New Albany Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL) for two (2) of 18 sampled residents. Resident # 57, and #62 Findings Include: Review of the facility's policy titled, COMPREHENSIVE PLAN OF CARE with a revision date of 2/17/2025, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Resident #57 Record review of Resident #57's Care Plan Report revealed that he had an ADL self-care performance deficit related to generalized muscle weakness and had interventions that included to assist with all ADL's as needed. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review and facility policy review the facility failed to ensure resident's requiring assistance with Activities of Daily Living (ADL) were given care as they needed to maintain hygiene for two (2) of 18 sampled residents. Resident #57, and #62 Findings include Review of the facility's policy titled, Activities of Daily Living (ADL) with a revision date of 9/15/2022, revealed under Policy: Based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and facility policy review the facility failed to ensure an environment that is free from accident hazards and the safety of a resident during care for one (1) of 18 sampled residents. Resident #31 Findings Include: Review of the facility policy titled, INCIDENT AND ACCIDENT REPORTING, with a revised date of 9/05/2023, states It is the policy of this facility that everything possible should be done to avoid accidents or incidents involving patients .Proper reporting helps correct the current incident and prevent future incidents like it . An observation and interview on 06/23/25 at 10:30 AM with Resident #31, revealed a bandage on her right arm. Resident #31 stated, The aide scratched me with her nails when she was giving me care. During an interview with Resident #31's daughter on 6/23/25 at 10:35 AM at the facility, her daughter stated that she noticed the bandage on her arm last week and stated her mother told her someone scratched her, and she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to utilize Personal Protective Equipment (PPE) for a resident (Resident #188) who was under contact isolation on one (1) of three (3) survey days. Findings Include: Review of the facility policy Infection Prevention and Control with revision date of 02/17/25 revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . An observation on 06/23/25 at 9:36 AM, revealed Certified Nursing Assistant (CNA) #1 enter Resident #188's room to answer her call light without utilizing Personal Protective Equipment (PPE). There was Contact Precaution signage on her door and a three-drawer cart outside of her room in the hall with gowns, gloves, masks and shoe covers inside. An interview on 06/23/25 at 9:40 AM with CNA #1, revealed that she went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff and resident interviews, record review and facility policy review, the facility failed to resolve a grievance of missing clothing for six (6) of 11 residents reviewed for grievances. Resident #9, Resident #28, Resident #39, Resident #47, Resident #54, and Resident #66. Findings Include: Record review of the facility policy titled Conflict Resolution and Resident Complaint and Grievance Process with a revision date of 09/06/2022 revealed under, Complaints and Grievances: . If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the facility shall send a response to the resident stating that the facility continues to work to resolve the complaint and the facility shall follow-up with another response within 24 hours. During the Resident Council meeting on 12/05/23 at 1:10 PM, Resident #54 revealed that items of missing clothing have been a big concern at the previous resident council meetings. She revealed that she frequently gets clothes delivered to her room that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide privacy for a resident with a urinary catheter as evidence by no privacy bag covering the urine drainage bag for one (1) of four (4) residents with catheters reviewed. Resident # 79 Findings Include: Record review of facility policy titled Resident Rights dated 2020, revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 7. Privacy and confidentiality. a. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment .personal care . Record review of facility note on letterhead revealed Our catheter policy does not use the verbiage 'privacy bag'. It is added to include this verbiage as of 12/6/23, staff are being in serviced on the use of privacy bags. This was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review and facility policy review, the facility failed to complete a thorough investigation for one (1) of three (3) residents with incidents reviewed. Resident #27 Findings Include: Record review of the facility policy titled Incident and Accident Reporting with a revision date of 9/05/2023 revealed under, Policy: . It is important that the incident and accident report and investigation be completed timely and thoroughly to ensure an accurate record of the event . Record review of the Incident Note dated 11/24/23 at 2:34 PM revealed, Resident noted sitting in floor with back against w/c (wheelchair) wheels locked on w/c (wheelchair) cushion was under resident able to move upper ext (extremities) without pain. c/o (Complains of) back et hip pain et ambulance services called at this time. No other injuries noted at this time. neuro (neurological) checks initiated et wnl (within normal limits) at this time. transferred from floor to stretcher via 4 (four) ems (emergency medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for monitoring of side effects of an anticoagulant (Resident #15) and to provide a privacy bag on a urinary catheter bag (Resident #79) for two (2) of 21 resident care plans reviewed. Resident #15 and Resident #79 Findings Include: Record review of facility policy titled, Comprehensive Care Plan dated 10/10/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #79 Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Refernce F759 Based on observation, staff interview, record review and facility policy review the facility failed to administer resident medications based on professional standards of practice for 10 of 36 medication administration opportunities. Resident #9 and Resident #59 Findings include. Review of the facility policy titled, Medication Administration with a revised date of 06/08/2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Review of the facility policy titled, Medication Errors with a revised date of 09/05/2023 revealed, The facility shall ensure medications will be administered as follows: According to physician's orders . In accordance with accepted standards and principles which apply to professionals providing services. Resident #59 On 12/6/23 at 7:50 AM, a medication administration observation with Licensed Practical Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review and facility policy review the facility failed to monitor for the side effects of an anticoagulant (blood thinner) for one (1) of five (5) resident medication reviews. Resident #15 Findings Include: Record review of the facility policy titled High-Risk Medication - Anticoagulants with a revision date of 12/22/2022 revealed under, Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. Also revealed under, Policy Explanation and Compliance Guidelines: . 4. The resident's plan of care shall alert staff to monitor for adverse consequences . Record review of the December 2023 Medication Administration Record (MAR) for Resident # 15 revealed an order with a start date of 9/05/23, Eliquis tab (tablet) give 1 (one) tablet by mouth every 12 hours related to Personal History of other Venous Thrombosis and Embolism. Record Review of the December 2023 Medication Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F658 Based on observation, staff interview, record review, and facility policy review the facility failed to maintain a medication error rate of less than 5% by ensuring that residents received all physician-ordered medications for 10 of 36 medication administration opportunities observed during medication pass. The medication error rate was 27.78%. Findings include: Review of the facility policy titled, Medication Administration with a revised date of 06/08/2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .11. Review MAR (Medication Administration Record) to identify the medication to be administered . 19. Sign MAR after administration. 20. If medication is a controlled substance, sign the narcotic book. Review of the facility policy titled, Medication Errors with a revised date of 09/05/2023 revealed, .POLICY: It is the policy of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to honor a resident's food choice for one (1) of three (3) residents reviewed. Resident #17 Findings Include: Review of the facility policy titled, Resident Rights and Responsibilities with a revision date of 10/10/22 revealed .5. Self Determination .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . An observation and interview on 12/04/23 at 11:39 AM, with Resident #17 stated she does not like rice, and they keep serving her rice. An observation of the resident's lunch tray revealed the resident had rice served on her tray and her meal ticket revealed that rice was a dislike. An interview on 12/5/23 at 10:15 AM, with District Dietary Support revealed that the Certified Nurse Assistants (CNA) goes around to a list of residents and tells those residents what the menu is for the day and what the alternate is. She stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.