Inspection Reports for
Charlestown Place at New Albany

The facility was found deficient in multiple areas including failure to follow medication administration parameters for residents, incomplete PICC line dressing changes, lack of respiratory assessments during nebulizer treatments, and inadequate monitoring for a resident receiving hemodialysis. All deficiencies were noted to have minimal harm or potential for actual harm affecting a few residents.

The facility was found deficient in ensuring gradual dose reductions for psychotropic medications, appropriate pressure ulcer care and prevention, prevention of urinary tract infections, provision of nutritional supplements, and follow-up on pharmacy recommendations. Several residents had pressure ulcers with inadequate preventive interventions, improper catheter care was observed, nutritional supplements were inconsistently provided, and pharmacy recommendations were not addressed timely.

This citation relates to Complaint 25754913 regarding resident rights violations and Complaint 25809923 regarding medication administration errors.

The facility failed to ensure a resident received showers per her preference and another resident received his mail unopened and untimely. Additionally, the facility administered blood pressure medication despite out-of-parameter blood pressure readings for one resident.

This citation relates to Complaint 13098303.1-24(a).

The facility failed to ensure routine dental services were provided timely for 3 of 4 residents reviewed. Documentation of dental authorizations and services was lacking or delayed, resulting in unmet dental care needs including multiple tooth extractions.

This citation relates to Complaint IN00457155.

The facility failed to ensure timely completion of admission paperwork for 1 of 3 residents reviewed. The admission paperwork was supposed to be completed within 48 to 72 hours of admission but was delayed. The facility implemented a systemic plan to correct the deficiency, including audits, revised checklists, follow-up reviews, and staff training.

This visit was related to multiple nursing home complaints: IN00454370 (corrected), IN00456144 (no deficiencies), IN00457155 (deficiency cited at F620), and IN00457176 (no deficiencies).

Complaint IN00454370 was corrected. No deficiencies were cited related to complaints IN00456144 and IN00457176. A federal/state deficiency related to complaint IN00457155 was cited at F620. Overall, the facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to complaint IN00454370.

Complaint IN00457155 was substantiated with a federal/state deficiency cited at F620. Complaints IN00456144 and IN00457176 had no deficiencies related to allegations. Complaint IN00454370 was corrected.

The facility was found deficient related to Complaint IN00457155 regarding admissions policy, specifically failing to complete a resident's admission paperwork in a timely manner. Other complaints had no deficiencies cited or were corrected.

The visit was complaint-related for Complaints IN00453742, IN00453811, IN00454370, and IN00454530. Complaints IN00453742 and IN00453811 were corrected. Complaint IN00454370 was substantiated with a deficiency cited. Complaint IN00454530 was not substantiated with any deficiencies.

Complaint IN00453742 and IN00453811 were corrected. Complaint IN00454370 resulted in a Federal/State deficiency cited at F622. Complaint IN00454530 had no deficiencies related to the allegations. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.

This citation relates to Complaint IN00454370.

The facility failed to ensure that the receiving emergency department was notified of a resident's pending arrival and failed to provide bed hold policy documentation to residents discharged to the hospital for 4 of 4 residents reviewed. Documentation was missing for hospital notification and bed hold policy provision.

Complaint IN00454370 resulted in a federal/state deficiency related to the allegations. Complaint IN00454530 had no deficiencies cited. Complaints IN00453742 and IN00453811 were corrected.

The facility failed to ensure that information was provided to the receiving emergency department for one resident and failed to provide bed hold policies to residents discharged to the hospital for four residents. Some complaints were corrected, while one complaint resulted in a federal/state deficiency citation.

Complaints investigated included IN00452133 (no deficiencies cited), IN00452809 (deficiency cited at F760), IN00453742 (deficiency cited at F684), and IN00453811 (deficiencies cited at F684 and F695).

The facility was found deficient in ensuring neurological checks were completed after unwitnessed falls for 2 of 4 residents reviewed, respiratory assessments and proper nebulizer equipment storage for 1 of 3 residents, and preventing a significant medication error for 1 of 3 residents reviewed.

This inspection relates to Complaints IN00453742, IN00453811, and IN00452809.

The facility failed to ensure neurological checks were completed after unwitnessed falls for 2 of 4 residents reviewed, failed to complete respiratory assessments and properly store nebulizer equipment for 1 of 3 residents, and failed to prevent a significant medication error for 1 of 3 residents reviewed.

The investigation was triggered by complaints IN00447226, IN00448143, and IN00449144. Deficiencies related to complaints IN00447226 and IN00449144 were substantiated with cited deficiencies. Complaint IN00448143 had no deficiencies cited.

The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, inaccurate vital sign assessments, incomplete documentation of urine output for residents with indwelling catheters, failure to follow fluid restriction orders, inadequate respiratory equipment maintenance and orders, and failure to implement medication orders properly.

The inspection relates to complaints IN00449144 and IN00447226 involving failure to notify physicians, inaccurate vital sign documentation, failure to document urine output, failure to follow fluid restrictions, inadequate respiratory care, and medication administration errors.

The facility was found deficient in notifying physicians of resident condition changes, accurate vital sign assessments, documentation of urine output for residents with indwelling catheters, adherence to fluid restriction orders, respiratory equipment maintenance and physician orders, and implementation of medication orders.

The facility was found not in compliance with Life Safety Code requirements including issues with egress doors, cooking facilities, sprinkler system maintenance, fire extinguisher inspections, smoke barrier penetrations, fire drills, fire door inspections, and emergency generator testing.

The facility failed to provide a bed that accommodated a resident's height, had multiple documentation issues with controlled drug administration for 12 residents, failed to promptly dispose of discontinued and expired medications, and had unsanitary kitchen conditions including grease buildup and food debris.

This visit included investigation of Complaints IN00441570, IN00441712, IN00442755, IN00442598, and post-survey revisits to Complaints IN00435623, IN00439316, IN00439663, and IN00439706. All complaints were either corrected or had no deficiencies related to the allegations.

The facility had deficiencies related to resident accommodations, medication documentation and storage, expired and discontinued medications, and kitchen sanitation. Corrective actions and education were implemented to address these issues.

This inspection relates to complaints IN00439105, IN00439316, IN00439706, and IN00439663. The complaints involved issues of resident rights violations, medication misappropriation, medication administration errors, and inadequate medical record keeping.

The facility failed to maintain clean and sanitary toilets for residents, ensure proper narcotic medication security and administration, follow medication hold parameters related to heart rate, and maintain accurate medication administration and controlled substance records. Additionally, there were failures in wound care documentation and insulin administration documentation.

Complaints IN00439105, IN00439316, IN00439663, and IN00439706 were substantiated with federal/state deficiencies cited at tags F602 and F842. Complaints IN00437974, IN00438638, IN00440360, and IN00441040 had no deficiencies related to the allegations.

The facility was found to have deficiencies related to cleanliness of resident toilets, medication administration errors including failure to hold medication based on heart rate parameters, and inaccurate medication and controlled substance records. Some complaints were substantiated with federal/state deficiencies cited, while others had no deficiencies related to the allegations.

This citation relates to Complaint IN00435623.

The facility failed to ensure nursing staff followed medication parameters for one of four residents reviewed, specifically administering Lisinopril despite systolic blood pressure and heart rate being below prescribed thresholds.

Complaint IN00435623 was substantiated with a federal/state deficiency cited at F684. Other complaints (IN00435044, IN00436560, IN00436635, IN00436650, IN00436866) had no deficiencies related to the allegations.

The facility was found deficient related to Complaint IN00435623 for failing to ensure nursing staff followed medication parameters for 1 of 4 residents reviewed (Resident C). No deficiencies were cited for the other complaints. Resident C was discharged with no negative outcomes related to the deficient practice.

This citation relates to Complaint IN00430915. The complaint involved failure to notify a physician of a resident's change in condition and failure to maintain a safe environment free from accident hazards.

The facility failed to notify the physician of Resident B's multiple loose stools and failed to ensure Resident D's room was free of electrical hazards, resulting in burns from a melted phone charger cord. Documentation of education related to these issues was lacking or delayed.

Complaint IN00430915 was substantiated with federal/state deficiencies cited related to failure to notify physician of resident's condition and failure to maintain a safe environment.

The facility was found deficient for failing to notify a physician about a resident's multiple loose stools and for failing to ensure a resident's room was free of accident hazards, resulting in a burn injury. Corrective actions and education were initiated to address these issues.

The facility failed to develop and implement a complete care plan addressing a resident's refusal of care and failed to ensure treatments for pressure ulcers were completed as ordered for two residents.

Complaint IN00427985 was investigated with no deficiencies related to the allegations cited. Unrelated deficiencies were identified during the investigation.

The facility failed to ensure a comprehensive care plan was in place for a resident's refusal of care and failed to ensure treatments for pressure ulcers were completed as ordered for two residents. Documentation and care plan updates were lacking for refusal of turning and repositioning, and treatment administration records showed missed treatments for pressure ulcers.

This citation relates to Complaint IN00424248. The investigation was substantiated with findings of missing narcotic medication and incomplete controlled drug records.

The facility failed to ensure protection against misappropriation of resident property for one of three residents reviewed. The investigation found missing narcotic medication and discrepancies in controlled drug records, leading to corrective actions including audits and staff education.

Complaint IN00424248 was substantiated with a federal/state deficiency cited at F602. Complaints IN00425390 and IN00426633 were not substantiated with any deficiencies.

The facility was found to have a deficiency related to misappropriation of resident property involving missing narcotic medication for one resident (Resident B). No deficiencies were found related to the other two complaints. The facility implemented corrective actions including audits, education, and staff changes.

The facility was found not in compliance with several Life Safety Code requirements including corridor doors not closing and latching, means of egress obstructions, improper locking arrangements on exit doors, corridor width obstructions, emergency lighting testing deficiencies, hazardous area separations, kitchen fire suppression inspection delays, fire alarm system testing and sensitivity testing deficiencies, sprinkler system obstructions and inspection gaps, fire alarm and sprinkler system out-of-service policies incomplete, portable fire extinguisher inspection deficiencies, corridor doors impeded from closing, incomplete fire drill documentation, and unattended soiled linen and trash receptacles improperly stored.

Complaint IN00414596 was substantiated with a federal/state deficiency cited at F744 related to dementia care and failure to update care plans after aggressive behaviors and altercation.

The facility failed to implement and update a resident's plan of care after aggressive behaviors and a resident-to-resident altercation involving one resident with dementia. The care plan lacked documentation of the altercation and appropriate interventions were not updated timely.

This Federal tag relates to Complaint IN00414596.

The facility failed to implement and update the care plan for Resident D after aggressive behaviors and an altercation with another resident. Interviews and record reviews confirmed the care plan was not updated to reflect these significant behavioral changes despite policies requiring timely updates.

The facility was found deficient in multiple areas including failure to obtain proper consent for psychiatric services, delayed physician notification of rectal bleeding leading to hospitalization, inaccurate resident assessments, inadequate pressure ulcer care, improper fluid status management, insufficient behavioral health services, inadequate social services follow-up for residents with behavioral issues, failure to maintain dishwasher temperatures for proper disinfection, and failure to offer pneumococcal vaccinations per CDC guidelines.

Complaint survey completed on July 31, 2023. Plan of correction submitted for complaint survey.

The facility was found deficient in multiple areas including failure to inform resident's family and obtain physician orders for psychiatric services, failure to ensure prompt physician notification of rectal bleeding, inaccurate behavioral assessments, inadequate pressure ulcer prevention, improper fluid status management, insufficient behavioral health services, failure to provide pneumococcal vaccinations per CDC guidelines, inadequate first aid coverage, and dishwasher temperature below required levels.

Complaint IN00398549 was unsubstantiated due to lack of sufficient evidence. Complaint IN00399561 was substantiated with federal/state deficiencies cited at F686, F690, and F693.

The facility failed to ensure treatments for pressure ulcers were completed as ordered for 2 of 3 residents reviewed, catheter care was not provided or documented as ordered for 2 of 3 residents, and gastrostomy tube site care was not provided or documented for 1 of 2 residents reviewed for enteral feeding.

Complaint IN00395587 was substantiated with a deficiency cited at F580. Complaints IN00392244 and IN00395550 were unsubstantiated due to lack of sufficient evidence. Complaints IN00395974, IN00396407, and IN00397149 were substantiated with no deficiencies related to the allegations cited.

The investigation substantiated one complaint (IN00395587) with a federal/state deficiency cited related to failure to notify a resident's family member prior to a hospital transfer. Other complaints were either unsubstantiated or substantiated with no deficiencies cited. The facility provided a plan of correction addressing the notification deficiency.

The facility was found in substantial compliance with Emergency Preparedness Requirements but had deficiencies related to emergency generator load testing documentation, smoke detector sensitivity testing, sprinkler heads covered with paint, smoke barrier door coordinators, and generator monthly load test logs missing a 5 minute cool down time.