Health inspection·October 4, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure central catheter access lines were removed in a timely manner, as ordered by the physician. This affected one (Resident #70) of three residents reviewed for central catheter access lines. The facility census was 72. Residents Affected - Few Findings include: Review of Resident #70's closed medical record revealed an admission date of 08/29/23 with diagnoses that included urinary tract infection (UTI), diabetes mellitus and congestive heart failure. Review of hospital discharge records and facility admission records revealed the use of Invanz (antibiotic) one gram daily by Peripherally Inserted Central Catheter (PICC) until 09/04/23 for UTI treatment. Review of the Medication Administration Record (MAR) revealed special instructions for the Invanz which indicated PICC line to be removed after Invanz treatment completed. Additional review of the physician's orders revealed orders to discontinue and remove Resident #70's PICC line on 09/08/23, 09/11/23 and 09/12/23. Review of the nurses' notes indicated the PICC line was removed on 09/15/23, 11 days after orders initially indicated removal on 09/04/23. Interview with Registered Nurse (RN) #85 on 10/03/23 at 1:10 P.M. verified Resident #70's PICC line was removed on 09/15/23 and not removed as ordered by the physician on 09/04/23, 09/08/23, 09/11/23 and 09/12/23. This deficiency represents non-compliance investigated under Complaint Number OH00146578. 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: 365993 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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)