Inspection Reports for
Newburgh Health Care

At this 2nd PSR, Newburgh Health Care was found in compliance with Emergency Preparedness and Life Safety Code requirements. However, a deficiency was noted related to Electrical Equipment Testing and Maintenance, for which a temporary waiver was approved until 06/30/2025.

The facility was found not in compliance with Emergency Preparedness Requirements including failure to annually review and update the emergency preparedness plan, policies and procedures, communication plan, training and testing program, and emergency preparedness exercises. Additional deficiencies were found in life safety code compliance including emergency lighting testing, sprinkler system maintenance, fire alarm system policies, fire drills, smoking regulations, electrical equipment maintenance, and use of extension cords.

The facility was found not in compliance with emergency preparedness requirements including failure to annually review and update emergency plans, policies, communication plans, and training. Deficiencies were also found in life safety code compliance such as incomplete fire safety plans, inadequate fire drill documentation, sprinkler system maintenance, emergency power system testing, and improper use of electrical equipment and fire suppression systems.

The facility was found deficient in multiple areas including care plan conferences, care plan development and revision, fall prevention interventions, respiratory care, medication administration, dietary manager qualifications, facility assessment, quality assurance meetings, infection prevention, and intellectual disability program implementation.

The facility had multiple deficiencies including failure to complete quarterly care plan conferences, incomplete care plans after new diagnoses or orders, inadequate fall prevention interventions and documentation, improper respiratory care including unlabeled oxygen equipment, medication administration errors, unqualified dietary manager, incomplete facility assessment, inconsistent Quality Assurance and Performance Improvement meetings, infection prevention and control program deficiencies including lack of certified infection preventionist and failure to implement proper hand hygiene and barrier precautions.

This citation relates to Complaint IN00449014.

The facility failed to maintain a safe and sanitary environment as evidenced by sticky and soiled hallway floors observed during multiple walkthroughs. The housekeeping schedule indicated floor care was planned daily, but staff interviews revealed floors were not mopped every day as required.

Complaint IN00449014 was investigated and federal/state deficiencies related to the allegations were cited at F921. The citation relates to failure to maintain a safe and sanitary environment.

The facility failed to provide a safe and sanitary environment as hallway floors were found sticky and soiled in multiple locations during three random observations. The issue was confirmed through observations, interviews, and record reviews.

The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards including emergency preparedness policies, emergency power system maintenance, fire safety, electrical safety, and fire drills. Deficiencies included incomplete emergency preparedness policies, missing generator load test documentation, inadequate emergency lighting testing, hazardous area door issues, fire door inspection lapses, incomplete fire drill documentation, and electrical receptacle testing deficiencies.

This citation relates to Complaint IN00423804.

The facility failed to promote and facilitate resident self-determination related to bathing for one resident. Resident F's preference for showers and hair washing three times a week was not honored, with only bed baths provided and hair washing omitted.

Complaint IN00423804 was substantiated with Federal/State deficiencies cited at F561 related to resident self-determination and bathing preferences.

The facility failed to promote and facilitate resident self-determination related to bathing for 1 of 3 residents reviewed. Resident F's preference for showers and having her hair washed three times a week was not honored, resulting in deficiencies cited related to resident rights and self-determination.

The investigation was triggered by complaints regarding resident dignity, self-determination, medication management, and infection control. The citation relates to Complaint IN00423804.

The facility failed to ensure resident dignity and self-determination, including respect for resident preferences and proper staff conduct. There were failures in timely notification of changes in resident condition, improper use and evaluation of psychotropic medications, improper medication storage, and inadequate infection prevention and control practices.

Complaint IN00423804 was investigated and Federal/State deficiencies related to the allegations were cited at F561.

The facility was found deficient in multiple areas including resident dignity and rights, self-determination, notification of changes in condition, psychotropic medication management, medication storage, infection prevention and control, and staff training requirements.

This Federal tag relates to Complaint IN00415380. The complaint involved a resident with dementia eloping from the facility due to inadequate supervision and failure to follow elopement protocols.

The facility failed to ensure adequate supervision to prevent a resident with dementia from eloping. The resident exited the front door unnoticed, and staff did not notify family, physician, or authorities prior to the family alerting the facility.

Complaint IN00415380 was substantiated with federal and state deficiencies cited related to allegations of inadequate supervision resulting in resident elopement.

The facility failed to ensure adequate supervision to prevent a resident with dementia from exiting the facility and returning home unsupervised. The front door was found unlocked with no staff present, and the resident was discovered outside the facility after an elopement incident. The facility implemented corrective actions including updated care plans, increased supervision, and policy revisions.

Complaint IN00385996 was substantiated. The deficiencies related to failure to provide written notice of transfer/discharge to residents or representatives and failure to notify the area ombudsman of transfers/discharges.

The facility failed to ensure that written notice of transfer/discharge was provided to residents or their representatives for 2 of 3 residents reviewed for hospitalizations, and failed to notify the area ombudsman of transfer/discharges for all 3 residents reviewed. The Social Service Director indicated a misunderstanding about notification requirements, which was corrected with a revised process.

The visit was complaint-related, triggered by concerns about resident care, medication management, safety hazards, infection control, and staffing. Specific complaints included failure to accommodate resident preferences, unsafe medication practices, wandering residents entering other rooms, and inadequate infection prevention measures. The complaints were substantiated based on observations, interviews, and record reviews.

The facility was found deficient in accommodating resident preferences for bathing, revising care plans timely, ensuring medication safety and appropriateness, maintaining a safe environment free from hazards, posting accurate staffing information, and implementing infection prevention and control practices. Several residents were affected by these deficiencies, including failure to provide showers on preferred days, failure to revise care plans, unsafe medication storage, wandering residents entering other rooms, improper catheter care, and staff not adhering to mask protocols.