Altercare of Canal Winchester Post-Acute Rc

Inspectors wroteBased on closed medical record review, hospital record review, facility policy review, and interviews, the facility failed to timely identify and seek necessary medical intervention following an acute change in condition for Resident #78. This resulted in Immediate Jeopardy, with actual serious life-threatening harm beginning on 03/12/26 at 12:34 P.M., when Resident #78 was noted to be lethargic (a reduced level of consciousness), with elevated blood glucose of 522 milligrams per deciliter (mg/dL, normal results 70-99 mg/dL). The resident's blood sugar was not re-checked for four hours and remained elevated at 353 mg/dL when it was rechecked. The resident continued with limited food and fluid intake and lethargy. The facility failed to monitor the resident, provide comprehensive assessments, and medical support for the resident. On 03/13/26 at 8:30 A.M. [...]

Inspectors wroteBased on closed medical record review, hospital record review, facility policy review and interview, the facility failed to follow physician orders for Resident #88's urinary catheter and failed to develop and implement a comprehensive and individualized plan of care for the urinary (indwelling) catheter including consistent monitoring/assessment of urinary output to prevent a significant complication from catheter use. This affected one resident (#88) of three residents reviewed for urinary catheters. The facility census was 57 residents. Actual harm occurred on 08/26/25, when Resident #88, who was cognitively impaired, was noted to have a change in condition, which included blood and pus observed in his urinary catheter bag. [...]

Inspectors wroteBased on resident interviews, staff interview, record review and facility policy review, the facility failed to promptly respond to resident and family concerns brought up by residents in resident council meetings. This had potential to affect all 57 residents at the facility. The facility census was 57.

Inspectors wroteBased on observations, resident, family, and staff interviews, nurse practitioner interview, record review, review of resident council meeting minutes, and review of the facility assessment, the facility failed to have sufficient nursing staff to meet the needs of the residents. This affected nine residents (#39, #23, #84, #54, #4, #71, #31, #93, and #88) with the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on record review, review of the facility assessment, review of the Administrator Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 21 residents (#39, #23, #84, #54, #4, #71, #78, #88, #31, #55, #91, #93, #6, #9, #12, #61, #85, #87, #83, #81, #86) and had the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on record reviews, observations, staff and resident interviews and facility policy review, the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal hygiene including assistance with eating, nail care, and bathing/showering. This affected seven (Residents #6, #9, #12, #61, #85, #87, and #93) of 12 residents reviewed for activities of daily living. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to ensure a complete and accurate medical record for five (Residents #9, #23, #74, #84 and #88) of 37 sampled residents reviewed in the course of the survey. The facility census was 57.

Inspectors wroteBased on observations, record review, staff interview and policy review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment that helped to prevent the development and transmission of communicable diseases and infections. This affected five (Residents #31, #81, #83, #84, and #86) 37 sampled residents sampled in the course of the survey. The facility census was 57.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed treat the resident with respect and dignity to promote and enhance their quality of life. This affected one (Resident #84) of two residents reviewed for indwelling catheters. The census was 57.

Inspectors wroteBased on review of resident medical record, resident family interview, and staff interview, the facility failed to notify the resident representative of a change in treatments. This affected one resident (Resident #55) out of thirty-seven residents reviewed during the annual survey process. The facility census was 57.

Inspectors wroteBased on observations, record review, staff interview, family interview, and policy review, the facility failed to ensure a resident/responsible party had the right to choose activities and schedules consistent with their interests, assessments, and care plan. This affected one resident (#6) of 37 sampled residents. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to notify the provider of significant weight change and weight refusals for Resident #95. This affected one resident (#95) of 37 residents reviewed for notifications. The facility census was 57.

Inspectors wroteBased on review of concern tracking logs, policy review, record review, staff interview, and resident interview, the facility failed to make prompt efforts to resolve complaints/grievances by resident/family members. This affected three residents (Residents #31, #55, and #93) of three residents reviewed for concerns and had the potential to affect all residents of the facility due to the lack of policy/procedure and system in place. The facility census was 57.

Inspectors wroteBased on review of medical record, staff interview and review of facility policy, the facility failed to report an injury of unknown origin to the State in a timely manner. This affected one resident (#88) out of five residents reviewed for abuse. The facility census was 57 residents.

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to execute a timely discharge for a resident. This affected one resident (#41) of eight residents reviewed for the discharge process. The facility's census was 57.

Inspectors wroteBased on observations, record review, staff interview, resident interview, policy review, and family interview, the facility failed to comprehensively assess residents in the areas of activities and dental status. This affected two residents (#6, #13) of 37 residents reviewed for accuracy of assessments. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to develop baseline plans of care that included the interventions necessary to properly care for residents within 48 hours of admission. This affected three (Residents #84, #86 and #93) of 37 residents reviewed for plans of care. In addition, the facility failed to ensure that a summary of the baseline plan of care was provided to the resident or representative. This affected one (Resident #93) of 37 residents reviewed for plans of care. The census was 57.

Inspectors wroteBased on resident record reviews, staff interviews and review of the facility policy, the facility failed to develop comprehensive care plans for three residents. This affected three (Residents #6, 10, and 88) out of thirty-seven resident records reviewed for comprehensive care plans. The facility census was 57 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure required plan of care meetings were held with residents and resident representatives. This affected one (Resident #4) of 37 resident records reviewed for care plans. The facility census was 57.

Inspectors wroteBased on observations, resident interviews, family interviews, staff interviews, record review and facility policy review, the facility failed to provide an ongoing activity program based on resident preferences to create opportunities for a meaningful life. This affected one (Resident #6) of 37 sampled residents. The facility census was 57.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident with a pressure ulcer received the necessary care and treatment as ordered to promote healing, prevent infection, and prevent new ulcers from developing. This affected one resident (#93) of six residents reviewed for pressure ulcers. The facility census was 57.

Inspectors wroteBased on medical record review, observations, staff interview, and facility policy review, the facility failed to ensure fall interventions were in place. This affected one (Resident #4) of two residents reviewed for falls. The census was 57Findings include: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included aphasia, high blood pressure, major depression, insomnia, anemia, cerebral infarction, anxiety and history of embolism. Review of the quarterly MDS assessment dated [DATE] revealed her cognition was moderately impaired. She required supervision or touching assistance for eating, personal hygiene and turning and repositioning, partial to moderate assistance oral hygiene, toileting, substantial to maximal assistance for shower/bathing. Occasionally incontinent of urine and frequently incontinent of bowel. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to The facility failed to ensure accurate and timely monitoring of Resident #93's weight, resulting in an undetected and unevaluated significant weight loss. This affected one (Resident #93) of four residents reviewed for nutritional status. The facility census was 57.

Inspectors wroteBased on observation, medical record review, staff interview and policy and procedure review, the facility failed to appropriately check for placement of the gastrostomy tube prior to administration of medication. This affected one (Resident #6) of four residents observed for medication administration. The facility census was 57.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure Resident #93 was provided with adequate pain management. This affected one (Resident #93) of two residents reviewed for pain. The facility census was 57.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure medications were available to be administered for Resident #74. This affected one (Resident #74) resident out of 37 residents reviewed for medications. The facility census was 57.

Inspectors wroteBased on record review, review of pharmacy recommendations, staff interview, and facility policy, the facility failed to ensure medication regimen reviews were completed monthly for Resident #8 and #11 and failed to follow-up timely on pharmacist's recommendations for Resident #7 and Resident #8. This affected three residents (#7, #8, and #11) of five residents reviewed for pharmacy recommendations. The facility census was 57. Findings Include: 1. Review of Resident #11 's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory disease, multiple sclerosis, dysphagia, hypertension, diabetes mellitus and major depressive disorder. Review of the comprehensive minimum data set assessment dated [DATE] revealed his cognition was intact, evidenced by a Brief Interview for Mental Status (BIMS) score of 14. [...]

Inspectors wroteBased on medical record review, review of pharmacy recommendations, and staff interview, the facility failed to ensure pharmacy recommendations were addressed with an adequate indication for use of the medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 57.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were free of significant medication errors and that medications were given in accordance with physician's orders. This affected one resident (Resident #83) of 37 sampled residents. The facility census was 57. Findings Include:Review of Resident #83's hospital records (prior to admission to the facility) revealed he was diagnosed with Clostridioides difficile (C. diff), (a bacterium causing severe diarrhea, fever, and colon inflammation often triggered by antibiotic use) on 04/02/26. He was placed on Contact plus precautions in the hospital on [DATE]. Contact plus precautions were noted as enhanced infection control measures used, alongside standard precautions, to prevent the spread of highly contagious pathogens, particularly C. diff. [...]

Inspectors wroteBased on resident medical record review and staff interviews, the facility failed to complete labs as ordered for two residents. This affected two residents (#88 and 90) out of thirty-seven medical records reviewed during the annual survey. The facility census was 57 residents.

Inspectors wroteBased on observations, record review, staff interview, resident interview, and facility policy review, the facility failed to assist Resident #13 in obtaining dental services. This affected one resident (#13) of one resident reviewed for non-Medicaid dental services. The facility census was 57.

Inspectors wroteBased on record review, staff interview, resident interview, and facility policy review, the facility failed to assist residents in obtaining dental services. This affected two residents (#10 and #62) of three residents reviewed for dental services. The facility census was 57.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to implement care planned interventions for nutritional supplements for Resident #60 to maximize the healing potential of wounds. This affected one resident (#60) of three reviewed for wounds. The facility census was 63. Findings Include:Review of the medical record for Resident #60 revealed an admission date of 08/28/25. Pertinent diagnoses included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage 4 (severe), acute kidney failure, depression, anxiety disorder, muscle weakness, pressure ulcer of sacral region, unspecified stage; pressure ulcer of left heel, unspecified stage, and obesity. [...]

Inspectors wroteBased on interview, concern log review, Resident Council Meeting review and record review the facility failed to ensure resident concerns were addressed timely and appropriately. This affected seven residents (#2, #15, 16, #17, #21, #26, #37) who were identified to regularly attend resident council. Facility census was 58.

Inspectors wroteBased on observations, staff interview and record review, facility failed to ensure menus and spreadsheets were followed and full meals were provided. This affected five Residents #18, #19, #20, #38 and #57 of five reviewed for nutrition. Facility census was 58.

Inspectors wroteBased on observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure residents were placed in proper isolation type, with appropriate signage. Facility also failed to ensure staff were knowledgeable to isolation status of residents and failed to wear the correct personal protective equipment (PPE). This affected four Residents #19, #20, #23, and #24 of four reviewed for isolation status. Facility also failed to ensure proper sanitization of the glucometer affecting Resident #12 and ensure infection control was maintained during medication administration affecting Resident #68. Facility census was 58.

Inspectors wroteBased on observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure falls were investigated thoroughly, appropriate interventions were implemented based on the cause of the falls and ensure interventions were in place per the care plan. This affected three Residents #2, #23, and #63 of three reviewed for falls. Facility census was 58.

Inspectors wroteBased on staff interviews, review of employee file and policy review, facility failed to ensure residents were free from significant medication error when Narcotics were not given as ordered and documented for Resident #67 and medications were not given as ordered for Resident #66 upon admission. This affected two Residents #66 and #67 of three reviewed for medications. Facility census was 58.

Inspectors wroteBased on observation, record review, staff interview and review of the facility policy, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevent program to ensure residents were thoroughly assessed, interventions were initiated timely and in place as planned and/or staff timely identified the development new pressure ulcers. This affected two residents (#216 and #213) of six residents reviewed for pressure ulcers. The facility census was 61. Actual Harm occurred on 08/04/24 when Resident #216, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, was assessed to develop an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the sacrum. [...]

Inspectors wroteBased on observation, record review, facility staff interview and policy review the facility failed to ensure appropriate hand hygiene was conducted during medication administration for Resident #105 of three reviewed (#28 and #104), and the facility failed to ensure enhanced barrier precautions were in placed and followed for three (Resident #2, #19 and #104) of three reviewed for EBP. The facility census was 61.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #30's needs were addressed in a timely manner when she waited for 29 minutes for her call light to be answered. This affected one resident (#30) of one resident reviewed for call lights. The facility census was 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records during routine medication administration, leaving information visible to the public. This affected two (Resident #104 and #105) out of three residents observed during medication administration. The facility census was 61.

Inspectors wroteBased on observation, interview and record review the facility failed to provide set up meal assistance to a resident with limited range of motion. This affected one (Resident #213) of three residents who require set up assistance with meals. The facility census was 61.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place for Resident #2 and #19 and failed to ensure complete and timely investigations were completed for Resident #2 and #205. This affected three residents (#2, #19, and #205) of five residents reviewed for falls. The facility census was 61.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #38 had reasonable access to fluids. They additionally failed to ensure Resident #19 was weighed monthly and failed to ensure Resident #2's significant weight change was addressed and that her nutrition status was accurately assessed. This affected three residents (#2, #19, and #38) of six residents reviewed for nutrition and hydration. The facility census was 61.

Inspectors wroteBased on interview and medical record review the facility failed to ensure nonpharmacological interventions were attempted and documented prior to administering 'as needed' anxiety medication. This affected one resident (#2) of five residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on record review, facility staff interview and policy review the facility failed to ensure one (Resident #42) timely received speech therapy services regarding a change in nutritional condition/status. This affected one of five residents reviewed for nutrition. The facility census was 61. Findings Include: Review of Resident # 42's medical record revealed an admission date of 02/26/24. Further review revealed diagnoses of chronic obstructive pulmonary disease, unspecified, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Dysphagia, oropharyngeal phase, diabetes and encounter for attention to gastrostomy tube. Review of the Minimum Data Set, dated [DATE] revealed Resident #42 had a feeding tube and was receiving a mechanically altered diet. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported incident (SRI), review of facility investigation, resident and staff interview and policy review the facility failed to prevent the misappropriation of Resident #21's prescribed narcotics. This affected one resident (#21) of three residents reviewed for misappropriation. The facility census was 62.

Inspectors wroteBased on record review, review of facility Self-Reported incident (SRI), review of facility investigation, resident and staff interview, and policy review the facility failed to timely investigate an allegation of misappropriation. This affected one resident (#21) of three reviewed for misappropriation. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, and resident interview, the facility failed to implement an effective and individualized pain management program for Resident #50 per physician's orders. This affected resident (#50) of three sampled residents. The facility census was 60. Actual harm occurred on 02/25/24 when Resident #50 experienced significant physical pain when her ordered narcotic pain medication was not administered for over 26 hours. The resident indicated during this time period, the pain which she reported was to her feet was rated a nine on a scale of one to 10 (with 10 being the most severe pain) limiting her ability to get out of bed and eat and causing her to cry.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident received timely and physician ordered treatment after a change in condition. This affected one of three sampled residents ( #63). The facility census was 60.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurately documented. This affected two of three sampled residents (#50, #63). The facility census was 60.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a sanitary environment for resident showers. This affected one resident (#64). The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to administer as needed stool softeners to prevent a bowel obstruction. This affected one resident (#13) of three residents reviewed for constipation. The facility census was 66. Actual harm occurred on 12/28/23 to Resident #13, who had a diagnosis of constipation, when facility staff failed to assess and monitor the resident and failed to provide ordered medical treatment when the resident did not have a bowel movement for six days resulting in the resident experiencing a bowel obstruction requiring hospitalization and treatment.

Inspectors wroteBased on medical record review and staff interview the facility failed to notify a resident's physician of weight gain as ordered. This affected one resident (#13) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hypertension, type II diabetes, chronic obstructive pulmonary disease, hyperlipidemia, and constipation. Additional diagnoses were added on 01/01/24 including encephalopathy and abdominal distention. Review of a quarterly minimum data set (MDS) assessment completed on 10/03/23 revealed Resident #13 had intact cognition, no behaviors, was always incontinent of bowel, and was dependent on staff for toileting assistance. [...]

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to perform oral hygiene for Resident #4 and #9, shaving assistance for Resident #9, showers, and nail care for Resident #317 and #322. This affected four residents (Resident #4, #9, #317, and #322) of seven residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on staff interview, resident interview, medical record review, and facility policy review, the facility failed to sufficiently staff the facility to provide activities of daily living assistant for Resident #4, #9, #317, and #322. This affected four residents (Resident #4, Resident #9, Resident #317, and Resident #322) of eight residents reviewed for sufficient staffing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #51's call light was within his reach. This affected one resident (Resident #51) of one resident reviewed for accommodation of needs.

Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to identify and treat Resident #4's stage III pressure ulcer. This affected one resident (Resident #4) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on staff interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and #46 oxygen (O2) equipment was stored properly and Resident #4's oxygen orders were documented accurately. This affected two Residents (#4 and #46) of three residents reviewed for respiratory care.

Inspectors wroteBased on observations, medical record review, and resident and staff interviews, the facility failed to provide Resident #8 social services to obtain sufficient clothing. This affected one resident (Resident #8) of one resident reviewed for social services.