Inspection·September 12, 2019

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 observation, medical record review, policy review, and interview, the facility failed to ensure timely physician notification of signs of a urinary tract infection for Resident #38. This affected one of 23 residents whose medical records were reviewed. Findings include: Review of Resident #38's medical record revealed diagnoses including diabetes mellitus and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was able to make herself understood. Resident #38 was assessed as being alert, oriented and cognitively intact. Resident #38 was frequently incontinent of bowel and bladder and required extensive assistance from staff for toilet use. On 09/09/19 at 2:15 P.M., Resident #38 was observed approaching Licensed Practical Nurse (LPN) #672 stating she was urinating every half hour and that it hurt. LPN #672 stated she would have to tell somebody and would probably need to get a urine sample. Resident #38 stated she doubted it. Record review revealed no evidence of physician notification on 09/09/19. A nursing note dated 09/10/2019 at 11:14 A.M. written by LPN #639 revealed Resident #38 complained of pain and burning with urination. The note indicated an attempt was made to obtain a urine sample through a straight catheterization with a scant amount of discharge obtained. Resident #38's physician was notified and an order was received to start antibiotic treatment with Cefuroxime. On 09/12/19 at 11:52 A.M., LPN #672 was interviewed by phone. LPN #672 stated she reported Resident #38's symptoms to LPN #639 who followed-up on the health concern. LPN #672 verified she did not report Resident #38's symptoms to the physician on 09/09/19. On 09/12/19 at 12:00 P.M., LPN #639 stated LPN #672 reported Resident #38's symptoms to her the morning of 09/10/19. Resident #38 had a standing order to obtain a urine sample via clean catch or straight catheterization which she attempted to do but the attempt was unsuccessful. LPN #639 stated she contacted Resident #38's physicians regarding the signs of a urinary tract infection on 09/10/19. On 09/12/19 at 12:18 P.M., the Director of Nursing (DON) stated if residents complained of symptoms of a urinary tract infection, the physician should be notified the same day. Review of the facility's policy, Change in the Resident's Condition or Status, updated November 2016, revealed a significant change in condition was identified as a condition which would not normally (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 4 Event ID: 366027 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 366027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632 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)