Health inspection·July 12, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record review, incident report review, staff interview, family interview, and policy review, the facility failed to notify a resident representative when there was a medication error requiring a need to alter treatment. This affected one of six sampled residents (Resident #56). The facility census was 55. Findings include: Review of the medical record for Resident #56 revealed an admission date of 06/09/23 and diagnoses including hypertension, congestive heart failure, and lumbar fusion. Record review did not reveal a diagnosis of diabetes or any physician's orders for insulin. A Minimum Data Set assessment on 06/16/23 documented a brief interview for mental status score of 13, indicating intact cognition. Review of an incident report dated 06/15/23 revealed Licensed Practical Nurse (LPN) #91 documented she had checked the wrong resident's blood sugar at 10:00 A.M. (result of 139 milligrams per deciliter (mg/dL) and gave 18 units of lantus insulin (long acting insulin) to the wrong resident (Resident #56). The physician was notified on 06/15/23 at 10:20 A.M. The incident report further documented that a family member, son, was notified on 06/15/23 at 11:00 A.M. Review of nurses progress notes for Resident #56 revealed LPN #91 documented on 06/15/23 at 7:58 P.M. that the resident's blood sugar had been monitored every hour from 10:00 A.M. to 6:00 P.M. with the blood sugars ranging from 116 to 160. No reactions to receiving the insulin were noted. It was documented that LPN #91 spoke with the nurse practitioner again who gave orders to check Resident #56's blood sugar again at 10:00 P.M. on 06/15/23, and at 2:00 A.M. and 6:00 A.M. on 06/16/23. There was no evidence in the medical record that the resident did not want her family notified of the medication error. A history and physical documented by the physician on 06/16/23 at 6:07 A.M. stated Resident #56, who was non-diabetic, was apparently given 18 units of Lantus insulin in error yesterday. The error was caught immediately. Incident report done. Patient, medical team, director of nursing, and administrator notified. Patient was given orange juice and hourly blood glucose checks were commenced. Blood glucose readings remained over 110 for the next six hours and she ate her lunch and dinner well with mid afternoon and bedtime snacks. Had no symptoms throughout. Blood glucose checks changed to every four hours overnight which also remained above 110. Blood glucose checks stopped in the morning. Resident denies any blood glucose concerns on 06/16/23. Record review revealed the resident had two children listed as contacts: a son and a daughter. (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 6 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 07/12/2023 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)