Our Home New Albany

Based on observations, review of the facility call policy, and staff interview, the facility failed to ensure all residents rooms had call lights in the resident rooms in the memory care unit. This affected 18 residents (Residents #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, and #83) who resided on the memory care unit. The facility census was 83.

Findings include:

Observations of the memory care unit on 03/27/25 at 8:50 A.M. revealed none of the rooms in the memory care unit had call lights near the residents' beds. There were pull cords for requesting staff assistance located next to the toilets in the residents' bathrooms.

Interview on 03/27/25 at 8:52 A.M. with Maintenance #185 confirmed the only call lights available in the memory care unit were in the restrooms and call lights were not present in the residents' rooms in the memory care unit. Maintenance #185 stated the rest of the facility the residents used call pendants.

Interview on 03/27/25 at 9:38 A.M. with Nursing #188 confirmed there were no call systems in the residents' rooms, and the residents in the memory care unit do not have pendants.

Interview on 03/27/25 at 9:42 A.M. with the Administrator and Maintenance #188 confirmed none of the residents in memory care have a pull cord/call light or pendant available nearby the resident's living area.

Review of the facilities Call Light policy dated 01/01/24 revealed the facility is committed to providing timely assistance to residents through an efficient call light system, ensuring responses align with individual care requirements and Ohio state guidelines.

This violation represents non-compliance investigated under Complaint Number OH00164108.

Based on observations, staff interview, and facility policy review, the facility failed to ensure all food was stored, prepared, and served in a safe and sanitary manner. This had to the potential to affect 81 of 81 residents in the facility.

Findings Include:

1. Observations on 11/18/24 at 8:38 A.M. and 11:47 A.M. revealed ice built up in the walk in freezer. The ice was hanging over two boxes of frozen pork. One box of frozen pork had ice built up on top of the box.

Interview with Dietary Manager #200 on 11/18/24 at 8:45 A.M. confirmed there was ice built up in the walk in freezer. She revealed they have had issues with the condenser in the freezer and it kept freezing up. She revealed staff would move food from underneath the built up ice, but that did not happen between breakfast and lunch.

2. Observations on 11/18/24 at 8:35 A.M. and 11:54 A.M. revealed a scoop left in the container of cocoa.

Interview with Dietary Manager #200 on 11/18/24 at 11:55 A.M. confirmed there was a scoop left in the container of cocoa. She confirmed it should not have been in there.

Requests were made to the facility on 11/18/24 for a food storage policy; however, there was nothing listed in any of the policies provided regarding not keeping scoops or utensils in containers of food/product.

3. Observation on 11/18/24 at 8:40 A.M. revealed a quarter container of buttermilk in the refrigerator. The best used by date on the container stated 11/01/24.

Interview with Dietary Manager #200 on 11/18/24 at 8:46 A.M. confirmed the buttermilk was past the used by date and still in the refrigerator. She immediately removed the container and disposed of it.

Review of facility undated Proper Food Dating Policy and Procedure revealed the facility was committed to proper food dating practices to maintain food safety, quality, and compliance with the state department of health regulations. The policy aimed to prevent the consumption of expired food items, minimize food waste, and uphold high standards of resident care and safety. Handling expired food items: remove any food items past their used-by or expiration dates from storage immediately. Dispose of expired items according to facility waste management policies and state regulations.

4. Observation on 11/18/24 at 12:05 P.M. revealed the facility staff taking the temperature of the pulled chicken. The temperature of the chicken was 130 degrees Fahrenheit. Dietary Cook #201 served two portions of pulled chicken onto buns without getting the chicken to the appropriate temperature. She was stopped by the surveyor from serving the sandwiches to residents due to the temperature not being appropriate and safe.

Observation on 11/18/24 at 12:08 P.M. revealed Dietary Cook #201 stirring the pulled chicken on the steam table, and then taking the temperature again. After approximately two minutes of keeping the thermometer in the chicken, the temperature of the chicken rose to 164 degrees Fahrenheit, which was still one degree below the appropriate cooking temperature of chicken.

Interview with Dietary Cook #201 on 11/18/24 at 12:05 P.M. and 12:08 P.M. confirmed the chicken did not get to 165 degrees Fahrenheit. The cook was observed to continue to serve the chicken to the residents.

Review of facility undated Temperature Checks in Culinary Setting Policy and Procedure revealed the facility was committed to teaching and maintaining best practices with regular temperature checks of all food and ensuring food was within state guidelines. Employees would adhere to Chapter 3717-1-03 Food Code Reference Guide from the state department of health to ensure proper heating temperatures and times.

Review of the State department of health Chapter 3717-1-03 Food Code Reference Guide revealed raw poultry was to be cooked to 165 degrees Fahrenheit and maintain that temperature for at least seven seconds.

5. Observations on 11/18/24 from 12:06 P.M. to 12:25 P.M. revealed Dietary Cook #201 with gloves on her hands. During this time period, she touched the following items without changing her gloves and/or washing her hands: serving utensils, plates, bowls, dirty counter top of the steam table, order sheets/paper for each resident's food order, sandwich buns, pulled chicken, fries, sweet corn, cutting board, and knife to cut the chicken sandwiches.

Interview with Dietary Cook #201 on 11/18/24 at 12:26 P.M. revealed she was to change her gloves after touching different types of food and/or if the gloves become dirty. She confirmed all the items she touched without changing her gloves.

Observations on 11/18/24 from 12:27 P.M. to 12:32 P.M. revealed Dietary Cook #201 touched the following items with gloves on her hands, and did not change them: plates, serving utensils, order sheets for resident food orders, sandwich buns, fries, pulled chicken, dirty counter of the steam table, cutting board, and knife to cut the chicken sandwiches.

Review of facility undated Single-Use Glove in Culinary Setting Policy and Procedure revealed the facility was committed to teaching and maintaining best practices with gloves where food is prepared and served. If gloves become contaminated they would be replaced.

6. Observation on 11/18/24 at 12:24 P.M. revealed Dietary Cook #201 placed a chicken sandwich, corn, and fries on a lunch plate to be served. Dietary Manager #200 told Dietary Cook #201 the resident did not want corn, so Dietary Cook #201 scooped the corn from the plate, back into the pan of unserved corn on the steam table.

Interview with Dietary Cook #201 on 11/18/24 at 12:26 P.M. confirmed she scooped the corn back into the pan on the steam table.

Based on record review, staff interview, and facility policy review, the facility failed to conduct fire drills as required. This had the potential to affect 81 of 81 residents in the facility.

Findings Include:

Review of facility fire drills, dated November 2023 to October 2024, revealed there were no second shift fire drills completed between June 2024 and October 2024. Additionally, there were no third shift fire drills completed between March 2024 and August 2024.

Interview with Regional Maintenance Director #300 on 11/18/24 at 1:15 P.M. confirmed the facility was missing the above fire drills. The Regional Maintenance Director revealed the facility had a calendar to complete fire drills as required, and stated they must have gotten off schedule at some point during the year.

Review of facility Fire Safety and Evacuation policy, dated 09/16/24, revealed the facility shall conduct the following fire drills: twelve fire drills, one conducted on each shift at least every three months.