Inspection·January 8, 2025

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on medical record review, staff interview, review of facility contracts, and review of the facility policy, the facility failed to obtain laboratory tests as ordered by the physician. This affected one (Resident #24) of three residents reviewed for laboratory services. The facility census was 66 residents. Findings include: Review of the medical record for Resident #24 revealed an admission date of 10/21/24 with diagnoses including dementia, anxiety disorder, hypertension, hyperlipidemia, atherosclerosis of aorta, urinary tract infection, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 10/28/24 revealed the resident had severe cognitive impairment. Review of the progress note for Resident #24 dated 12/09/24 revealed the resident had bilateral edema in her extremities. The nurse contacted the physician and obtained an order for the following stat (immediate) laboratory blood tests: complete blood count (CBC), complete metabolic panel (CMP). Review of the physician's orders for Resident #24 revealed an order dated 12/09/24 for a stat CBC and CMP. Review of the progress note for Resident #24 dated 12/11/24 revealed the lab did not draw the resident's blood. The note did not include documentation regarding why the blood braw was not completed. Review of the physician's orders for Resident #24 revealed an order dated 12/13/24 for a stat CBC and CMP. Review of the laboratory results for Resident #24 revealed a CBC and CMP was completed for the resident on 12/13/24. Review of the physician's orders for Resident #24 revealed an order dated 12/16/24 to obtain an additional CBC. Review of the laboratory results for Resident #24 dated 12/16/24 to 01/07/25 revealed they did not include the CBC which was ordered for the resident on 12/16/24. Interview on 01/07/25 at 11:15 A.M. with the Director of Nursing (DON) confirmed the facility had (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 01/08/2025 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)