New Albany Care Center

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to properly store and date food items in the kitchen. This had the potential to affect 60 of 61 residents who resided in the facility who received foods prepared in the facility kitchen. The facility identified (Resident #45) who had an ordered was ordered a nothing by mouth diet.

Inspectors wroteBased on medical record review, resident interview, staff interview and review of the facility the facility failed to arrange transportation for scheduled medical appointments. This affected one (Resident #112) of 25 sampled residents. The facility census was 61 residents.

Inspectors wroteBased on review of resident funds accounts, staff interview, and review of the facility policy, the facility failed to obtain written authorizations to manage resident funds accounts. (Residents #123 and #124). This affected two (Residents #123 and #124) of five residents reviewed for resident funds accounts. The facility census was 61 residents.

Inspectors wroteBased on review of resident funds accounts, staff interview, and review of the facility policy, the facility failed to provide written notification for the need to spend down resident funds to residents and/or resident representatives. This affected one (Resident #22) of five residents reviewed for resident fund accounts. The facility census was 61 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide assistance with bathing and shaving to dependent residents. This affected one (Resident #2) of 41 facility-identified residents (#2, #4, #6, #11, #14, #20, #21, #22, #23, #24, #26, #27, #28, #29, #31, #32, #33, #34, #36, #41, #42, #43, #44, #45, #47, #48, #50, #53, #57, #61, #112, #114, #116, #119, #161, #165, #168, #170, #171, #174, #175) who required assistance with shaving. The facility census was 61 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility staff failed to ensure residents received the proper treatment and assistive devices to maintain hearing. This affected two (Residents #15 and #48) of two residents reviewed for hearing. The facility census was 61 residents.

Inspectors wroteBased on medical record review, observation, resident representative interview, resident interview, staff interview, and review of the facility policy, the facility failed to pressure ulcer interventions were implmented for residents with pressure ulcers. This affected one (Residents #25 ) of five residents reviewed for pressure ulcers. The facility census was 61 residents.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to ensure oxygen was administered according to physician orders. This affected one resident (Resident #45) of two residents reviewed for oxygen administration. The facility identified 13 residents (#2, #28, #34, #41, #44, #45, #121, #122, #162, #165, #170, #173, #174) who were receiving oxygen. The facility census was 61 residents.

Inspectors wroteBased on medical records review staff interview the facility failed to respond in a timely manner to consultant pharmacist recommendations. This affected one (Resident #42) of five residents reviewed for unnecessary medications. The facility census was 61 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility staff failed to ensure residents were free from significant medication errors. This affected one (Residents #48) of five residents reviewed for unnecessary medications. The facility census was 61 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure kitchen staff blended pureed food to an appropriate texture prior to serving to the residents. This affected two residents (Residents #32 and #33) of two residents with orders for a pureed diet. The facility census was 61 residents.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure that residents who were at risk for developing multidrug-resistant organisms (MDRO) were placed in enhanced barrier precautions (EBP) per facility policy. This affected one (Resident #57) of 23 residents reviewed for EBP. The facility census was 61 residents.

Inspectors wroteBased on closed medical record review, staff interview, and facility policy review, the facility failed to provide timely, adequate and necessary care, monitoring and treatment for Resident #62 who exhibited an acute change in condition. Actual harm occurred on 12/10/24 when Resident #62, who had an order for continuous use of oxygen, was noted to have an acute change in condition (decreased oxygen saturation levels and increased confusion) throughout the night that was not timely monitored or treated. In addition, there was no evidence the change in condition was reported timely to the physician. Per a facility fall investigation, on 12/10/24 at 5:45 A.M. the resident sustained an unwitnessed fall out of bed with low documented oxygen saturation levels. The resident was subsequently transported to the emergency room with a critically low oxygen saturation level of 64%. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to notify the physician and resident representative of a change in resident condition, in a timely manner. This affected one (Resident #62) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, constipation, disorder of muscle, cognitive communication deficit, dilated cardiomyopathy, pleural effusion, hyperkalemia, acute kidney failure, chronic kidney disease, atrial fibrillation, major depressive disorder, insomnia, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hypertension, peripheral vascular disease, anemia, type II diabetes, and personal history of pulmonary embolism. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain a complete medical record regarding resident changes of condition that occurred. This affected one (Resident #62) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, constipation, disorder of muscle, cognitive communication deficit, dilated cardiomyopathy, pleural effusion, hyperkalemia, acute kidney failure, chronic kidney disease, atrial fibrillation, major depressive disorder, insomnia, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hypertension, peripheral vascular disease, anemia, type II diabetes, and personal history of pulmonary embolism. [...]

Inspectors wroteBased on medical record review, facility investigation review, staff interview, and review of the facility fall management guide the facility failed to ensure Resident #25 was provided adequate assistance and supervision during the provision of personal care to prevent a fall with injury. Actual harm occurred on 10/23/24 when Resident #25, who had cognitive impairment and required staff assistance for personal care including toileting sustained a fall in the bathroom after being left on the toilet unattended. The resident was assessed to have a laceration to the head (as a result of the fall) and was transported to the hospital where she was admitted and received 15 sutures to the area. The resident was hospitalized from [DATE] until 10/28/24. This affected one resident (#25) of three residents reviewed for accidents. The census was 59. Findings Include: [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, review of facility documents, and review of the facility policy review the facility failed to administer medications as ordered by the physician. This affected one (Resident #80) of three residents reviewed for medication administration. The facility census was 60 residents.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to maintain Resident #47 and Resident #165's dignity when urinary catheter bags were uncovered and visible to others. This affected two residents (#47 and #165) of six residents reviewed for dignity. The facility census was 61. Findings Include: 1. Review of the medical record for Resident #47 revealed an admission date of 06/27/22 with diagnoses including hemoperidoneium, localized edema, and obstructive and reflux uropathy. Review of the care plan, dated 06/29/22 revealed Resident #47 had a Foley catheter due to the diagnosis of obstructive uropathy. [...]

Inspectors wroteBased on record review, beneficiary notice worksheet review and interview the facility failed to provide an Advanced Beneficiary Notice (ABN) to Resident #315, prior to the resident being cut from Medicare part A therapy services and remaining in the facility. This affected one resident (#315) of one resident reviewed for beneficiary notices who had remained in the facility after being cut from services. Findings Include: Review of the facility beneficiary notice worksheet revealed Resident #315 was the only resident who had been cut from Medicare part A therapy services and remained in the facility in the last six months. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure all required information was included on bed hold notices issued to Resident #31, Resident #33, and Resident #64 who experienced hospitalizations. This affected three residents (#31, #33 and #64) of three residents reviewed for hospitalization. Findings Include: 1. Review of the medical record for Resident #33 revealed an admission date of 04/07/22 and a re-admission date on 05/18/22. Resident #33 had diagnoses including encephalopathy, sepsis, other intestinal obstruction, bacteremia, type II diabetes mellitus, Alzheimer's Disease, altered mental status, and urinary tract infection. Resident #33's payor source was Medicaid. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #26, who required extensive assistance from staff for personal hygiene received showers as scheduled. This affected one resident (#26) of one resident reviewed for activities of daily living. Findings Include: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, severe morbid obesity, chronic obstructive pulmonary disease (COPD), diabetes, heart failure peripheral vascular disease, depression, pacemaker, atrial fibrillation and lymphedema. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/07/22 revealed the resident was moderately cognitively impaired. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive and individualized range of motion program for Resident #50 who was assessed to have limitations in range of motion. This affected one resident (#50) of one resident reviewed for range of motion. Findings Include: Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, aphasia, hemiplegia, encephalopathy, diabetes, and anxiety. A physical therapy evaluation, dated 06/07/21 revealed the resident appeared to be at his baseline with all functional mobility and activities and daily living. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place to reduce the risk of falls for Resident #21 as care planned. This affected one resident (#21) of three residents reviewed for accidents. Findings Include: Review of the medical record for Resident #21 revealed an admission date on 12/21/18 with diagnoses including dementia with behavioral disturbance, cerebral infarction (stroke), chronic kidney disease, and unspecified protein-calorie malnutrition. Review of the care plan, dated 10/07/20 revealed Resident #21 was at risk for falls due to weakness, limited mobility, cognitive impairment, and impaired safety awareness. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure interventions were in place to decrease the risk of urinary tract infections associated with the use of indwelling urinary catheters for Resident #31. This affected one resident (#31) of three residents review for urinary catheters. Findings Include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including respiratory failure, acute kidney failure, hypertension, cerebral infarction, hemiplegia, dysphagia, visual deficit, cerebral atherosclerosis, bradycardia, hyperlipidemia, transient cerebral ischemic attack, dementia, peripheral vascular disease, chronic kidney disease, hydronephrosis, retention of urine, polyneuropathy, weakness, and age related cataract. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure weekly weights were obtained as ordered to monitor the nutritional status of Resident #13. This affected one resident (#13) of three residents reviewed for nutrition. Findings Include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including anemia, high blood pressure, malnutrition, anxiety, depression and osteoarthritis. Review of the physician's orders, revealed an order dated 01/31/22 to obtain weekly weights. Review of the weight report from March to August 2022 revealed weights were not obtained weekly as ordered. Weights were only documented as being obtained on 03/07/22, 03/21/22, 04/03/22, 04/04/22, 04/18/22, 04/25/22, 05/02/22, 05/04/22, 05/16/22, 05/23/22, 05/30/22, 06/06/22, 06/13/22, 06/20/22, 06/27/22, 07/11/22 and 07/25/22. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized behavioral health program to address Resident #256's depression diagnosis and anti-depressant medication use. This affected one resident (#256) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure non-pharmacological interventions were attempted and documented prior to the administration of as needed (PRN) pain medications . This affected three residents (#13, #56 and #60) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, high blood pressure, malnutrition, anxiety, depression, osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/11/22 revealed the resident had moderately impaired cognition and required extensive assistance from one staff member for bed mobility, dressing, toilet use and personal hygiene. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure an antibiotic for prophylactic treatment of urinary tract infections was justified and necessary for Resident #53. This affected one resident (#53) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on personnel file review, facility policy and procedure review and interview the facility failed to implement their abuse policy and procedure to ensure new hire reference checks were completed upon hire as part of the facility screening process. This had the potential to affect all 61 residents residing in the facility. Findings Include: Review of the following employee personnel files revealed reference checks were either not completed, not completed timely, or had no date to support when the reference check was completed: The Director of Nursing (DON) was hired on 12/29/21. Review of the employee's personnel file revealed no evidence reference checks were completed until 02/16/22. Admissions Director (AD) #32 was hired on 11/08/21. Review of the employee's personnel file revealed she only had one reference check completed and it was undated. [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#6, #16, #32 and #33) out of 64 residents interviewed for dignity and respect. The facility census was 64.

Inspectors wroteBased on medical record review, resident interview and staff interview, the facility failed to complete resident showers per resident preference. This affected one resident (Resident #33) out of three residents reviewed for choices. The facility census was 64.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide physician ordered care for a resident with lymphedema. This affected one of one resident reviewed for edema.