Inspection·August 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident review (SRI), interview, and facility policy review the facility failed to ensure Resident #21 was free from staff-to-resident physical abuse. This finding affected one resident (#21) of five residents reviewed for Abuse, Neglect and Misappropriation of Resident Property. The facility census was 70. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle weakness and need for assistance with personal care. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of physical abuse SRI Tracking #244568 dated 02/26/24 revealed Resident #21 became behavioral when State Tested Nursing Assistant (STNA) #833 and STNA #904 attempted to provide care to the resident on 02/24/24 at approximately 10:30 P.M. Resident #21 ended up biting down on STNA #904's forearm and drew blood. STNA #904 reacted by slapping Resident #21 which caused him to release her forearm. The allegation was unsubstantiated. Review of Resident #21's Illustration of Documentation and Measurements of Skin Areas form dated 02/24/24 at 10:40 P.M. revealed the resident had a red area (handprint) on the right side of the face. Review of Resident #21's Event Statement Form dated 02/26/24 authored by the Administrator revealed she interviewed STNA #904 over the phone. The statement indicated STNA #833 and STNA #904 went into the resident's room around 10:00 P.M. on 02/24/24. The resident was transferred using a Hoyer mechanical lift from the wheelchair to the bed. He was fine and did not seem agitated. After the transfer, the staff started taking off his pants to provide care at which point he became agitated. The staff told him exactly what was happening and he started hitting and kicking the staff. STNA #904 rolled him towards her so that peri care could be completed for a bowel movement when the resident lifted his head and bit into the STNA #904's right forearm very hard until it drew blood. Resident #21 eventually released STNA #904's arm, and the nurse was notified. STNA #904 stated she did not slap the resident, but he must have been lying on one side of his cheek which must have caused some redness. (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 6 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 08/20/2024 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)