Inspection·September 9, 2021

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 Based on observation, interview, and record review, the facility failed to ensure personal hygiene in the form of showers was completed as scheduled for residents unable to complete showers independently. This affected two (Resident #2 and Resident #27) of three residents reviewed for showers. The facility census was 27. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 08/20/20. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), dyspnea, unspecified dementia without behavioral disturbance, major depressive disorder, osteoarthritis, unspecified rotator cuff tear or rupture of right shoulder, anxiety disorder, schizoaffective disorder, Bipolar disorder, and weakness. The Annual Minimum Data Set (MDS) on 08/25/21 revealed Resident #2 had moderately impaired cognition and was totally dependent on staff for assistance with bathing. Review of the plan of care for Resident #2 revised 05/18/21 revealed the resident had impaired Activity of Daily Living (ADL) function and required assistance to perform/complete ADL's. Goals for the resident included: provide nail care and shampoo hair with showers per weekly schedule, groom hair daily and encourage resident to participate as able, provide assistance with morning and afternoon care, encourage resident to participate with hygiene as tolerated, assist with and/or shave facial hairs daily as needed or per resident preference. Review of shower logs from 07/01/21 through 08/30/21 revealed from 07/05/21 to 08/05/21, Resident #2 only received either an other bath or a partial bed bath. The resident received a complete bed bath on 08/05/21. From 08/09/21 to 08/18/21, there were no documented showers or bed baths completed. On 08/18/21, Resident #2 refused a shower. From 08/18/21 to 08/30/21, there were no documented showers or bed baths completed. Interview on 09/07/21 at 11:09 A.M. with Resident #2 revealed the resident had not received a shower in three weeks until yesterday, 09/06/21. The resident stated he did refuse a shower or a bed bath sometimes but that was because the staff offered to assist him when it was too late in the day. Interview on 09/09/21 at 2:30 P.M. with the Director Of Nursing (DON) confirmed residents are scheduled for showers or bed baths at least twice a week. The other bath did not include washing Resident #2's hair or completing nail care. The aide washed the resident up while he was in the bathroom. The DON confirmed there was no documentation the resident received a complete bed bath or shower from 07/05/21 through 08/05/21 or from 08/09/21 through 08/30/21. (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: 366196 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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)