Inspection·October 24, 2024

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 medical record review, facility Self-Reported Incident (SRI) review, video recording review, interviews, and facility policy review, this facility failed to ensure residents were not recorded without their consent or knowledge. This affected one (Resident #300) of the four residents reviewed for respect and dignity. The facility census was 66. Findings include: Review of the medical record for Resident #300 revealed an admission date of 07/19/2025 with a discharge date of 09/26/2024. Diagnoses included burns to the left and right foot, osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and Parkinson's disease. Review of Resident #300's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #300 was noted to experience delusions and rejection of care at times. Review of the facility Self-Reported Incident #252058 dated 09/19/2024 revealed that Stated Tested Nursing Assistant (STNA) #20 alleges recording of Resident #300 in the facility's common area. Resident #300 was interviewed and states he didn't recall any said event occurring. Narrative Summary of Incident included: STNA #20 called the Director of Nursing (DON) and stated she was made aware of Resident #300 being recorded. STNA #20 states Resident #300 and the staff member involved was Agency STNA #79 who was not at the facility during the time of the allegations being reported. The staffing agency was immediately contacted to suspend Agency STNA #79 pending investigation. Resident #300 was interviewed and does not recall the event occurring. Resident #300 also confirms he has no issues or concerns with caregivers. Agency STNA #79 states she did record resident and her dancing in the common area but had no ill intent behind recording. She states they were laughing and having fun. Additional staff and residents were interviewed, and no direct witnesses identified. After investigation was completed, the facility determined this allegation of verbal abuse was unsubstantiated. As a result of this investigation, the facility completed the following: As a result of the investigation the facility cannot conclude that abuse occurred. Willful intent to harm could not be verified. While Agency aide acknowledges the allegation occurred, the intention was not to harm the resident. Further, the resident did not suffer any physical harm, pain, or mental anguish. The resident does not recall any incident occurring. Out of precaution, this agency aide was placed on a Do Not Returned list. (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 10/24/2024 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)