Charlestown Place at New Albany

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident C) clinical record was updated, as requested by the resident's Power of Attorney, for 1 of 3 residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident B) representative was notified of an acquired venous ulcer and a gradual dose reduction in medication for 1 of 3 residents reviewed for notification of changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring was in place for residents (Resident B and Resident C) when a gradual dose reduction (GDR) was implemented for 2 of 3 residents; and failed to ensure a resident (Resident B) was immediately assessed for injury after a witnessed fall for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility to ensure a resident (Resident B) was transferred, via mechanical lift, with two staff members present during the transfer for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of a medication for 1 of 3 residents reviewed for medical records.

Inspectors wroteBased on interview and record review, the facility management failed to timely report an incident to the Indiana Department of Health when a resident (Resident E) acquired a second degree burn from a coffee spill for 1 of 5 residents reviewed for reportable incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure medications were not administered to residents (Resident C and Resident D) when out of the physician ordered parameter blood pressure readings for 2 of 4 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely wound treatments were implemented for a resident (Resident E), upon admission, for 1 of 3 residents reviewed for pressure ulcer prevention.

Inspectors wroteBased on interview, and record review, the facility failed to prevent a Stage 4 pressure ulcer development (a severe, full-thickness wound extending to muscle, tendon, or bone, featuring deep tissue loss, often with slough, tunneling, and high infection risk) for a resident who was admitted without a skin impairment to the bilateral buttocks and sacrum, was identified by the facility to be at risk for the development of a pressure ulcer, who had co-morbidities, frequent moisture, and total dependence on staff for repositioning. The facility failed to ensure services were provided to the sacral wound and facility acquired full thickness skin tears on the bilateral buttocks obtained during a fall to prevent the wounds from deteriorating to a stage four pressure injury that required surgical debridement, and hospitalization for sepsis with in 3 weeks of admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow medication administration parameters (Resident F and Resident K) for 2 of 3 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident B) PICC (peripherally inserted central catheter) line dressing changes were completed for 1 of 1 resident reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure respiratory assessments were in place for residents (Resident C, Resident D and Resident H) receiving nebulizer treatments for 3 of 4 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring was in place for a resident (Resident H) receiving hemodialysis for 1 of 1 resident reviewed for quality of care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure care plan interventions and treatments were in place or completed as ordered by the physician for 5 of 7 residents reviewed for pressure wounds (Residents 2, 52, 64, 14, 73). This deficient practice resulted in a resident acquired bilateral unstageable heel wounds (Resident 2).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received periodic gradual dose reductions for the anti-psychotic and anti-depressant medications to determine necessity at current dosages for 1 of 5 residents reviewed for unnecessary medications. (Resident 56)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the prevention of UTIs (Urinary Tract Infections) and proper infection control techniques for 1 of 2 residents reviewed for bowel and bladder. (Resident 2)

Inspectors wroteBased on record review and interview, the facility failed to ensure nutritional supplements were provided to 2 of 9 residents reviewed for skin treatments and nutrition. (Residents 14 and 92)

Inspectors wroteBased on record review and interview, the facility failed to follow up on 2 of 8 Consultant Pharmacy recommendations with the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 56)

Inspectors wroteBased on observation interview and record review, the facility failed to ensure a resident (Resident D) received showers per her preference and failed to ensure a resident (Resident H) received his mail unopened and in a timely manner for 2 of 3 residents reviewed for resident rights. Findings Include:1 The clinical record for Resident D was reviewed on 8/11/25 at 1:08 p.m. The resident's diagnoses included, but were not limited to, depression and anxiety. The annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident's cognition was intact. On 8/8/25 at 2:40 p.m., the resident was observed sitting up in her wheelchair watching television. The resident's hair was observed to be flat and oily in appearance and her bilateral lower extremities were wrapped with ace wraps. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a blood pressure medication was held for a resident (Resident K) with out of parameter blood pressures for 1 of 3 residents reviewed for quality of care. Findings Include: The clinical record for Resident K was reviewed on 8/11/25 at 2:16 p.m. The resident's diagnosis included, but was not limited to, hypertension. The care plan, dated 6/9/25, indicated the resident had altered cardiovascular status due to hypertension and medications were to be administered as ordered by the physician. The physician's order, dated 4/5/25, indicated the resident was to receive Lisinopril (medication for high blood pressure) 10 mg (milligrams) daily in the morning. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 110. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure routine dental services were provided timely for 3 of 4 residents reviewed dental services. Findings Include:1. The clinical record for Resident B was reviewed on 7/16/25 at 1:13 p.m. The resident's diagnoses included, but were not limited to, iron deficiency anemia, anxiety and chronic pain. The annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident's cognition was intact. During an interview, on 7/16/25 at 4:25 p.m., the resident indicated she had not been seen by the dentist since she admitted to the facility. The admission paperwork, dated 10/5/23, and signed by the resident, indicated Resident B elected for the facility's third partner provider services for dental. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident B) admission paper work was completed in a timely manner for 1 of 3 residents reviewed for admissions.

Inspectors wroteBased on interview and record review, the facility failed the ensure information was provided to the receiving emergency department (Resident B) pending arrival for 1 of 3 residents and failed to ensure the bed hold polices were provided to residents (Resident B, Resident C, Resident D and Resident E) discharged to the hospital for 4 of 4 residents reviewed for transfers/discharges.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure neurological checks were completed on residents (Resident H and Resident K) with unwitnessed falls for 2 of 4 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory assessments were completed for a resident and failed to ensure nebulizer equipment was stored appropriately for 1 of 3 residents reviewed for respiratory care. (Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant medication error did not occur for 1 of 3 residents reviewed for medication errors. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a resident's (Resident K) low blood pressure and continuous complaints of shortness of breath for 1 of 3 residents reviewed of notification of changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed staff accurately assessed a residents' (Resident K) vital signs for skilled charting and obtain vital signs daily for 1 of 3 resident's skilled assessments reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff documented urine output for residents' with indwelling catheters for 3 of 4 residents reviewed for bowel and bladder. (Residents B, F and G)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed a resident's fluid restriction order from the physician, for 1 of 3 residents reviewed for hydration. (Resident K)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's orders were in place for weekly maintenance of the nebulizer equipment (Resident B and Resident H); failed to ensure a nebulizer face mask was stored appropriately and the tubing was dated (Resident B); and failed to ensure physician's orders were in place for routine oxygen administration (Resident K) for 3 of 4 residents reviewed for respiratory.

Inspectors wroteBased on interview and record review, the facility failed to ensure an order to increase a resident's Lasix (diuretic) was implemented for 1 of 3 residents reviewed for significant medication errors. (Resident K)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure documentation on the Controlled Drug Receipt/Record/Disposition Form of administered narcotics for 12 of 64 residents observed for medication storage in the 500, 400, and 800 Hall medication carts. (Residents 32, 76, 96, 45, 20, 58, 219, 87, 218, 43, 15, and 77)

Inspectors wroteBased on observation and interview, the facility failed to ensure discontinued and expired medications were promptly disposed of during 4 of 7 observations of medication storage. (Medication Carts 300, 400, 800, and Medication room [ROOM NUMBER])

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen equipment, ceiling vents and the kitchen floor were free from food debris and grease build up for 3 of 3 kitchen observations. This deficiency had the potential to affect 118 residents who received meal trays from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was provided a bed and mattress that could accommodate his height comfortably for 1 of 69 resident beds observed for accommodation of needs. (Resident 60).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents (Residents E and H) toilets were clean and sanitary for 2 of 4 residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to follow medication administration hold parameters related to a resident heart rate (Resident C) for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration records and controlled substance records accurately reflected the administration of narcotic medication for 3 of 4 residents reviewed for medical records. (Residents C, F, and H)

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff followed medication parameters for 1 of 4 residents reviewed for quality of care. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a resident's (Resident B) loose stool for 1 of 3 residents reviewed for change of condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's (Resident D) room was free of potential hazards and education was provided to the resident (Resident D) on the risks of negative outcomes secondary to potential hazards for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a plan of care was in place for a resident's (Resident D) refusal of care for 1 of 3 residents reviewed for for care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' (Residents D and E) treatments were completed, as ordered by the physician, for 2 of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure prompt notification to the physician of rectal bleeding for a resident on an anticoagulant, which resulted in the resident's hospitalization for anemia and acute blood loss. The resident had to have a blood transfusion for 1 of 3 resident's reviewed for physician notification. (Resident 82)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received behavioral health services as required for 1 of 3 resident's reviewed for behavioral health services. This deficient practice resulted in a resident with ineffective behavior interventions and uncontrollable behaviors. (Resident 86) Findings Include: The record for Resident 86 was reviewed on 7/26/23 at 11:37 a.m. The diagnoses included, but were not limited to, developmental disorder of speech and language, anxiety disorder, altered mental status, and lack of expected normal physiological development in childhood. The Quarterly MDS (Minimum Data Set) assessment, dated 6/15/23, indicated the resident was moderately cognitively impaired. The MDS indicated the resident did not exhibit behavioral symptoms such as hitting, kicking, pushing, scratching, and grabbing. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate social services follow-up after unwanted and inappropriate behavior interactions from a resident with behavior concerns for 8 of 9 residents reviewed for Social Services. (Residents 24, 80, 320, 57, 20, 60, and 86)

Inspectors wroteBased on observation and interview, the facility failed to ensure the dishwashing equipment was at an appropriate temperature to disinfect dishes. This had to potential to affect all 115 resident residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered pneumococcal vaccinations as recommended by the CDC (Centers for Disease Control) for 3 of 5 residents reviewed for pneumococcal immunizations. (Residents 377, 18, and 22)

Inspectors wroteBased on record review and interview, the facility failed to inform the resident's family in advance of the treatment risks, benefits and additional options for psychiatric services and failed to obtain a physician's order for treatment prior to the implementation of psychiatric services for 1 of 24 residents reviewed for resident rights. (Resident 110)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set assessments were correctly documented for behaviors for 1 of 25 residents reviewed for accuracy of assessment. (Resident 86)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure ulcer prevention interventions were provided as indicated in the resident's care plan for a resident with a known history of pressure ulcers for 1 of 7 residents reviewed for pressure ulcers (Resident 34).

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate fluid status management related to administration of diuretics, clarification of orders for duplicate therapy, and weight monitoring for 1 of 3 residents reviewed for fluid status management. (Resident 26)

Inspectors wroteBased on interview and record review, the facility failed to adequately implement social services to address the continuous behavior of crying, pacing, agitation, restlessness and adjustment to the secured unit for a resident with a diagnosis of dementia for 1 of 3 residents reviewed for Dementia Care. (Resident 110)