Inspection·June 6, 2024

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 review of the medical record and staff interview, the facility failed to provide treatment as ordered for Resident #62. This affected one resident (#62) out of three residents reviewed for wound care. The facility census was 60. Residents Affected - Few Findings include: Review of the closed medical record revealed Resident #62, was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including infection following a procedure, chronic respiratory failure, type II diabetes, cellulitis of left lower limb, and chronic kidney disease. Review of the after-visit summary revealed Resident #62 was at the hospital from [DATE] through 05/02/24 for a postoperative wound infection. The hospital discharge orders revealed Resident #62 was ordered a wound vacuum system to the left upper anterior thigh/groin to be changed every Monday and Thursday for two weeks. A contact layer such as an oil emulsion gauze was to be placed at the base of the wound followed by black foam. The wound vacuum was to be at 125 millimeters of mercury (mmHg) with continuous low suction. A progress note dated 05/06/24 at 12:00 P.M. authored by Social Worker #117 revealed a meeting was held with Resident #62 and a family member. A family member asked about the wound treatment to Resident #62's groin area. The floor nurse spoke with Resident #62's family. A progress note dated 05/06/24 at 9:11 P.M. authored by an agency nurse revealed Resident #62's family member insisted Resident #62 be sent to the hospital to have the wound to left groin evaluated. Resident #62's wound remained open to air without the wound vacuum placed. Resident #62 was transferred to the hospital. Interview on 06/06/24 at 12:38 P.M. Social Worker #117 revealed Resident #62 had a wound, and a wound vacuum had been ordered. Social Worker #117 was unsure about treatments being provided to Resident #62's wound. Interview on 06/06/24 at 12:44 P.M. with the Director of Nursing (DON) revealed a wound vacuum was ordered on 05/01/24 for Resident #62, but a new process for ordering the wound vacuum had been put in place. The wound vacuum did not arrive and was not available when Resident #62 was admitted on [DATE]. On 05/03/24 the company that supplied the wound vacuum was contacted. The company reported they did not receive the order on 05/01/24. The wound vacuum arrived sometime in the evening on 05/03/24. The DON stated the wound vacuum was scheduled on the treatment administration record (TAR) to be changed on day shift on Mondays, Wednesdays, and Fridays. On 05/03/24 the day shift nurse had marked the TAR that the wound vacuum was not available. The DON verified the wound vacuum was in Resident #62's room but was not applied on 05/03/24, 05/04/24, 05/05/24, or 05/06/24. DON stated an agency (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 2 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 06/06/2024 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)