Health inspection·July 12, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the closed medical record for Resident #80 revealed an admission date of 06/19/24 with diagnoses including aftercare following joint replacement surgery, hypertension, heart failure, and depression with a discharge date of 06/20/24 at 11:20 P.M. Review of the Minimum Data Set (MDS) assessment for Resident #80 dated 06/20/24 revealed the resident was cognitively intact. Review of the admitting physician's orders for Resident #80 dated 06/20/24 revealed orders for the following medications: Eliquis at 9:00 A.M. and 9:00 P.M., Arthrotec at 9:00 A.M., aspirin at 9:00 A.M., Wellbutrin at 9:00 A.M., calcium carbonate-vitamin D at 9:00 A.M., carvedilol at 9:00 A.M. and 5:00 P.M., cetirizine at 9:00 A.M., docusate sodium at 9:00 A.M. duloxetine at 9:00 A.M., furosemide at 9:00 A.M., levothyroxine at 6:00 A.M., losartan at 9:00 A.M., methadone at 9:00 A.M. and 9:00 P.M., Myrbetriq at 9:00 A.M. oxybutynin at 9:00 A.M., topiramate at 9:00 A.M. and 9:00 P.M., Ursodiol at 9:00 A.M. and 9:00 P.M. Review of the interdisciplinary progress note for Resident #80 dated 06/20/24 revealed the resident was concerned regarding her medications and told staff she was leaving against medical advice (AMA.) Resident #80 contacted her husband and left the faciity on [DATE] at 11:30 P.M. Review of the Medication Administration Record (MAR) for Resident #80 dated June 2024 revealed the resident did not receive her routine morning or evening medications on 06/20/24. The chart code 07 was entered in the MAR which indicated the progress notes would include an explanation of why the medications were not administered. Review of the progress notes for Resident #80 dated 06/20/24 revealed they did not include documentation to indicate why the resident's medications were not administered. There was no notation of notification to the pharmacy or to the prescriber to indicate the resident had missed doses of routine medications. (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 2 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 07/12/2024 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)