Inspection·December 28, 2019

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. A review of Resident #33's medical record revealed an admission date of 03/05/19 and the diagnoses of multiple sclerosis (MS), depression and high blood pressure. A Minimum Data Set (MDS) assessment, dated 11/26/19, revealed the resident was cognitively intact, and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. A care plan, dated 03/25/19 revealed the resident had a self care deficit related to MS, weakness and limited mobility. Interventions included extensive assistance as needed and showers per schedule and as needed. An interview on 12/26/19 at 9:34 A.M. with Resident #33 revealed she was unhappy with the attitude of State Tested Nurse Assistant (STNA) #47 during her care on 12/24/19. She stated she requested to receive showers on Tuesdays and Fridays before dinner, and on the afternoon of 12/24/19 at 4:00 P.M. she had asked STNA #47 when she would be getting her shower. STNA #47 stated to her that she would get a shower when she said she could get a shower. 2. A review of Resident #16's medical record revealed an admission date of 02/15/15 and the diagnoses of morbid obesity and congestive heart failure. An MDS assessment, dated 10/24/19, revealed the resident had intact cognition. 3. A review of Resident #6's medical record revealed an admission date of 10/30/17 and the diagnoses of major depression, rheumatoid arthritis and chronic pain. An MDS assessment, dated 12/12/19 revealed the resident had intact cognition. 4. A review of Resident #32's medical record revealed an admission date of 12/08/17 and the diagnoses of major depression. An MDS assessment dated [DATE] revealed the resident had intact cognition. A resident council meeting on 12/27/19 at 3:00 P.M. revealed Resident #6 and Resident #16 complained about the attitudes and demeanor of STNA #13 and STNA #47. They stated the two staff were short with the residents, they yelled at times and the residents feared retaliation if the facility punished the two STNAs. An interview on 12/28/19 at 12:29 P.M. with the Administrator verified she completed interviews (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: 366155 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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)