Inspection·May 18, 2023

F 0684 (NP), inform physician and or NP of any changes in skin conditions, and monitor for pain. Level of Harm - Actual harm Review of physician's orders for April 2023 and May 2023 revealed no orders for care of the surgical wounds. Residents Affected - Few Review of the Treatment Administration Record (TAR) for April 2023 and May 2023 revealed no documentation Resident #23 received care and treatment to the surgical wounds to right groin and right calf. Review of the skilled nursing note dated 04/22/23 revealed Resident #23's skin was warm, dry with dressing in place. A skilled nursing note dated 04/23/23 revealed Resident #23's skin was warm, dry with dressing place. A skilled nursing note dated 04/29/23 revealed Resident #23's skin was warm, dry with no dressing in place. A skilled nursing note dated 05/01/23 revealed Resident #23's skin was warm, dry, with dressing in place. A skilled nursing note dated 05/02/23 revealed Resident #23's skin was warm, dry with dressing in place. A skilled nursing note dated 05/03/23 revealed Resident #23's skin was warm, dry with dressing in place. Review of the weekly wound monitoring sheets dated 04/25/23 revealed Resident #23 had a surgical wound to right calf and right groin area. No exudate or odor noted. The staples were in place and the top of the right calf wound remained open. The wound treatment was to leave open to air. A weekly wound monitoring sheet dated 05/03/23 revealed Resident #23 had a surgical wound to right calf and right groin area. The open area at top of right calf had moderate amount of serosanguinous drainage with no odor. The skin was separating from the staples per the in house wound physician due to arteries not healing after surgery. Resident #23 had a follow up appointment with surgeon this date (05/03/23). Review of the comprehensive Minimum Data Set assessment, dated 04/28/23 revealed Resident #23 had intact cognition. Resident #23 required limited assistance of one person for bed mobility and transfers. Ambulation did not occur during the look back period. The assessment indicated Resident #23 had a surgical wound with no treatment. Review of hospital documentation dated 05/03/23 by attending Surgeon #4 revealed Resident #23 returned to his office today for surgical follow up. Resident #23's entire right calf incision had dehisced (a partial or total separation of previously approximated wound edges, due to failure of proper wound healing) and had skin necrosis (death) in that area. Resident #23 also had an open area to the proximal incision that measured less than one cm. The physician probed the area with a wooden swab and return of 0.5 cubic centimeter of purulent drainage was extruded from the site. The wounds were cleaned, and dressed. Resident #23 stated the wound dressings had not been changed in four days. Resident #23 was a direct admit to the hospital for intravenous antibiotics, wound care including debridement and wound vacuum placement. The wound team assessment on 05/04/23 revealed the dressings were removed, the wounds cleaned and cultures were obtained from both wounds. The wounds were redressed as Resident #23 was having surgical debridement the following day. Resident #23 had surgical wound debridement on 05/04/23 with a wound vacuum placed on groin area and dressing applied to right calf. On 05/08/23 a wound vacuum was placed on the right calf as well. An interview on 05/11/23 at 1:14 P.M. with the Director of Nursing (DON) confirmed by review of Resident #23's physician's orders there was not an order addressing Resident #23's surgical wounds, including care, monitoring or treatment. The DON stated Resident #23 had two surgical wounds with staples and typically those wounds would be monitored and left open to air. The DON confirmed all wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 2 of 4 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 05/18/2023 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)

F 0684 Level of Harm - Actual harm care and treatment for wounds would be on the resident's TAR and wound monitoring sheets would be completed weekly. The DON stated she did not recall if Resident #23 had wound dressings in place. On 05/03/23 the DON asked the in house wound physician to assess Resident #23's wounds as they did not look good. Residents Affected - Few A phone interview on 05/11/23 at 3:35 P.M. with the in house wound physician, Physician #5, revealed the nurses at the facility had asked him to look at Resident #23's right leg. Physician #5 stated the wound concerns could be from a complication from the surgery and the necrosis tissue on the edge of the incision was typical with little blood supply. Physician #5 would expect the facility nursing staff to provide care and treatment for wounds and follow the physician orders. Physician #5 also stated surgical wounds with staples would not necessarily have wound care. Usually, the first 48-72 hours the surgeon would not want the dressing removed although Physician #5 was not sure if this was the case for Resident #23. Physician #5 did not know if Resident #23 had a dressing to her wounds. There was not a dressing in place when Physician #5 assessed the wounds on 05/03/23. An interview on 05/17/23 at 9:45 A.M. with the Medical Director, Physician #3, revealed Physician #3 completed his admission assessment for Resident #23 on the Wednesday after her admission on [DATE] and stated the wounds had no issues or problems. Physician #3 did not recall if Resident #23 had dressings in place to the wounds. Physician #3 assessed Resident #23 again around 05/03/23 and stated there was a small area dehiscing at the opening at the top of the groin incision. There was no drainage and no cellulitis (bacterial infection involving the inner layers of the skin). The physician did not give any orders for care or treatment as Resident #23 was scheduled to see the surgeon. Physician #3 stated his expectations for a wound with staples would be to clean daily, monitor and dressing change per surgeon's orders. Physician #3 also stated he would expect the nursing staff to ask for orders for wound care if not on discharge instructions. An interview on 05/17/23 at 10:20 A.M. with Licensed Practical Nurse (LPN) #14 revealed Resident #23 arrived at the facility later in the evening. LPN #14 did not recall any orders for care of the surgical wounds. LPN #14 stated wounds should have orders to monitor and clean, but in this case there were no orders. LPN #14 said when there was a wound and no orders, she would ask the day shift nurse to contact the surgeon for orders. LPN #14 was an agency nurse and worked again on 05/02/23. Resident #23's son asked LPN #14 to look at his mother's wounds. LPN #14 stated the wounds looked pretty nasty and she covered them with a dry dressing. LPN #14 stated she did not notify the physician. An interview on 05/17/23 at 10:30 A.M. with Registered Nurse (RN) #46 revealed on admission all residents received a skin assessment and if the resident had a wound, the nurse would assess the wounds and notify the physician of admission and request orders if needed. The admitting nurse would put orders in the chart and complete all assessments. A subsequent interview on 05/17/23 at 10:50 A.M. with the DON revealed there was not a dressing on Resident #23's surgical wounds that she witnessed. There was not an order for wound care, and with no orders the wound would be left open to air. The DON again stated that was how the facility handled surgical wounds with staples. The facility did not provide a policy or procedure guide stating that information. Review of facility policy titled Wound Care with no date, revealed the facility failed to verify that there was a physician order for wound care as indicated in the policy. Review of the facility policy titled Admissions to the Facility with no date, revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 3 of 4 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 05/18/2023 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)

F 0684 failed to notify the attending physician for information needed for the immediate care of the resident including orders for care of surgical wounds as indicated in the policy. Level of Harm - Actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142638. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366196 If continuation sheet Page 4 of 4