Crowne Healthcare Of North Baldwin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, a review of BinaxNOW COVID-19 Ag CARD, a review of facility policy titled Coronavirus Testing, and a review of facility's staff vaccination status, the facility failed to ensure a licensed staff member performed COVID-19 testing per manufacturer's guidelines for two of three staff who were unvaccinated for COVID-19 and observed being tested for COVID-19. This has the potential to affect all residents and staff. Findings Include: A review of BinaxNOW COVID-19 Ag CARD product insert with copyright date of 2020 revealed: .PRINCIPLES of the PROCEDURE .To perform the test, a nasal swab is collected from the patient, . The patient sample is inserted into the test card .The swab is rotated 3 (three) times clockwise and the card is closed, . PRECAUTIONS . 19. False Negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. A review of facility policy titled Coronavirus Testing with date implemented of 3/2019 and date reviewed 3/2020 and 9/2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of a facility policy titled Dining Room Duties, the facility failed to ensure a Certified Nursing Assistant, Employee Identifier (EI) #5 did not stand while feeding Resident Identifier (RI) #51 his/her lunch meal in the dining room on 11/17/2021. This deficient practice affected RI #51; one of four sampled residents observed being fed their meals. Findings Include: A review of a facility policy titled Dining Room Duties, with an effective date of 01/2017, revealed: . PROCESS: . h) When feeding a resident, staff must sit beside or across from the resident. RI #51 was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease and Abnormal Weight Loss. RI #51's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 10/08/2021, coded RI #51 as needing extensive assistance with eating. On 11/17/2021 at 11:51 AM, the surveyor observed EI #5 standing while feeding RI #51 his/her lunch meal. On 11/17/2021 at 12:10 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure the feeding tube containers of Resident Identifier (RI) #27 and RI #31 were labeled appropriately. This deficient practice affected RI #27 and 31, two of five residents receiving tube feeding at the facility. Findings include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, with a copyright date of 2017, page 1092, UNIT VII Physiological Basis for Nursing Practice, revealed the following: . STEP . (2) . Label bag with tube-feeding type, strength, and amount (include date, time, and initials). Change bag every 24 hours. RATIONALE . Helps decrease bacterial colonization. (1) RI #27 was originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with a diagnosis of Gastrostomy Status. RI #27's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], coded RI #27 as receiving tube feedings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of a pharmacy policy titled Ordering and Receiving Medications, the facility failed to ensure Resident Identifier (RI) #57's as needed Oxycodone-Acetaminophen 7.5-325 milligram (Percocet) supply was not depleted from 11/11/2021 until 11/17/2021. This affected RI #57, one of two residents sampled for pain. Findings Include: A review of undated facility policy titled Ordering and Receiving Medications revealed: . Policy: . The facility will only be responsible for ordering new medications, PRN (as needed) medications, . Procedure: . C. Refills/Reorders Policy: The facility will reorder medications when there is a 5 (five) day supply remaining in order to keep continuity in the medication supply. Nurses should not allow any medication to be depleted before ordering from the pharmacy. D. Controlled Substances Policy: Medications classified as controlled substances are subject to special ordering, receipt, and record keeping in accordance with state/federal laws and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and review of a facility policy titled Medication Administration the facility failed to ensure licensed staff documented pain medication on the Electronic Medication Administration Record as administered when administering pain medication to Resident Identifier (RI) #57. This affected one of two residents sampled for pain. Findings Include: A review of a facility policy titled Medication Administration with an implemented date of 3/2018 and revised date of 3/2021 revealed: Policy: Medications are administered by licensed nurses, . as ordered by the physician and in accordance with professional standards of practice, . Policy Explanation and Compliance Guidelines: . 17. Sign MAR after administered. 18. If medication is a controlled substance, sign narcotic book. A review of RI #57's CONTROLLED SUBSTANCE RECORD (narcotic log/book/record) and Medication Administration Record (MAR or eMAR) revealed on 11/1/2021 29 doses of Percocet remained in RI #57's supply and were recorded as administered on the CONTROLLED SUBSTANCE RECORD between 11/1/2021 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a housekeeping/laundry staff member, Employee Identifier (EI) #6 did not carry residents' clothing in a manner that caused the clothing to contact her personal clothing, 2) EI #6 sanitized her hands while delivering clean clothes to Room Locaters (RL) #1, RL #2, and RL #3; and 3) EI #6 sanitized her hands after touching a resident's recliner chair in RL #1. These deficient practices were observed in three of 43 rooms at the facility; and involved EI #6, one of one laundry staff member observed delivering residents' personal laundry. Review of a facility polity titled Hand Hygiene , with a revised date of 03/2021, revealed the following: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of a facility policy titled, Leftover Food Storage and Use the facility failed to ensure unlabeled, undated and expired food items were not found stored in a kitchen cooler used to serve residents. This had the potential to effect all 62 residents served meals from the kitchen. Findings Include: Review of a facility policy titled Leftover Food Storage and Use effective date 6/26/2012, revealed: Process: b. Leftovers foods should be covered, labeled and dated . i. Labels should have the following information . Food Item, Open Date and Discard Date. On 4/02/19 at 7:49 AM a brief initial tour of the kitchen was conducted. During this observation a canister with a red lid holding sliced cheese was observed to have no open use by date or name of the food; 1/2 boneless ham in a storage bag, no open, use by date or name of the food item; shredded cheese label ITEM: cheese DATE 3-16-19 . USE BY: 3/29/19 . On 04/03/19 02:00 PM, in an interview with Employee Identifier (EI) #5, Dietary Team Leader/Manager. She was asked what did she observe on 4/2/19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Pharmacist recommendations, interviews and review of the facility policy titled, Use of Psychotropic Drugs, the facility failed to ensure Gradual Dose Reductions were attempted for Resident Identifier (RI) #14 for the continued use of a psychotropic medications. This affected RI #14, one of five residents who were sampled for unnecessary medications use. Findings Include: A review of the facility policy titled, Use of Psychotropic Drugs with an implementation date of March 2018 revealed, . Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: . 6. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and a review of the facility policy titled, Care Plans the facility failed to ensure the plan of care was followed for RI (Resident Identifier) #205 regarding unwanted facial hair. This affected RI #205, one of eighteen residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Care Plans with an effective date of January 2017, revealed: . Regulatory Reference: PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and time tables to meet a resident's medical, nursing and mental/psychosocial needs, that are identified in the comprehensive assessment. A review of the medical record for RI #205 revealed an admission date of 4/11/18, with diagnoses to include Cancer, Hypertension, and Arthritis. A review of the admission MDS (Minimum Data Set) assessment, dated 4/18/18, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of a facility policy titled, Hygiene and Grooming the facility failed to ensure a resident was not observed with unwanted facial hair on one of three survey days. This affected RI (Resident Identifier) #205, one of eighteen sampled residents observed for ADL (Activities of Daily Living) care. Findings Include: A review of the facility policy titled, Hygiene and Grooming with a effective date of January 2004, revealed: . PURPOSE: Good hygiene and grooming help (helps) prevent the spread of infection and promote the resident's feelings of self worth and dignity. STANDARD: Guidelines for the provision of hygiene and grooming services are: . Shaving daily or as needed. A review of the medical record for RI #205 revealed an admission date of 4/11/18, with diagnoses to include Cancer, Hypertension, and Arthritis. A review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed RI #205 required extensive assistance of one person for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.