Health inspection·April 10, 2025

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 record review and interview, the facility failed to ensure a resident, who required assistance with personal care, received assistance with activities of daily living (ADLs). This affected one resident (#11) of six residents reviewed for ADL assistance. The facility census was 71. Residents Affected - Few Findings include: Closed record review revealed Resident #11 was admitted to the facility on [DATE]. Review of the resident's Face Sheet revealed the resident had admitting diagnoses including displaced midcervical fracture of left femur, closed fracture with routine healing, respiratory failure, chronic obstructive pulmonary disease, and hypertension. Resident #11 discharged from the facility on 03/31/25 to home. Review of ADL documentation including bed mobility, transfers, eating, toileting, bathing, bowel and bladder incontinence care from 03/29/25 through 03/31/25 revealed no evidence Resident #11 received any assistance with her ADLs on 03/30/25 and 03/31/25. Interview on 04/09/25 at 8:51 A.M. with Resident #11's family revealed while visiting Resident #11, her clothes had not been changed, she had not received assistance with eating and was left laying flat to eat so she had food all over her clothes and face. Interview on 04/10/25 at 2:10 P.M. with the Administrator confirmed there was no documented evidence Resident #11 received assistance with her ADLs on 03/30/25 or 03/31/25. The surveyor requested a facility policy for ADL care to residents but a policy was not received at the time of the survey. This deficiency represents non-compliance investigated under Complaint Number OH00164242. 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: 365750 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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)