Inspection·November 20, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including laceration to scalp, muscle weakness, hyperlipidemia, anemia, dementia, atrial fibrillation, pain, vitamin B12 deficiency, vitamin D deficiency, hypertension, history of falling (02/21/19), and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited cognitive impairment and required partial/moderate (staff) assistance for toilet use. Review of Resident #25's current care plan revealed the resident was at risk for falls and potential injuries. In addition, review of the plan of care revealed the resident had an activity of daily living (ADL) self-care deficit with an intervention to have one person assistance while using the bathroom/toilet. Review of Resident #25's progress note dated 10/23/24, revealed the nurse found Resident #25 lying on the bathroom floor with blood coming from her head. Emergency medical services (EMS) were called, and the resident was taken to the emergency room for evaluation. Review of Resident #25's progress note dated 10/28/24 revealed the resident returned from the hospital with 15 sutures to the right side of her head as a result of the fall on 10/23/24. Review of a facility self-reported incident (SRI), tracking number 253458 and facility investigation documents, dated 10/29/24, revealed Resident #25 was found in the bathroom (by herself) by Certified Nursing Assistant (CNA) #101 the evening of 10/23/24. The facility information included Resident (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 11/20/2024 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)