Inspection·December 20, 2023

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, observation and interview, the facility failed to ensure all residents on the 400 hall were monitored and provided timely assistance with incontinence care throughout the night. This finding affected six residents (Residents #1, #18, #33, #37, #51, #63) of 39 residents who reside on the 400 hall. Residents Affected - Some Findings include: Review of the staffing schedules and staffing punches for the nightshift on 10/19/23 revealed from 10:00 P.M. to 6:00 A.M., the facility had two nurses including Licensed Practical Nurse (LPN) #814 assigned to the 100 and 200 halls (worked 5:30 P.M. to 6:00 A.M.) and LPN #813 assigned the 300 and 400 halls (worked 10:00 P.M. to 6:00 A.M.). Review of the staffing schedules and staffing punches for the nightshift on 10/19/23 revealed the facility had seven State Tested Nursing Assistants (STNAs) including STNA #817 assigned the 300 hall (worked 2:14 A.M. to 6:50 A.M.), STNA #819 assigned the 300 hall (worked 10:00 P.M. to 2:30 A.M.), STNA #820 assigned the 300/400 halls (worked 10:00 P.M. to 2:12 A.M.) and STNA #810 assigned the 400 hall (worked 10:00 P.M. to 6:08 A.M.). The facility census was 74. Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including cognitive communication deficit, muscle weakness and vascular dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment, was dependent on toileting hygiene, and required substantial to dependent level assistance with mobility. Review of Resident #18's medical record revealed the resident was admitted on [DATE] with diagnoses including morbid obesity, major depressive disorder, and muscle weakness. Review of Resident #18's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and was always incontinent of bowel and bladder. Resident #18 was dependent on toilet hygiene, mobility, and transfers. Review of Resident #33's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, unspecified lack of coordination and unsteadiness on the feet. Review of Resident #33's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #38's medical record revealed the resident was admitted on [DATE] with diagnoses including unsteadiness on the feet, presence of cardiac pacemaker and unspecified. Review of Resident #38's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate (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 3 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 12/20/2023 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)