Health inspection·November 7, 2023

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** Based on closed record review and interview, the facility failed to timely notify Resident #63's family representative and physician of the resident's complaints of pain in the left arm. This finding affected one resident (#63) of three residents reviewed for notification. Findings include: Review of Resident #63's closed medical record revealed the resident was admitted on [DATE] with diagnoses including bipolar disorder, pain in the left shoulder, and obsessive-compulsive disorder. Review of Resident #63's Activities of Daily Living (ADL) care plan dated 04/26/22 revealed the resident required a Hoyer (mechanical) lift transfer with the assistance of two staff members. Review of Resident #63's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #63's State Tested Nursing Assistant (STNA) Witness Statement form authored by STNA #804 dated 10/06/23 at 9:30 P.M. indicated the STNA went into the resident's room on 10/06/23 at 7:15 P.M. for bedtime care. Resident #63 was in the wheelchair and the Hoyer lift pad was not positioned underneath the resident properly. The STNA had the resident put her hands on the armrest of the wheelchair and push up to scoot back in her chair. The STNA pulled the Hoyer lift pad down. The resident said ouch and the STNA told her that if it hurt, they should not continue. The STNA proceeded to hook up the Hoyer lift to the Hoyer lift pad that was underneath the resident and put her into bed without the assistance of a second staff member. When Resident #63 was up in the air, she complained of left arm pain, and she was placed in bed. The STNA went to get a nurse due to the resident's complaint of pain. Resident #63's progress notes dated 10/06/23 had no documented evidence the resident was assessed and monitored when the resident complained of left arm pain during the resident's nighttime care and subsequent transfer using a Hoyer lift to transfer the resident from the wheelchair into the bed. Review of Resident #63's progress notes dated 10/07/23 at 9:47 A.M. indicated the resident stated she wanted an x-ray of her left arm due to pain. An assessment was completed, and the range-of-motion (ROM) was within normal limits (WNL). No edema or redness was noted on the left arm. The Nurse Practitioner (NP) was notified, and a new order for an x-ray was obtained due to pain. Review of Resident #63's x-ray of the left shoulder dated 10/07/23 revealed a moderately displaced (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 5 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 11/07/2023 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)