Resident #56's PAS/RR dated 02/16/19 revealed diagnoses including mood disorder and
schizoaffective disorder. There was no evidence delusional disorder was captured on the PAS/RR.
On 01/09/20 at 11:25 A.M., interview with Administrator #24 verified Resident #56's PAS/RR dated
02/16/19 was inaccurate as it did not include the resident's diagnosis of delusional disorder.
Based on record review and interview the facility failed to ensure Preadmission Screening and/or
Assessment Resident Review(PAS/RR and/or PASARR) documentation was accurate and submitted as
required. This affected two residents (#34 and #56) of four residents reviewed for PASRR.
Findings include:
1. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with
medical diagnoses including dementia, insomnia, anxiety and major depression. On 05/11/19 an additional
diagnoses were added including Schizoaffective disorder/Schizophrenia, delusional disorder and
unspecialized psychosis.
The record revealed a PASSAR was completed upon admission and an updated assessment was
completed on 11/05/19. The updated PASARR dated 11/5/19 did not include the diagnosis of
Schizophrenia, which could possible identify the resident with serious mental illness, of which she could
require specialized services.
Interview with Licensed Social Worker (LSW) #34 on 01/08/20 at 11:10 A.M. revealed she completes the
facility PASRR screenings and submits new evaluations with any change in mental health diagnosis. The
interview revealed she did not accurately complete the 11/05/19 evaluation, as she was getting the current
diagnosis from the face sheets in the chart. The interview confirmed the face sheets did not match the
residents diagnosis and or the current Minimum Data Sets (MDS) 3.0 information.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 5 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure Resident #48's care plan was revised
to reflect the use of eyeglasses. This affected one resident (#48) of two residents reviewed for
communication-sensory.
Findings include:
Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses
including mild macular degeneration and unspecified dementia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48
was severely impaired for daily decision-making and had adequate vision with the use of eyeglasses.
Review of Resident #48's electronic physician's orders dated January 2020 revealed Resident #48 was to
wear glasses.
Review of the care plan titled At Risk for Impaired Vision revised 12/02/19 revealed no evidence the care
plan included macular degeneration or that the resident wore glasses.
On 01/09/20 at 8:49 A.M., observation revealed Resident #48 was in his bed, awake and was not wearing
glasses. At the time of the observation, interview with Licensed Practical Nurse (LPN) #78 revealed she
had not seen the resident ever wears glasses and asked the resident if he wore glasses. The resident
stated yes, but did not know where his glasses were. State Tested Nurse Aide (STNA) #32 stated the
resident did wear glasses and they both began looking for his glasses.
On 01/09/20 at 9:00 A.M. State Tested Nurse Aide (STNA) #32 approached this surveyor with a pair of
glasses and stated she had found Resident #48's glasses in the bottom drawer of his end table. There was
no evidence the resident's plan of care had been updated to include the diagnosis of macular degeneration
or that the resident wore glasses.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 6 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including mild
macular degeneration and unspecified dementia.
Residents Affected - Some
Review of the care plan title At Risk for Impaired Vision related to medication use and age-related changes
revised 12/02/19 revealed no evidence the resident wore glasses or had macular degeneration.
Review of the care plan titled ADL Functional/Rehabilitation Potential revised 12/02/19 revealed the
resident had impaired ability to perform or participate in daily ADL care related to cognitive impairment. The
care plan had an area to document if the resident was to wear glasses, and if so, were the glasses for
reading only. There was no evidence the care plan was revised to reflect the resident wore glasses.
Review of the care plan titled Impaired Ability to Perform or Participate in Daily ADL Care revised 12/02/19
revealed to keep eye glasses within reach of the resident.
Review of a Vision Consult dated 12/16/19 revealed the resident had mild macular degeneration, the
resident was to be monitored regularly. The resident's glasses were also evaluated at the time of the
consult.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48
was severely impaired for daily decision-making and had adequate vision with the use of glasses.
Review of the electronic physician's orders dated 01/09/20 revealed on 07/19/18 Resident #48 was ordered
to wear glasses.
On 01/06/20 at 3:19 P.M., observation revealed Resident #48 was seated in the lobby and was not wearing
glasses.
On 01/09/20 at 8:49 A.M., observation revealed Resident #48 was in his bed, awake and was not wearing
glasses. At the time of the observation, interview with Licensed Practical Nurse (LPN) #78 revealed she
had not seen the resident ever wears glasses and asked the resident if he wore glasses. The resident
stated yes, but did not know where his glasses were. State Tested Nurse Aide (STNA) #32 stated the
resident did wear glasses and they both began looking for his glasses.
On 01/09/20 at 9:00 A.M., STNA #32 approached the surveyor and stated she had found the resident's
glasses in the bottom drawer of his end table and verified the resident glasses were not within reach as
care planned.
4. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses
including dementia and moderate cataracts.
Review of the care plan titled Impaired Ability to Perform or Participate in daily ADL care related to cognitive
function dated 08/22/19 revealed interventions including to assist as needed to clean eye glasses and keep
within reach of resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 7 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Review of the Vision Consult dated 08/23/19 revealed moderate cataracts affecting visual acuity; however,
no treatment was recommended at this time and new prescription glasses were ordered.
Review of the care plan titled Impaired vision and wears glasses revised 12/02/19 revealed interventions
included to assist the resident with his glasses and to clean his glasses as needed.
Residents Affected - Some
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had adequate vision with
the use of glasses.
Review of the Social Service Progress Note dated 12/30/19 revealed Resident #36 received new glasses.
On 01/06/20 at 11:39 A.M., observation revealed Resident #36 was sitting in a recliner in his room wearing
black glasses. The glasses were observed to be dirty with a heavy, grease-like film over the lens.
On 01/09/20 at 8:36 A.M., observation revealed Resident #36 was seated at a table adjacent to the nurses'
station eating breakfast and was not wearing his glasses.
On 01/09/20 at 8:42 A.M., interview with STNA #82 verified Resident #36 was not wearing his glasses and
his glasses should have been put on when he got up for the day. STNA #82 stated staff had to remind the
resident that he needed his glasses and put them on for him. At the time of the interview, LPN #78 also
verified Resident #36 needed to wear his glasses, staff needed to clean the glasses and went to the
resident's room to look for his glasses.
Based on observation, record review and interview the facility failed to ensure residents who were
dependent on staff for personal care received the assistance they needed for nail care, the removal of
unwanted facial hair and/or the application of glasses. This affected two residents (#36 and #48) of two
residents reviewed for communication-sensory and two residents (#15 and #38) of four residents reviewed
for activities of daily living (ADL) care.
Findings include:
1. A review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE].
Her diagnoses included Huntington's disease (an inherited disease that causes the breakdown of nerve
cells in the brain affecting functional abilities and results in movement, thinking and psychiatric disorders),
unspecified psychosis, major depressive disorder, muscle weakness, lack of coordination and chronic
fatigue.
A review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment, an assessment tool used
by the facility to identify a resident's level of care for reimbursement purposes, dated 10/29/19 revealed the
resident had clear speech. She was able to make herself understood and was usually able to understand
others. Her cognition was moderately impaired. She was not known to reject care. She required an
extensive assist of two for transfers. She required an extensive assist of one for locomotion on the unit and
for personal hygiene.
A review of Resident #15's care plans revealed she had a care plan in place for an impaired ability to
perform or participate in daily ADL care related to Huntington's disease. Her goal was for her to participate
with ADL's as much as possible and to have a neat appearance daily. Her interventions
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 8 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
included providing nail care with showers per weekly schedule and to assist with and/or shave her facial
hairs every day as needed or per resident preference. The care plans did not indicate she was
non-compliant with personal care to include the removal of facial hair or the trimming of her finger nails.
A review of Resident #15's active physician's orders revealed she was identified as being a limited assist of
one for nail care and shaving as indicated under ADL assistance needed with grooming.
A review of the shower schedule for the front hall (100 hall) revealed Resident #15's scheduled shower
days were on Tuesdays and Fridays. They were to be completed by the 6:00 P.M. to 6:00 A.M. shift (night
shift).
A review of Resident #15's shower sheets revealed the resident's last documented shower was noted to
have been given on 01/07/20. The sheet documented the resident had been given a partial bed bath
instead of her shower due to having complaints of pain. The aide giving the partial bed bath indicated the
resident's finger nails had been trimmed as part of the care received. It was not noted whether or not the
resident was assisted with the removal of any unwanted facial hair.
On 01/06/20 at 2:02 P.M., an observation of Resident #15 revealed she was lying in bed in her room. She
was observed to have some facial hair that had not been removed on her chin and her finger nails were
long and in need of being trimmed.
On 01/08/20 at 9:45 A.M., a follow up observation of Resident #15 revealed she still had facial hair on her
chin that had not been removed and her finger nails remained long and untrimmed.
On 01/08/20 at 9:45 A.M., an interview with the Director of Nursing (DON) revealed nail care was to be
provided as part of the resident's shower or personal hygiene care. She confirmed Resident #15's finger
nails were long and in need of being trimmed. She asked the resident if she wanted her nails trimmed and
the resident replied that would be all right with her. The DON also confirmed the resident had some facial
hair on her chin that had not been removed.
On 01/08/20 at 1:55 P.M., an interview with State Tested Nursing Assistant (STNA) #22 revealed Resident
#15 was an extensive assist for personal care and was compliant with her personal care. She indicated the
resident enjoyed getting her nails done. She confirmed the resident was known to have facial hair at times
and staff have to remove it for her when it was noted. She stated it was the resident's preference to have
her facial hair removed on her shower days and as needed. She verified the resident was a night time
shower on Tuesday and Fridays. She reported she had noted the resident had some facial hair earlier that
morning and she had since shaved it for her. She stated the resident's finger nails had been trimmed when
she saw her that morning despite them being verified as still being long and in need of being trimmed with
the DON at 9:45 A.M.
2. A review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE].
Her diagnoses included Huntington's disease, unspecified psychosis, major depressive disorder, and
muscle weakness.
A review of Resident #38's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had unclear
speech. She rarely or never made herself understood and rarely or never was able to understand others.
Her vision was highly impaired without the use of any corrective lenses. The resident's cognitive skills for
daily decision making was severely impaired. She was not noted to display any
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 9 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
behaviors nor was she known to reject care. She was totally dependent on two for transfers and personal
hygiene. She was totally dependent on one for locomotion on and off the unit and ambulation did not occur.
She was known to have a functional limitation in her range of motion for her upper and lower extremities
bilaterally.
A review of Resident #38's care plans revealed she had an impaired ability to perform or participate in daily
care related to her Huntington's disease and spasticity of her extremities. Her goal was for her to participate
with ADL's as much as possible and to be neat in appearance daily. Her interventions included providing
nail care with showers per the weekly schedule, provide assistance with all ADL care as needed, and
anticipate resident needs as able. The resident's care plans did not indicate she was non-compliant with
personal care to include the trimming of her finger nails.
A review of Resident #38's active physician's orders revealed the resident was a total assist of one staff for
nail care as indicated under ADL assistance needed with grooming.
A review of the facility's shower schedule for the front hall (100 hall) revealed Resident #38 was to be
showered every Monday and Thursday. The showers were to be completed by the 6:00 P.M. to 6:00 A.M.
(evening shift).
A review of Resident #38's shower sheets revealed her last documented shower was provided on 01/06/20.
There was a place to document on the shower sheet if the resident's finger nails had been trimmed. Staff
were to circle yes or no to indicate if the nails had been trimmed but it was left blank.
On 01/06/20 at 12:30 P.M., an observation of Resident #38 revealed her finger nails were long and in need
of being trimmed. A subsequent observation on 01/08/20 at 8:43 A.M. revealed her finger nails remained
long and had not been trimmed as part of her last bathing activity that took place on 01/06/20.
On 01/08/20 at 9:35 A.M., an interview with STNA #53 revealed Resident #38 was a total assist for her
personal care. She stated the resident was compliant with her care, but certain things were more difficult to
do due to the movements she had in her extremities. The resident was not able to help much with her
personal care due to those same movements. She indicated the resident was cooperative with nail care
and she had not known her to refuse to allow them to be trimmed. She stated nail care should be done a
couple times a week with their showers and on an as needed basis. She reported the resident's showers
were completed by the night shift. She was asked to verify the length of the resident's nails. She checked
them and confirmed the resident's fingernails were long and in need of being trimmed. She also confirmed
they had not been trimmed recently and had not been trimmed when her shower was completed on
01/06/20.
On 01/08/20 at 9:45 A.M., an interview with the DON revealed nail care was to be done with showers and
on an as needed basis. She verified Resident #38's fingernails were long and in need of being trimmed.
She confirmed it did not appear they had been trimmed when her last shower was given on 01/06/20.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 10 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, activity calendar review and interview the facility failed to ensure cognitively
impaired residents on the secured unit were being offered preferred activities and offering scheduled
activities after 6:00 P.M This affected two resident (#36 and #365) of two residents reviewed for activities
and had the potential to affect all residents on the secured unit (Resident #2, #4, #8, #11, #13, #14, #16,
#18, #19, #21, #22, #26, #27, #28, #29, #30, #31, #32, #34, #37, #39, #40, #41, #48, #50, #51, #53, #54,
#55, #56, #58, #59, #60 and #366) on the evening shift.
Residents Affected - Some
Findings include:
1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses
including unspecified dementia, cognitive communication deficit and muscle weakness.
Review of Resident #36's activity assessment dated [DATE] revealed the resident was religious, had a
history of drawing/coloring and required engagement for activity involvement due to cognitive impairments.
Activity time preferences included morning, afternoon and evenings and preferred activities included, but
were not limited to, music, spiritual/religious activities, cards/other games, watching television, talking and
conversing.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36
was severely impaired for daily decision-making.
Review of the Speret Hall (secured unit) Activity Calendar dated December 2019 revealed religious-based
activities were scheduled on 12 days and arts/crafts was scheduled on 11 days. Further review of the
calendar revealed only four activities were scheduled for the entire month after 3:15 P.M
Review of the care plan titled Activities, revised 12/02/19 revealed Resident #36 needed encouragement to
engage in structured leisure pursuits and was supportive through regular visits. Interventions included to
encourage and assist the resident to activities of interest including but not limited to: social groups,
religious-based activities, arts/crafts, and music.
Review of Resident #36's Activity Participation Record dated December 2019 revealed no evidence the
resident was offered to participate in spiritual/religious activities during the month and was only offered
arts/crafts on one of 11 scheduled days.
On 01/06/20 at 11:29 A.M. and 4:53 P.M., confidential interviews with family members revealed it was
unknown if staff offered various activities to residents on the secured unit. The family members stated they
do not see residents being offered activities if the residents were in their rooms, and it was unknown if
preferred activities were offered. One family member stated activities of interest were observed and their
family member was not offered the activity.
On 01/07/20 at 3:30 P.M., observation revealed staff was engaging residents who were in the dining room
with trivia and balloon toss. Resident #36 was in his room and staff was not observed offering the activity to
Resident #36.
On 01/13/20 at 12:32 P.M. and 12:58 P.M., interview with Administrator #24 verified the activity calendar for
the secured unit did not include many structured activities after 3:00 P.M.; however, it
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 11 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
was her expectation that all staff implement various activities throughout the day. Administrator #24 stated
activities were documented on the Activity Participation Record and verified this did not indicate when or if
the residents were offered scheduled or preferred activities. Administrator #24 verified Resident #36's
Activity Participation Records' did not indicate the resident was offered activities of preference. On 01/13/20
at 1:10 P.M., further interview with Administrator #24 verified the current documentation does not reflect if
activities or activities of interest were being consistently offered to all residents on the dementia unit.
2. Medical record review revealed Resident #365 was admitted to the facility on [DATE] with diagnoses
including unspecified dementia without behavioral disturbance and mood disorder.
Review of the Activities assessment dated [DATE] revealed the resident was religious had special
talents/hobbies including social skills, watch television, religion and euchre (card game). Activity time
preferences included morning, afternoon and evenings and no general activity preferences were
documented.
Review of the care plan titled Activities revised 12/26/19 revealed the resident needed encouragement to
engage in structured leisure pursuits and family was supportive through regular visits. Resident preferences
included it was very important to have books, newspapers, and magazines to read, to do favorite activities
and participate in religious services or practices. The church was notified of the resident's admission per
the resident request.
Review of the Activity Participation Record dated December 2019 revealed Resident #365 was not offered
or participated in preferred activities including reading, spiritual/religious activities or games/cards/trivia.
Review of the Speret Hall Activity Calendar dated 01/01/20 through 01/13/20 revealed five religious
activities and four library activities.
Review of the Activity Participation Record dated 01/01/20 through 01/13/20 revealed no evidence Resident
#365 was offered to participate in preferred activities including reading or spiritual/religious activities.
On 01/06/20 at 12:00 P.M., observation revealed no music was playing as scheduled per the Activity
Calendar. Resident #365 was observed sitting at the dining room table with her eyes closed. No activities
were observed to be offered to the resident.
On 01/07/20 at 3:30 P.M., observation revealed Resident #365 was not encouraged, offered or participating
in any activities. Other residents were observed participating in balloon toss.
On 01/09/20 at 8:42 A.M., interview with STNA #82 revealed she was not familiar with Resident #365's
activity preferences because the resident was recently admitted .
On 01/13/20 at 12:32 P.M. and 12:58 P.M., interview with Administrator #24 verified the activity calendar for
the secured unit did not include many structured activities after 3:00 P.M.; however, it was her expectation
that all staff implement various activities throughout the day. Administrator #24 stated activities were
documented on the Activity Participation Record and verified this did not indicate when or if the residents
were offered scheduled or preferred activities. Administrator #24 verified Resident #365's Activity
Participation Records' did not indicate the resident was offered
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 12 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
activities of preference. On 01/13/20 at 1:10 P.M., further interview with Administrator #24 verified the
current documentation does not reflect if activities or activities of interest were being consistently offered to
all residents on the dementia unit.
On 01/13/20 at 1:20 P.M., interview with Activity Coordinator #45 verified residents were care planned
according to their preference and the importance of each activity so staff were aware and could encourage
the residents to participate in those activities.
The facility identified Resident #2, #4, #8, #11, #13, #14, #16, #18, #19, #21, #22, #26, #27, #28, #29, #30,
#31, #32, #34, #36, #37, #39, #40, #41, #48, #50, #51, #53, #54, #55, #56, #58, #59, #60, #365 and #366
resided on the secured unit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 13 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to implement a comprehensive and individualized bowel
protocol for Resident #418 when the resident did not have a bowel movement recorded for eight days. This
affected one resident (#418) of five residents reviewed for unnecessary medication use.
Residents Affected - Few
Findings include:
A review of Resident #418's medical record revealed the resident was admitted to the facility on [DATE]. His
diagnoses included osteomyelitis (infection involving the bone), Stage III pressure ulcer (a full thickness
skin loss potentially extending into the subcutaneous tissue layer) of the sacral region, muscle weakness,
and chronic back pain.
A review of Resident #418's physician's orders revealed the use of Norco (an opioid narcotic analgesic that
contains Hydrocodone and Acetaminophen) 10- 325 milligrams (mg) by mouth (po) every four hours as
needed for pain and Methadone (opioid narcotic analgesic) 10 mg three times a day on a scheduled basis
for pain. To help with constipation that was associated with opioid narcotic analgesics, the resident had an
order to receive Senna Plus 50 mg/ 8.6 mg po every day. His orders included a as needed (prn) order for
Bisacodyl (a laxative) 10 mg suppository one rectally every day as needed for constipation. The order for
the Bisacodyl suppository on a prn basis had been in place since his admission.
A review of Resident #418's bowel movement report since his admission revealed the resident was not
recorded as having had a bowel movement for eight days between 12/20/19 and 12/27/19. He had a large
bowel movement on 12/19/19 and did not have another recorded bowel movement until a small and
medium bowel movement was recorded on 12/28/19.
A review of Resident #418's medication administration record (MAR) for December 2019 revealed no
evidence of the resident being given the Bisacodyl 10 mg suppository that was ordered every day prn for
constipation between 12/20/19 and 12/27/19 when no bowel movements were recorded as having
occurred. The December 2019 did not even include the prn Bisacodyl as being a medication he had
ordered that could be given on a prn basis. Findings were verified by the Director of Nursing (DON).
On 01/13/20 at 9:48 A.M., an interview with the DON revealed she did not have any documented evidence
Resident #418 had a bowel movement between 12/20/19 and 12/27/19. She acknowledged that was an
eight day period in which the resident was not documented as having had a bowel movement with no
evidence of a prn laxative being given to help promote a bowel movement to occur. She stated the nurses
were to note if a resident was flagged for no bowel movement for three days in the computer. If a bowel
movement was not noted for three days, the nurse was to contact the physician to get an order for their
bowel protocol (if an order did not already exist) to be implemented or to administer a prn laxative that had
already been ordered. She could not explain why the MAR for December 2019 did not include the prn
Bisacodyl order since it had been ordered since his admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 14 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure Resident #12's fall prevention
interventions, including the use of a call light was in place as per the resident's plan of care. This affected
one resident (#12) of three residents reviewed for accidents.
Findings include:
A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Her
diagnoses included muscle weakness, lack of coordination, unsteadiness on her feet, and repeated falls.
A review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the
resident did not have any communication issues. She was able to make herself understood and was able to
understand others. Her cognition was moderately impaired. She was not known to have any behaviors nor
was she known to reject care. She required supervision with set up help for transfers, walking in her room
and toilet use. Balance issues were noted with surface to surface transfers, moving from a seated to
standing position, walking, turning around and with moving on and off a toilet. She had the use of a walker
as a mobility device.
A review of Resident #12's care plans revealed she was at risk for falls related to an impaired gait stability,
incontinence, and the use of medications that predisposed her to falls. Her interventions included
encouraging the resident to use a call light for transfer and ambulation assistance.
On 01/06/20 at 3:50 P.M., an observation of Resident #12 revealed she was sitting in her room in her
recliner. She was asked to push her call light to verify it was working. The resident was not able to locate
her call light as it was clipped to a recliner cover that was on her chair in the back of the chair out of her
reach. An interview with the resident completed at the time of the observation revealed she did use her call
light when she needed something.
On 01/13/20 at 12:33 P.M., a follow up observation of Resident #12 again observed her in her recliner. She
was asked where her call light was and indicated she did not know. Her call light was observed to be
clipped to the privacy curtain between the two beds in that room. It was clipped high up on the privacy
curtain and out of the resident's reach. The resident commented she could not reach it where her call light
had been clipped to the privacy curtain. Findings were verified by Maintenance Employee #61.
On 01/13/20 at 12:34 P.M., an interview with Maintenance Employee #61 confirmed resident call lights were
to be kept in reach at all times if a resident was capable of using them. He denied the resident would have
been able to reach her call light with it being clipped to the upper part of her privacy curtain.
On 01/13/20 at 1:25 P.M., an interview with State tested nursing assistant (STNA) #63 revealed Resident
#12 was capable of using her call light for assistance if she needed to. She denied knowing the resident to
do so but stated she could if the need arose. She acknowledged the resident was at risk for falls and part of
her fall prevention intervention was to encourage the use of her call light for transfer and ambulation
assistance. She confirmed the resident's call light should be kept in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 15 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0689
reach at all times in the event she needed it.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 16 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
record review and interview the facility failed to ensure Resident #58's admission bladder assessment was
accurate. This affected one residents (#58) of 20 residents whose assessments and care plans were
reviewed.
Findings include:
Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses
including renal insufficiency and history of urinary incontinence.
Review of the Point of Care History level of control with bladder function dated 12/16/19 revealed Resident
#58 was incontinent of urine twice.
Review of the New admission Bladder Observation dated 12/16/19 revealed Resident #58 was continent of
bladder.
On 01/13/20 at 1:50 P.M., interview with Registered Nurse #81 verified Resident #58's admission bladder
assessment was inaccurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 17 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview the facility failed to ensure pneumococcal immunizations were
offered and/or provided to residents. The facility also failed to ensure written procedures were in place to
identify who and when pneumococcal vaccines would be offered (in accordance with Centers for Disease
Control (CDC) guidelines). This affected five residents (#11, #20, #23, #34 and #60) of five residents
reviewed for pneumococcal immunizations.
Residents Affected - Some
Findings include:
Review of Resident #11, Resident #20, Resident #23, Resident #34 and Resident #60's medical records
revealed vaccination records were maintained as part of the medical record. Each resident reviewed was
noted to have a vaccination authorization form. The form included influenza and pneumococcal vaccines
(both PCV-13 and PPSV-23). The records identified each of the residents had either consented or refused
the influenza vaccines. However, the pneumococcal vaccine section for each of the above five residents
were blank. The record identified no evidence any education was provided to the residents/families, in order
to make informed consents for the pneumococcal vaccines.
Review of the facility pneumococcal vaccination policy dated 11/2018 revealed upon admission residents
would be assessed for eligibility to receive the pneumonia vaccine, and when indicated, would be offered
the vaccination within 30 days of admission of the facility unless medically contraindicated or the resident
has already been vaccinated. The policy further identified the vaccination would be administered to
residents per facility physician approved vaccination protocol. However, the facility was unable to provide
this written, approved protocol during the survey.
Interview with the Director of Nursing on 01/08/20 at 3:20 P.M. verified the above five residents, had all
resided in the facility longer than 30 days and there was no information any of them had been provided
education for the pneumonia vaccines, made informed decisions related to the administration of the vaccine
and/or had information of previously receiving the vaccination. The interview further revealed no written
approved vaccination protocol could be located to provide to the surveyor. The interview confirmed all 5
residents vaccination forms were blank in the pneumococcal vaccine sections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 18 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and interview the facility failed to ensure the environment was maintained in a safe,
clean and sanitary manner. This affected nine residents (#12, #15, #20, #23, #35, #38, #45, #60, and #62)
of 24 residents whose rooms were observed.
Findings include:
1. On 01/06/20 at 12:29 P.M., an observation of Resident #38 and #35's room revealed the tile floor
between the two beds and in front of the bathroom had a blackish-gray colored substance on the floor
where the tiles met. The substance was dried and looked like grime buildup or adhesive that had worked it's
way up between the tile cracks. Resident #38's tilt and space wheelchair in her room was observed to have
a padded cushion on her footrests that was torn. The wall next to Resident #38's bed was observed to have
scuff marks in it. The drywall had some covering over it but the covering had not been painted and was
scuffed by the bed being raised and lowered while against the wall. Resident #35's wall by her bed also had
scuff marks on it.
On 01/13/20 at 12:42 P.M., a follow up observation of Resident #38 and #35's room revealed the floor
continued to have the blackish- gray colored substance on the floor. Maintenance Employee #61 used his
knife and scraped the substance off the floor. He stated the floor appeared to be in need of being stripped
and waxed. Resident #38's padded cushion to her wheelchair was still torn but had since been duct taped.
Maintenance Employee #61 verified it was torn and in need of being replaced. He was not sure who duct
taped it but acknowledged it could not be properly cleaned being duct taped. He stated he would have to
have another one ordered. The walls by Resident #38 and #35's bed remained scuffed. There was a vinyl
baseboard trim that was peeling away from the wall behind Resident #35's bed. Those findings were also
verified by Maintenance Employee #61. He stated he would have to repair the walls and then paint them.
2. On 01/06/20 02:00 P.M., an observation of Resident #15's room revealed her to have gouge marks in
wall by her bed. On 01/13/20 at 12:32 P.M., a follow up observation of Resident #15's room revealed her
walls continued to have gouge marks on them. The findings were verified by Maintenance Employee #61 at
the time of the observation on 01/13/20. He stated he would have to repair the walls then paint them.
3. On 01/06/20 03:12 P.M., an observation of Resident #45's shared bathroom revealed the sink counter
had a large area that was chipped across the front edge. It left an area of particle board exposed that could
potentially harbor mold if it got wet and made properly disinfecting the counter impossible. On 01/13/20 at
12:35 P.M., a follow up observation of Resident #45's shared bathroom revealed it continued to have the
counter top chipped in front of the sink. Findings were verified by Maintenance Employee #61 who stated
he was not aware the sink counter top was like that.
4. On 01/06/20 03:26 P.M., an observation of Resident #20's room revealed his bedside table had the outer
veneer wood covering to be peeling around the edges leaving a sharp and jagged edge. On 01/13/20 at
12:34 P.M., a follow up observation of the resident's room with Maintenance Employee #61 revealed the
bedside table was in the same disrepair. Findings were verified by Maintenance Employee #61. He stated
they had been slowly ordering new bedside tables to ensure they had enough to go around but were only
getting two or so a month. He stated he may have to order more so they could replace the ones in poor
repair.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 19 of 20
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
365481
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Altercare Newark North Inc.
151 Price Road
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
5. On 01/06/20 03:41 P.M., an observation of Resident #60's wheelchair revealed the padded cushion in her
chair was torn. On 01/13/20 at 12:41 P.M., a follow up observation of the resident's wheelchair cushion
revealed the cushion she was sitting on remained torn. Findings were verified by Maintenance Employee
#61 at the time of the observation on 01/13/20. He stated he would have to order a new one to replace it.
6. On 01/06/20 03:45 P.M., an observation of Resident #12's bedside table in her room revealed the veneer
coating to be peeling off leaving sharp edges. On 01/13/20 at 12:33 P.M., a follow up observation of
Resident #12's bedside table revealed it remained in the same disrepair. Findings were verified by
Maintenance Employee #61 on 01/13/20 at the time of the observation who again stated they were slowly
replacing them by ordering two a week.
7. On 01/06/20 at 4:47 P.M., an observation of Resident #62's room revealed her wall by the bed had some
chip marks in it. On 01/13/20 at 12:30 P.M., a follow up observation of the resident's room revealed the wall
remained in disrepair. Findings were verified by Maintenance Employee #61 during the observation on
01/13/20. He informed the resident he would have to come back at a later time and patch her walls before
painting it.
8. On 01/06/20 at 5:04 P.M., an observation of Resident #23's room revealed she had a gray plastic
bedside table next to her bed. The bedside table was dirty and had a red colored stain on it. On 01/13/20 at
12:31 P.M., a follow up observation revealed the resident's gray bedside table remained dirty with the same
reddish colored stain on it. It had not been cleaned since the prior observation had been made. Findings
were verified by Maintenance Director #61 at the time of the observation on 01/13/20. He confirmed it was
in need of being cleaned.
On 01/13/20 at 12:45 P.M., an interview with Maintenance Employee #61 revealed he was not aware of any
of the environmental issues that were pointed out to him. He stated he had work orders on his door for the
staff to use when such issues were identified and repairs were needed to be made. He denied he received
much in the way of work orders but most of what was communicated to him was by word of mouth. He
stated the staff should be identifying those areas when in a resident's room so they could let him know
repairs were needed to be made.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 20 of 20
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
FAQ · About this visit
Common questions about this visit
What happened during the January 13, 2020 survey of ALTERCARE NEWARK NORTH INC.?
This was a inspection survey of ALTERCARE NEWARK NORTH INC. on January 13, 2020. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALTERCARE NEWARK NORTH INC. on January 13, 2020?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.