Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident
#21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated falls,
anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity,
obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous
insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set
(MDS) assessment, dated 11/25/24, revealed she was cognitively intact.
Review of Resident #21 weights, dated 11/18/24 to 01/07/25, revealed the following weights and significant
changes: 11/18/24 the resident weighted 143 pounds (lbs), on 11/25/24 the resident weighed 199.8 lbs
reflecting a 39% weight gain in a week. On 11/28/24 the resident 213 lbs reflecting a seven percent weight
gain in three days. On 12/03/24 the resident weighted 201 lbs reflecting a six percent weight loss in five
days, on 12/09/24 the resident weighed 178.2 lbs reflecting an 11% weight loss in six days and a 25% gain
in twenty one days, and on 01/07/25 the resident weighed 188 lbs reflecting a six percent weight gain in a
month and a 31% weight gain in 50 days.
Review of Resident #21 progress and nutritional notes, dated 11/18/24 to 02/01/25, revealed no
documentation to support the physician was notified each time there was a significant change.
Review of Resident #21 current care plan related to nutritional status, revealed one of the interventions
included notifying the registered dietitian and physician if a significant weight change of greater than five
percent.
Interview with Registered Dietitian #199 and Regional Nurse Consultant #199 on 02/05/25 at 11:52 A.M.
and 12:00 P.M. confirmed nursing staff is responsible for notifying the physician when the dietitian tells them
there is a significant weight change. They confirmed there was no documentation to support the physician
was notified of Resident #21 significant weight changes.
Based on medical record review, and interview the facility failed to notify the physician of significant weight
changes for Residents #14, #21, and #53. This affected three residents (#14, #21, and #53) of five
residents reviewed for nutrition. The facility census was 68.
Findings include:
1. Review of Resident #53's medical record revealed an admission date of 04/18/24 with diagnoses
including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia,
generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression.
(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 16
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
02/06/2025
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)
F 0580
Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe
cognitive impairment.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #53's weight on 05/01/24 revealed a weight of 117 pounds (lbs).
Residents Affected - Few
Review of Resident #53's weight on 06/10/24 revealed a weight of 107.5 lbs.
Review of Resident #53's weight on 07/01/24 revealed a weight of 115.5 lbs.
Review of Resident #53's weight on 08/01/24 revealed a weight of 94 lbs. Which was a significant weight
loss of 18.6% over one month and 19.6% over three months.
Review of Resident #53's medical record from 08/01/24 to 08/31/24 revealed no indication Resident #53's
physician was notified of the significant weight change.
Review of Resident #53's weight on 09/01/24 revealed a weight of 93 lbs. This weight was a significant
weight loss of 13.2% over three months.
Review of Resident #53's medical record from 09/01/24 to 12/02/24 revealed no indication Resident #53's
physician was notified of the significant weight change.
Review of Resident #53's weight on 12/03/24 revealed a weight of 104.5 lbs. This weight was a significant
weight gain of 12.3% over three months.
Review of Resident #53's medical record from 12/03/24 to 02/03/25 revealed no indication Resident #53's
physician was notified of the significant weight change.
Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199
revealed Registered Dietitian #199 generated a report through the electronic medical record once a month
to identify significant weight changes. Registered Dietitian #199 revealed she notified nursing of significant
weight changes and they were supposed to notify the physician.
Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified there was no evidence the
physician had been notified of Resident #53's significant weight changes.
2. Review of Resident #14's medical record revealed an admission date of 09/01/23 with diagnoses
including dementia, acute systolic heart failure, dysphagia, major depression, and osteoarthritis.
Review of Resident #14's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she
had severely impaired cognition.
Review of Resident #14's weight on 02/01/24 revealed she weighed 199.2 lbs.
Review of Resident #14's weight on 05/01/24 revealed she weighed 204.5 lbs.
Review of Resident #14's weight on 08/01/24 revealed she weighed 177 lbs. This was a significant weight
loss of 11.1% over six months and 12.4% over three months.
Review of Resident #14's medical record from 08/01/24 to 09/02/24 revealed no evidence the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 2 of 16
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
02/06/2025
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)
F 0580
physician was notified of her significant weight change.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199
revealed Registered Dietitian #199 generated a report through the electronic medical record once a month
to identify significant weight changes. Registered Dietitian #199 revealed she notified nursing of significant
weight changes and they were supposed to notify the physician.
Residents Affected - Few
Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified there was no evidence the
physician had been notified of Resident #14's significant weight changes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 3 of 16
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
02/06/2025
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)
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** Based on
medical record review and staff interview, the facility failed to ensure dependent residents were able to take
baths/showers per preference and the facility did not develop a plan/mechanism to address constant
bathing refusals. This affected one (Resident #19) of three residents reviewed for activities of daily living
(ADLs). The census was 68.
Residents Affected - Few
Findings Include:
Resident #19 was admitted to the facility on [DATE]. Her diagnoses were syncope and collapse, adult
failure to thrive, cardiac arrest, anxiety disorder, type II diabetes, drug induced subacute dyskinesia, muscle
weakness, need for assistance with personal care, dysphagia, cognitive communication deficit,
hypertension, atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD), bipolar
disorder, hypokalemia, osteoporosis, hemiplegia and hemiparesis, difficulty walking, congestive heart
failure, repeated falls, dehydration, chronic respiratory failure, mood disorder, hyperlipidemia,
cerebrovascular disease, epilepsy, suicidal ideations, and pancreatitis.
Review of her minimum data set (MDS) assessment, dated 12/08/24, revealed she was cognitively intact.
Review of section GG, revealed she needed substantial/maximal assistance for bathing.
Review of Resident #19 shower logs, dated 10/15/24 to 02/04/25, revealed documented refusals for all
showers/baths offered except for three that were accepted, which were on 10/15/24, 10/29/24, and
11/01/24. A total of 29 baths/showers were offered, and after her acceptance of two showers on 10/15/24
and 11/01/24 and bed bath on 10/29/24, she refused 23 baths/showers in a row that were offered. Also,
review of her bath/shower logs, there was documentation that she requested to have a bath/shower the
next day, after refusing baths/showers on 11/08/24 and 01/17/25. There was no documentation to support
Resident #19 was offered a bath/shower the following day for either.
Review of Resident #19 ADL care plan, dated 08/24/23, revealed she is non-adherent with care/services,
which included refusing showers/bathing. The interventions for this care plan included: offer resident
alternatives when refusals occur and encourage following current physicians orders. There was no
documentation to support what alternatives were offered when Resident #19 refused bed baths/showers.
Review of Resident #19 progress notes, dated 10/15/24 to 02/04/25, revealed no documentation to support
the physician was notified to discuss the constant refusals of baths/showers. There was no documentation
to support the physician was contacted to discuss options or if there were changes in her medical condition
that would support her refusing baths/showers.
Interview with Resident #19 on 02/03/25 at 11:25 A.M. confirmed she does not receive baths/showers as
she desires.
Interview with Licensed Practical Nurse (LPN) #137 on 02/06/25 at 8:55 A.M. revealed if a resident refuses
baths/ADL care, she will be told by an aide, and then she will try another time to get the resident to comply.
If the resident continues to refuse, she will document the refusal on the shower logs and try again the next
time they are scheduled. She confirmed she does not report the refusals to the Director of Nursing (DON)
or to the physician typically.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 4 of 16
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
02/06/2025
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Interview with DON on 02/06/25 at 9:02 A.M. confirmed if a resident refuses showers, the aides will tell the
nurse, and the nurse will try again. If the resident continues to refuse, the nurse is to document on the
shower sheet the refusal, and then try again at next scheduled time or when resident requests a
bath/shower. She confirmed the constant refusals is typically not reported to the physician for review.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 5 of 16
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
02/06/2025
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)
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
medical record review, staff interview, and facility policy review, the facility failed to assess all residents after
falls to determine if they remained in the safest environment as possible. This affected one (Resident #21)
of five residents reviewed for accidents. The census was 68.
Findings Include:
Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated
falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity,
obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous
insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set
(MDS) assessment, dated 11/25/24, revealed he was cognitively intact.
Review of Resident #21 fall risk assessment, dated 11/18/24, revealed a score of one, which indicated he
was not a fall risk. There were no other fall risk assessments completed after 11/18/24.
Review of Resident #21 Event Reports, dated 11/19/24 to 01/23/25, revealed a total of four unwitnessed
falls; which were on 11/19/24, 11/24/24, 01/15/25 and 01/23/25. Review of each of the fall reports revealed
that Resident #21 was found on the floor of his room all four times and the falls were unwitnessed. There
were no new fall risk assessments completed after any of the four falls to determine if Resident #21 was at
risk for falls or to find underlying causes for his falls.
Interview with Regional Nurse Consultant #190 on 02/06/25 at 10:37 A.M. confirmed there were no other
fall risk assessments completed after his four falls from 11/19/24 to 01/23/25.
Interview with Director of Nursing (DON) on 02/06/25 at 11:11 A.M. confirmed Resident #21 has fallen four
times in the last two months. She stated the facility felt like first two falls were related to a new environment
for him, so they were going to monitor him a little closer. Then, his two falls on 01/15/25 and 01/23/25, she
felt it was related to his refusals to go to dialysis. When asked if she felt those were deemed to be changes
in condition, she stated they were. When asked if a new fall risk assessment could have discovered that
Resident #21 was a risk for falls (different than his existing fall risk assessment), she confirmed that also.
Review of facility Fall Prevention policy, undated, revealed it is the facility policy to maintain the safety of all
residents. The facility will assess the fall risk and communicate to the staff. The fall assessment will be
completed upon admission, quarterly, with identified significant changes, and annually. The facility will
develop a care plan, for the resident based on risk factors from the falls assessment. The facility will identify
and communicate residents that are high risk on the resident activity of daily living (ADL) care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 6 of 16
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
02/06/2025
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included cerebral
infarction, enterocolitis, dysphagia, and epilepsy.
Residents Affected - Some
A care plan dated 04/05/23 revealed Resident #37 was at risk for altered nutrition. The care plan revealed if
Resident #37 ate less than fifty-percent of a meal, a tube feed bolus was to be provided.
A physician order dated 05/14/24 revealed Resident #37 was ordered one can (250 milliliters) of Isosource
(nutritionally complete formula for dietary management of those undernourished or at risk for malnutrition) if
Resident #37 consumed less than 50-percent of a meal provided.
On 10/01/24, Resident #37 weighed 245 pounds (lbs).
The quarterly MDS dated [DATE] revealed Resident #37 had severely impaired cognition and required
partial to moderate assistance for eating.
Review of the meal intake documentation from 11/01/24 through 12/04/24 revealed Resident #37 ate less
than fifty-percent for 38 meals out of the 94 meals documented.
Review of the medication administration record from 11/01/24 through 12/04/24 revealed Resident #37 was
not administered Isosource as ordered for less than fifty-percent of meal consumption.
On 11/04/24, Resident #37 weighed 244 lbs, on 12/04/24, Resident #37 weighed 228 lbs reflecting a seven
percent weight loss in one month.
Interview on 02/05/25 at 11:52 A.M. Registered Dietician (RD) #199 verified RD#199 did not write a dietary
note for Resident #37 until 01/07/25. Interview on 02/05/25 at 3:39 P.M. Regional Nurse Consultant #190
verified Resident #37 had a weight loss of 16 lbs between 11/04/24 and 12/04/24. Regional Nurse
Consultant #190 also verified Resident #37 was not administered Isosource as ordered when Resident #37
ate less than fifty-percent of their meal.
3. Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease,
repeated falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia,
obesity, obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension,
venous insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data
Set (MDS) assessment, dated 11/25/24, revealed he was cognitively intact.
Review of Resident #21 weights, dated 11/18/24 to 01/07/25, revealed the following weights and significant
changes: 11/18/24 the resident weighted 143 pounds (lbs), on 11/25/24 the resident weighed 199.8 lbs
reflecting a 39% weight gain in a week. On 11/28/24 the resident 213 lbs reflecting a seven percent weight
gain in three days. On 12/03/24 the resident weighted 201 lbs reflecting a six percent weight loss in five
days, on 12/09/24 the resident weighed 178.2 lbs reflecting an 11% weight loss in six days and a 25% gain
in twenty one days, and on 01/07/25 the resident weighed 188 lbs reflecting a six percent weight gain in a
month and a 31% weight gain in 50 days.
Review of Resident #21 progress and nutritional notes, dated 11/18/24 to 01/02/25, revealed only
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 7 of 16
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
02/06/2025
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
one nutritional note (dated 01/09/25) to reflect significant weight change and/or any interventions to be put
in place. There was no hospitalization or health decline related to the significant weight change, but the
significant weight changes should have been discussed and addressed timely.
Review of Resident #21's current care plan related to nutritional status, revealed the only addressed weight
change was on 01/09/25, when it was documented as being a significant weight gain over a one month
period. In line with the nutritional progress note, dated 01/09/25, Resident #21 was starting to refuse
dialysis (resident choice), and that could have been a contributing factor for his significant weight gain. But
other than this one note, the other significant weight changes were not addressed.
Interview with Registered Dietitian #199 and Regional Nurse Consultant #199 on 02/05/25 at 11:52 A.M.
and 12:00 P.M. confirmed there was no documentation to support re-weights were requested when there
was a significant weight change and there was no documentation to support there was discussion about
possible interventions for all the significant weight changes.
Based on record review and interview the facility failed to monitor and document on Residents #14, #21,
#37, and #53's nutrition status, to implement nutrition interventions as ordered for Resident #37, and to
address significant weight changes for Resident's #14, #21, and #53. This affected four residents (#14, #21,
#37, and #53) of five residents reviewed for nutrition. The facility census was 68.
Findings include:
1. Review of Resident #53's medical record revealed an admission date of 04/18/24 with diagnoses
including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia,
generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression.
Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe
cognitive impairment.
Review of Resident #53's plan of care dated 04/04/24 revealed she was at risk for altered nutrition related
to altered mental status, diabetes mellitus, hypertension, and osteoporosis. The last weight change
mentioned was from June 2024. Interventions included supplements as ordered, offering menu alternatives
as needed, monitoring weekly weights for four weeks and then monthly if stable, notifying dietitian and
physician of significant weight changes, observing resident labs, reviewing resident skin status, and
providing diet as ordered.
Review of Resident #53's weight on 05/01/24 revealed a weight of 117 pounds (lbs).
Review of Resident #53's progress notes dated 06/19/24 revealed the dietitian made a note on the
resident. This was the last dietary note or assessment on Resident #53.
Review of Resident #53's weight on 06/10/24 revealed a weight of 107.5 lbs.
Review of Resident #53's weight on 07/01/24 revealed a weight of 115.5 lbs.
Review of Resident #53's weight on 08/01/24 revealed a weight of 94 lbs. Which was a significant weight
loss of 18.6% over one month and 19.6% over three months.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 8 of 16
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
02/06/2025
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident #53's medical record from 08/01/24 to 08/31/24 revealed no indication Resident #53's
significant weight loss was addressed, and no indications Resident #53 was reweighed.
Review of Resident #53's physician order dated 08/19/24 revealed she was admitted to hospice.
Review of Resident #53's medical record revealed a nutrition assessment was not completed to address
Resident #53's significant change having entered hospice care.
Review of Resident #53's weight on 09/01/24 revealed a weight of 93 lbs. This weight was a significant
weight loss of 13.2% over three months.
Review of Resident #53's medical record from 09/01/24 to 12/02/24 revealed no indication Resident #53's
significant weight loss was addressed, and no indications Resident #53 was weighed again.
Review of Resident #53's weight on 12/03/24 revealed a weight of 104.5 lbs. This weight was a significant
weight gain of 12.3% over three months.
Review of Resident #53's medical record from 12/03/24 to 02/03/25 revealed no indication Resident #53's
significant weight gain was addressed, and no indications Resident #53 was reweighed.
Review of Resident #53's meal intake documentation from 01/01/25 to 02/04/25 revealed there was no
documentation of her intake on 01/02/25, 01/03/25, 01/06/25, 01/07/25, 01/08/25, 01/15/25, 01/16/25,
01/17/25, 01/20/25, 01/25/25, 01/27/25, 01/29/25, 01/30/25, 01/31/25, 02/02/25, and 02/03/25. Only one
meal's intake was documented on 01/01/25, 01/04/25, 01/13/25, 01/21/25, 01/22/25, and 01/23/25. Only
two meal's intake was documented on 01/09/25, 01/10/25, 01/12/25, 01/14/25, 01/24/25, and 02/01/25.
Review of Resident #53's physician order dated 01/07/25 revealed an order for a mechanical soft diet.
Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199
revealed residents were to be seen by the dietitian upon admission, annually, with significant weight
changes, and significant changes. Registered Dietitian #199 generates a report through the electronic
medical record once a month to identify significant weight changes. Reweighs were to be done on residents
with significant weight changes within a week. They verified there were no notes to address Resident #53's
significant weight changes or her significant change when she went on hospice. The resident was not
weighed anymore due to hospice, she verified this was their policy and not a physician order.
Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified the inconsistent meal
intake documentation for Resident #53. She verified she was unable to find evidence her significant weight
changes were addressed.
2. Review of Resident #14's medical record revealed an admission date of 09/01/23 with diagnoses
including dementia, acute systolic heart failure, dysphagia, major depression, and osteoarthritis.
Review of Resident #14's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she
had severely impaired cognition.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 9 of 16
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
02/06/2025
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident #14's care plan dated 09/07/23 revealed the resident was at risk for altered nutrition
related to the need for long term and memory care and weight above the ideal body weight. Interventions
included offering menu alternatives as needed, honoring food preferences as available, monitoring weekly
weights for four weeks and then monthly, notify dietitian and physician of significant weight changes,
observing resident labs as available, providing diet as ordered, monitoring weights, intake and labs, and
monitoring need to adjust the diet and to further supplement.
Review of Resident #14's weight on 02/01/24 revealed she weighed 199.2 lbs.
Review of Resident #14's weight on 05/01/24 revealed she weighed 204.5 lbs.
Review of Resident #14's weight on 08/01/24 revealed she weighed 177 lbs. This was a significant weight
loss of 11.1% over six months and 12.4% over three months.
Review of Resident #14's medical record from 08/01/24 to 09/02/24 revealed no evidence her significant
weight change was addressed or that a reweigh was completed.
Review of Resident #14's weight on 09/02/24 revealed she weighed 192 lbs. Which was a significant weight
gain of 8.5% over one month.
Review of Resident #14's annual nutrition progress note dated 09/03/24 revealed it did not address her
previous month's weight loss or her supposed weight gain Her September weight was 192 lbs and the
dietitian indicated her weight was stable.
Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199
revealed residents were to be seen by the dietitian upon admission, annually, with significant weight
changes, and significant changes. Registered Dietitian #199 generates a report through the electronic
medical record once a month to identify significant weight changes. Reweighs were to be done on residents
with significant weight changes within a week. They verified a reweigh should have been done following
Resident #14's August 2024 significant weight changes, they additionally verified the dietitian had not
monitored the residents nutrition status since September 2024.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 10 of 16
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
02/06/2025
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and medical record review the facility failed to ensure proper justification for the use of
psychotropic medications. This affected one person (#5) of five residents reviewed for unnecessary
medications. The facility census was 68.
Findings include:
Review of the medical record for Resident #5 revealed an admission date of 12/31/24 with diagnoses
including rhabdomyolysis, fracture of nasal bones, paroxysmal atrial fibrillation, dysphagia, chronic diastolic
heart failure, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, and
unspecified dementia.
Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
she had severely impaired cognition.
Review of Resident #5's plan of care dated 01/03/25 revealed they received psychotropic medications
including antidepressants, antianxiety, and antipsychotic medications. Interventions included monitoring for
side effects of antianxiety and antipsychotic medication, administering medication as ordered, encouraging
any questions by resident, monitoring for target behaviors, offering non-pharmacological approaches prior
to as needed medications, psychological and or psychiatric consult, and physician to review medications.
Review of Resident #5's physician order dated 01/03/25 to 01/09/25 revealed an order for Seroquel (an
antipsychotic medication) 25 milligrams (mg) once a day for dementia.
Review of Resident #5's physician order dated 01/03/25 to 01/10/25 revealed an order for Seroquel 12.5
mg twice a day as needed. There was no diagnosis for the medication indicated.
Review of Resident #5's physician order dated 01/10/25 to 01/31/25 revealed an order for Celexa (an
antidepressant) 10 mg every day. There was no diagnosis indicated for the medication.
Review of Resident #5's physician order dated 01/31/25 revealed an order for Celexa 10 mg every day.
There was no diagnosis indicated for the medication, but the target behavior was refusal of care.
Review of Resident #5's physician order dated 01/31/25 to 02/03/25 revealed an order for Haloperidol
(Haldol) Lactate Solution (an antipsychotic) one mg every day as needed. There was no diagnosis indicated
for the medication, but the target behavior was refusal of care.
Review of the physician order dated 02/03/25 revealed an order for Seroquel 12.5 mg at bedtime. There
was no diagnosis for the medication indicated.
Interview on 02/07/25 at 8:59 A.M. with the Director of Nursing (DON) verified diagnoses had not been put
in the orders for the antipsychotics and antidepressants ordered for Resident #5. At this time Resident #5
did not have an appropriate diagnosis for antipsychotics and verified dementia was not an appropriate
diagnosis for the medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 11 of 16
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
02/06/2025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, medical record review, and review of facility policy the facility failed to ensure
Resident #223's medication was secured appropriately and not left in his room. This affected one resident
(#223) of one resident reviewed for accident hazards. The facility census was 68.
Findings include:
Review of Resident #223's medical record revealed an admission date of 01/23/25 with diagnoses including
hallucinations, rhabdomyolysis, spinal stenosis, other epilepsy, alcohol abuse, and atherosclerotic heart
disease.
Review of Resident #223's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE]
revealed he had intact cognition.
Review of Resident #223's physician orders revealed morning medications to be administered from 7:00
A.M. to 11:00 A.M. included acamprosate (psychotropic) delayed release 666 milligrams (mg),
cholecalciferol (vitamin)2,000 units, culturelle (probiotic) one capsule, gabapentin (anticonvulsant) 300 mg,
levetiracetam (anticonvulsant) 500 mg, multivitamin one tablet, magnesium chloride (supplement) 71.5 mg,
thiamine (vitamin) HCl 100 mg, and topiramate (anticonvulsant) 50 mg,
The medical record did not indicate the resident could self-administer medications
Observation on 02/03/25 at 11:30 A.M. revealed Resident #223 was in bed, in front of him was a
medication cup with nine pills in it. He took them out of the cup and laid them on the bedside table, there
was no nurse in the room.
Interview on 02/03/25 at 11:35 A.M. with Licensed Practical Nurse (LPN) #137 reported she thought he had
taken his pills when she gave them to him. At 11:42 A.M. LPN# 137 reported she had gone back in to the
room to watch him take the pills and verified they were his morning medications.
Review of the policy 'Medication Administration- General Guidelines' dated May 2020, revealed the resident
could only self-administer medications when indicated by the physician. Additionally, residents were to be
observed after administration to ensure the dose was completely ingested. To detect refusals, the nurse
should observe the patient taking and swallowing the medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 12 of 16
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
02/06/2025
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and interview the facility failed to ensure Resident #53 was given the
diet texture as ordered. This affected one resident (#53) of five residents reviewed for nutrition. The facility
census was 68.
Findings include:
Review of Resident #53's medical record revealed an admission date of 04/18/24 with diagnoses including
metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia,
generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression.
Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe
cognitive impairment.
Review of Resident #53's progress note dated 01/07/25 revealed the resident had been noted to be
pocketing food. hospice was notified and a new order was obtained to downgrade the resident's diet from
regular texture to mechanical soft.
Review of Resident #53's physician order dated 01/07/25 revealed the resident was to receive a
mechanical soft diet.
Observation on 02/05/25 of the breakfast meal at 8:18 A.M. revealed Resident #53 eating in her room. She
had a sausage patty that had been cut up to be a little larger than quarters.
Interview on 02/05/25 at 8:21 A.M. at 10:29 A.M. with Transitional Nurse Specialist #195 revealed she
declined to verify. However, she reviewed the physician order that indicated the resident was on a
mechanical soft diet and took the resident's diet order. Following this, she reported the kitchen had been
updated with the correct diet order.
Interview on 02/06/25 at 12:42 P.M. with Regional Nurse Consultant #190 revealed the nurse had never
communicated the diet change to the kitchen.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 13 of 16
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
02/06/2025
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interviews, and review of facility policy the facility failed to ensure the kitchen was
maintained in a clean and sanitary manner. This had the potential to affect 68 residents of 68 who
consumed food from the kitchen. The facility identified no residents who consumed nothing by mouth. The
facility census was 68.
Findings include:
Observation on 02/03/25 from 8:00 A.M. to 8:18 A.M. and on 02/05/25 at 11:30 A.M. revealed the following
concerns:
a. Package of bacon in the refrigerator was open to air, unlabeled, and undated
b. There was a silver cart with two surfaces holding meal trays that were covered in food splatter and food
debris. The food splatter also covered the back of the cart.
c. Observation of the kitchen revealed under the dishwasher revealed there were tiles missing, broken, and
chipped. A large section of missing tiles had a buildup of dirt and dust. The outside of the oven hood and
the wall above it revealed it was covered what appeared to be grease stains. The wall next to the oven had
dark colored drip stains spanning over most of the wall.
e. Observation of the window near the dishwasher area revealed the blinds were covered in dirt and food
splatter and were broken in many places.
f. Observation of the additional kitchen area revealed multiple places where the flooring was chipped and
broken.
g. Observation of the ceiling revealed there were food splatters and stains throughout the kitchen. The
areas surrounding ceiling vents were covered in dust.
Interview on 02/03/25 from 8:00 A.M. to 8:18 A.M. and on 02/05/25 at 11:30 A.M. with Dietary Coordinator
#181 verified the observations.
Observation on 02/03/25 from 8:00 A.M. to 8:18 A.M. revealed the dishwasher had been run twice and had
not met the expected temperature of 180 degrees Fahrenheit. Dietary Coordinator #181 checked the
sanitation level following this, and it was also insufficient.
Interview on 02/03/25 from 8:00 A.M. to 8:18 A.M. with Dietary Coordinator #181 verified the dishwasher
was not meeting the expected temperature of 180 degrees Fahrenheit. He reported they had added
chemicals to counteract the temperature being low. Dietary Coordinator #181 verified the sanitation level
was not appropriate to sanitize the dishes.
Observation on 02/03/25 at 9:12 A.M. revealed the dishwasher was run twice and did not meet the
temperature or sanitation requirement either time.
Interview on 02/03/25 at 9:12 A.M. with the Dietary Coordinator #181 revealed he believed it had been fixed
but verified it was still not running appropriately.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 14 of 16
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
02/06/2025
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)
F 0812
Review of the facility policy 'Operation and Cleaning Procedures' dated January 2020, revealed all areas of
the kitchen will be cleaned on a daily basis to insure proper sanitation in the operation.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 15 of 16
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
02/06/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of employee files, the facility tuberculosis risk assessment, and staff interview, the facility
failed to ensure two new employees were tested for tuberculosis. This had the potential to affect all 68
residents. Facility census was 68.
Residents Affected - Many
Findings include:
The tuberculosis risk assessment revealed a baseline skin testing for tuberculosis was performed with
two-step tuberculin skin test (TST) for healthcare workers. Healthcare workers were tested upon hire and
with exposure. The infection test records would be maintained in the employees file.
Review of employee files revealed Staff Coordinator #106 and Activities Coordinator #115 were hired on
08/05/24. Staff Coordinator #106 and Activities Coordinator #115 did not have the two-step TST performed.
Interview on 02/06/25 at 12:37 P.M. Staff Coordinator #106 verified a two-step TST was not completed for
Staff Coordinator #106 and Activities Coordinator #115.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365481
If continuation sheet
Page 16 of 16
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Back to topCitations
9 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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 6, 2025 survey of ALTERCARE NEWARK NORTH INC.?
This was a inspection survey of ALTERCARE NEWARK NORTH INC. on February 6, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALTERCARE NEWARK NORTH INC. on February 6, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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.