Inspection·October 28, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few staff to report immediately to the nurse any statements by the resident for the need to leave, to go to the bank, home, or work, attempt to determine what the resident wants or is searching for and try to convince the resident there is no need to look outside, and the resident can be outside only with staff one to one supervision and with instruction of the nurse.Review of the facility staffing for the night shift on 10/22/25 revealed the facility had two nurses and five aides scheduled to care for 68 residents. Staff assigned to the Memory Care Unit and Hall 300, located at one end of the building, were Licensed Practical (LPN) #189, and Certified Nursing Assistants (CNA) #144 and #189. At the opposite end of the building, covering Halls 100, 200 and 500 were LPN #122, CNA #102, CNA #146, and CNA #106.Review of the facility investigation dated 10/22/25 beginning at 6:15 A.M. revealed at 12:00 A.M. on 10/22/25 Resident #18 was assisted to the bathroom by CNA #144 at approximately 1:35 A.M. CNA #144, assigned to Hall 300 went to the Memory Care Unit to relieve CNA #189 for a break, leaving LPN #193 on Hall 300. At approximately 2:00 A.M., CNA #144 heard the door alarm from the employee entrance near Hall 300 and when CNA #189 returned at 2:05 A.M. from break, CNA #144 responded to the door alarm and when looking outside, found LPN #193 and CNA #146 attending to Resident #18. An assessment was performed by LPN #193, Resident #18 had no complaints of pain, LPN #193 requested CNA #144 get a wheelchair as LPN #193 and CNA #146 assisted Resident #18 back into the facility. Resident #18, once inside the building, was placed in a wheelchair and covered with a bath blanket. LPN #193 performed a second assessment and Resident #18 was bleeding from her face but denied any pain. Appropriate notifications were made, and Resident #18 remained in the wheelchair at the nurse ' s station with direct monitoring until Emergency Medical Services (EMS) arrived and transported Resident #18 to the hospital for evaluation at 2:52 A.M.Further review of the facility investigation revealed Resident #18 was found lying outside on the ground wearing a gown, brief, and slipper socks by LPN #193 and CNA #146 when they were returning from their breaks. The temperature outside was noted to be 45 degrees.Review of the hospital documentation dated 10/22/25 and printed at 5:54 A.M. revealed Resident #18 had a subtle deformity of the nasal bones on the right without bony displacement, consistent with a nondisplaced fracture. Resident #18 had an impacted, comminuted proximal right humeral fracture.Interview on 10/28/25 at 7:32 A.M. with CNA #189 revealed she was working in the Memory Care Unit on 10/22/25 and at 1:35 A.M. CNA #144 came to the unit to relieve her for break. CNA #189 stated she returned from break around 2:05 A.M. CNA #189 stated she took her break in an empty resident ' s room on the Memory Care Unit and denied hearing the door alarm until she came out of the room at the end of her break.Interview on 10/28/25 at 8:06 A.M. with Resident #18 revealed she had gotten a black eye and broken arm from a fall outside. Resident #18 could not recall how she got outside or why she was outside. When asked if she had any pain, Resident #18 stated she remembered she had pain in her right arm and in her head at the time of the incident on 10/22/25 and continues to have right arm pain. Resident #18 verified staff provide her with pain medication if she asks.Interview on 10/28/25 at 11:07 A.M. with CNA #129 revealed she had been in the activities room when the incident occurred on 10/22/25. CNA #129 stated she would come to work early on the days she was scheduled to see if extra help was needed, if not she would go into the activities room until the start of her shift. CNA #129 verified she heard the door alarm at the employee entrance going off for around five minutes but was not clocked in, so she did not respond. She thought the alarm may have been from LPN #193 and CNA #146 returning from their break.Interview on 10/28/25 at 11:11 A.M. with CNA #144 revealed she went to the Memory Care Unit to relieve CNA #189 for break when she heard the employee entrance door alarm near Hall 300. CNA #144 stated when she heard the door alarm, she could not leave the Memory Care Unit because she was the only staff member present on the unit. CNA #144 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365625 If continuation sheet Page 2 of 3 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 365625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Bucyrus Center Fo 1929 Whetstone Street Bucyrus, OH 44820 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete door had been alarming for about five minutes when CNA #189 returned from break, at which time she went to investigate and when looking outside found LPN #193 and CNA #146 assisting Resident #18 inside the building. LPN #193 asked her to get a wheelchair and once Resident #18 was inside the building she was seated in the wheelchair. CNA #144 stated she assisted LPN #193 in cleaning up Resident #18 ' s face and remained with Resident #18 until EMS arrived while LPN #193 made multiple calls. CNA #144 stated the last time she saw Resident #18 was at 12:15 A.M. when she assisted the resident to the bathroom. CNA #144 stated LPN #193 did not tell her she was going on a break. CNA #144 stated she was unaware of the residents on Hall 300 being left unattended.Interview on 10/28/25 at 3:36 P.M. with LPN #193 verified she worked on 10/22/25 and was the nurse assigned to the Memory Care Unit and Hall 300. LPN #193 said she could not recall what time she left the facility, but it was when CNA #146 approached her and asked if she wanted to go outside to smoke. LPN #193 verified when she left the building CNA #144 was on the Memory Care Unit and no other staff were present to monitor Hall 300. LPN #193 stated while outside, she asked CNA #146 to take her to a local restaurant, approximately a six minute drive from the facility. They got into CNA #146 ' s car and by the time they got to the end of the parking lot they decided they would not have enough time, so they turned around. When driving back to the staff parking lot, LPN #193 noticed Resident #18 laying on the ground in the parking lot, approximately 25 steps from the employee entrance, near the Memory Care Unit courtyard gate. LPN #193 stated Resident #18 was lying on the ground with her knees up to her chest. LPN #193 verified Resident #18 did not have her walker or her wheelchair, adding she did not know how Resident #18 could have made it outside. LPN #193 stated Resident #18 was repeatedly apologizing, saying she was on her way home. LPN #193 stated she and CNA #146 assisted Resident #18 back into the building after assessing the resident, placed Resident #18 into a wheelchair, cleaned her face, called the Director of Nursing, the resident ' s daughter, and EMS for transportation to the emergency room (ER).Review of the facility policy titled Elopement - Missing Resident with a last revision date of 05/01/25 revealed an elopement is when a resident leaves the nursing facility unattended without the facilities knowledge.Review of the facility policy titled Hours of Work with a last revision date of May 2024 revealed staff may have two ten-minute breaks during an eight-hour shift and no employee is permitted to leave company property during their breaks without special permission of the immediate supervisor.Review of the facility policy titled Routine Resident Checks with a last revision date of 05/01/25 revealed routine resident checks shall be made every two hours to ensure that the resident ' s safety and well-being are maintained.This deficiency represents non-compliance investigated under Master Complaint Number 2651195 and Complaint Number 2650725. Event ID: Facility ID: 365625 If continuation sheet Page 3 of 3