Health inspection·January 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the self-reported incident (SRI) and the facility's investigation, review of the facility policy, record review, and staff interviews, the facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Administrator or designee. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the Alleged Perpetrator's assignment on 10/06/23. The facility census was 40. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Review of the SRI control number 239906 dated 10/06/23 at 2:00 P.M. revealed there was an allegation of verbal abuse by a staff member to Resident #27 on 10/06/23 at approximately 8:30 A.M. State Tested Nursing Assistant (STNA) #100 and STNA #104 reported they were providing care for Resident #27 when STNA #150 (Alleged Perpetrator) entered the room. STNA #150 stated if he is going to act like a little expletive, I will not be giving him a shower today. STNA #150 then left the room. STNA #100 and STNA #104 completed care for Resident #27 and then reported the alleged incident to the nurse. Review of the statement signed by the Administrator on 10/06/23 revealed STNA #150 was interviewed via the telephone on 10/06/23 at 2:30 P.M. STNA #150 denied making the comment in front of Resident #27. A written statement dated 10/06/23 by STNA #104 revealed STNA #100 and STNA #104 were providing care for Resident #27 when STNA #150 walked in the room. Resident #27 pulled the covers over his head. STNA #150 stated I'm not going to give him a shower if he is going to act like a expletive. Between 1:00 P.M. and 1:30 P.M., STNA #150 was yelling down the hall about STNA #100 and STNA #104 making up lies about STNA #150. A resident's family was on the hall. The incident was reported to the front office and the department heads walked STNA #150 out of the facility. A statement dated 10/06/23 revealed Licensed Practical Nurse (LPN) #200 addressed the allegation with STNA #150. STNA #150 denied making the comment. LPN #200 reported there were conflicting stories of whether the comment was made in front of Resident #27 or in the hallway. A statement dated 10/06/23 by STNA #172 revealed STNA #150 had a bad attitude that day (10/06/23). Review of a typed statement by STNA #100 dated 10/09/23 at 10:58 A.M. revealed STNA #150 had been bragging about it being her last day and how much she hated working at the facility. STNA #150 was (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: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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)