Crowne Health Care Of Eufaula

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, residents record review, review of a facility policy titled ABUSE POLICY, review of Facility Reported Incidents (FRI), and review of the facility's investigative files, the facility failed to ensure residents in the facility were free from abuse perpetrated by employees of the facility and other facility residents. Specifically, 1) On 09/20/2024 Certified Nursing Assistant (CNA) #4, who was assigned to provide care for Resident Identifier (RI) #10, verbally and mentally abused RI #10 when other facility staff witnessed CNA #4 tell RI #10 not to shit in his/her brief or she would leave his/her big ass to sit in it. This deficiency was cited as the result of the investigation of complaint/report number AL00049007. 2) On 11/04/2024 RI #10 was verbally abused by RI #13, a resident with a history of verbally aggressive behaviors, when RI #13 asked RI #10 if he/she could play with RI #10's titties. The facility failed to ensure RI #13 had a plan of care to address the level of supervision RI #13…

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, review of a facility policy titled, ABUSE POLICY, review of the facility's investigative file and review of a Facility Reported Incident (FRI) received by the State Agency, the facility failed to ensure an allegation of verbal abuse involving Certified Nursing Assistant (CNA) #4 and Resident Identifier (RI) #10 was reported to the Administrator (ADM) immediately and within two hours of the incident after the incident occurred on 09/20/2024. This deficient practiced affected one of 11 FRIs reviewed, and one of 18 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00049007. Findings include: Review of a facility policy titled, ABUSE POLICY, dated 12/2024, revealed the following: . Procedure for Documentation and Investigation of Resident Abuse . 4. Notify . Administrator . immediately . RI #10 was admitted to the facility on [DATE]. The Alabama Department of Public Health Online Incident Reporting System form, submitted on…

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 resident record reviews, interviews, review of facility investigative files, and a facility policy titled Abuse Prevention Policy, the facility failed to report allegations of abuse within two hours to the State Agency. 1) On 07/30/2024 at 6:00 PM Certified Nursing Assistant (CNA) #17 heard a slap in Resident Identifier (RI) #1 and RI #3's room and the alleged physical abuse was not reported to the State Agency until 07/30/2024 at 8:30 PM, two and a half hours later. 2) On 08/20/2024 at 9:45 PM RI #1 was found to have injuries as a result of a tussle with roommate (RI #2). The incident of alleged physical abuse was reported to the State Agency the next morning on 08/21/2024 at 10:42 AM, over 12 hours later. 3) On 09/13/2024 at 3:00 PM RI #20 alleged physical abuse of being hit in the back by RI #1. The allegation of abuse was not reported to the State Agency until 09/18/2024, five days later. This deficient practice was cited a result of the investigation of complaint/report numbers AL00048506 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, review of a facility document titled, Maintaining Patient Trust Receipts, review of a facility document titled, Resident Trust Audit, and review of two unnamed facility documents, the facility failed to ensure residents' trust accounts were safeguarded when staff failed to follow facility procedure for issuing money from Resident Trust Accounts. This affected 66 of 73 residents sampled for review of personal funds including Resident Identifier (RI) #4, RI #6, RI #11, RI #13, RI #14, RI #15, RI #17, RI #19, RI #21, RI #23, RI #25, RI #28, RI #29, RI #31, RI #34, RI #40, RI #41, RI #42, RI #48, RI #49, RI #54, RI #55, RI #57, RI #60, RI #62, RI #66, RI #67, RI #68, RI #71, RI #74, RI #83, RI #84, RI #85, RI #86, RI #87, RI #89, RI #95, RI #101, RI #102, RI #105, RI #113, RI #114, RI #115, RI #119, RI #122, RI #132, RI #139, RI #142, RI #154, RI #208, RI #209, RI #210, RI #211, RI #213, RI #215, RI #218, RI #219, RI #220, RI #221, RI #222, RI #223, RI #224, RI #225, RI #260, RI…

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, facility's investigation, and a review of facility's policy titled, Abuse Policy, the facility failed to protect resident's funds from misappropriation when Employee Identifier (EI) #2 former Business Officer Manager stole $700 from Residents Trust Accounts. This deficient practice affected RI (Resident Identifier) #3, #15, #41, #48, #57 #62, #74, #83, #101, #103, #122, #132, #138, #139 and #142; fifteen of 73 sampled residents reviewed for misappropriation of residents' funds. Findings include: 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #3 's Quarterly Minimum Data Set (MDS) Assessment, dated 10/28/2022, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was cognitively intact. 2) RI #15 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #15 's yearly MDS, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively…

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, interview and record review the facility failed to provide Activities of Daily Living (ADL) assistance according to the resident's bathing preference for one of four residents sampled for ADLs, Resident #3. Findings included: Resident Identifier (RI) #3 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Anemia, Bursitis of left shoulder, Hypertension, Splenomegaly, Ovarian Cyst, and Cataract. Review of RI #3's Clinical Record since 3/1/21 revealed no documentation of resident refusals of care. Review of RI #3's Annual Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition. The MDS recorded the resident had no delirium, psychosis or negative behaviors and a mood severity score of zero (0). The MDS recorded the resident required physical help in part of the bathing activity. Review of the RI #3's Care Plan revealed a Smart Chart task list which states, *FYI…

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 policy review the facility staff failed to implement the Infection Control Policy designed to prevent transmission of infections during meal service in the dining room of the Memory Care Unit. This failure could result in cross-contamination between residents during meal service and had the potential to affect residents receiving meals on the Memory Care Unit. Findings include: Review of the facility Surveillance and Education Policy revised 3/17 reflected the Infection Control Nurse (ICRN) reviews findings relevant to infection control issues including .proper hand hygiene and topics of infection control training include .hand hygiene. Review of the facility's Hand Hygiene Policy and Procedure revised 4/2020 reflected perform hand hygiene .assisting a resident with meals, between resident contacts, after handling soiled equipment .and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Observation of meal service in the Memory Care dining room on 7/7/21 revealed Certified Nursing Assistants (CNAs) #6,…

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 made in the kitchen on 04/29/19 and 05/01/19, interviews with facility staff and a review of the facility's Food Storage and Personal Food Storage policies and a facility document titled Resource: Food Safety for Your Loved One, dietary staff failed to consistently label frozen meat and vegetables removed from their original packaging with an open and use by date. In addition, Nursing staff failed to label residents' food items brought in by family members and stored at each of the three nursing stations, with date of storage and use-by date to ensure timely disposal. This had the potential to affect all 159 residents for whom meals were prepared and served, as well as residents' refrigerated storage on 3 of 3 nursing stations. Findings Included: 1) DIETARY FOOD STORAGE The facility's Food Storage policy (dated 2013) specifies the following: . Procedure: . 15. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. On 04/29/19 at 3:49 PM, the…

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, Minimum Data Set (MDS) assessments and a review of CMS's (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to ensure RI #4's Significant Change (SC) MDS and RI #7's Annual MDS assessments were submitted timely. This had the potential to affect 2 of 4 residents whose assessments were reviewed for being over 120 days late. Findings Include: A review of CMS's RAI Version 3.0 Chapter 5: Submission and Correction of the MDS Assessments . page 5-3 specifies, the assessment must be submitted within 14 days of the MDS Completion Date A review of RI #4's 2/25/2019 Annual MDS, section VO200C was signed and dated 3/18/19. The document should have been submitted by 4/1/19. A review of RI #7's 2/25/2019 SC MDS section VO200C was signed and dated 3/18/2019. The MDS should have been submitted by 4/1/2019. On 5/02/2019 at 8:39 a.m., the surveyor reviewed four residents' assessments that were identified by CMS as 120 days over-due. On 5/02/2019 at 9:22 a.m., an interview was conducted with Registered Nurse (RN), EI…

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, interview, record review and review of a facility policy titled, Policy and Procedures for Aseptic Technique with Dressing Changes, the facility failed to ensure the licensed staff did not use the same gloves to clean a wound for Resident Identifier (RI) #106, then place the clean treatment and outer covering. This affected one of one resident observed for wound care. 1. A review of a facility policy titled Policy and Procedure for Aseptic Technique with Dressing Changes with a date of 7/18/05 revealed: . The goals for treating a wound are to prevent cross contamination and/or infection of an open area and to prevent additional trauma to area. RI #106 was readmitted to the facility on [DATE] with a diagnosis of Pressure ulcer of sacral region, stage 2. A review of RI #106's April 2019 Physician Orders revealed . 2/20/19 .Cleanse Unstageable Pressure Wound To Sacrum With Normal Saline Pat Dry . Apply Medihoney Calcium Alginate To Wound Bed Every Day Cover With . Adhesive. On 4/30/19 at 9:46…

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, interview, and a review of facility's policy titled, INFECTION CONTROL OXYGEN EQUIPMENT, the facility failed to ensure oxygen tubing and the humidifier bottle were replaced and dated appropriately for Resident Identifier(RI) #313. This affected 1 of 3 residents observed for oxygen therapy. Findings Include: A review of a facility policy titled, INFECTION CONTROL OXYGEN EQUIPMENT with a revised date of 8/2012, revealed: . Procedures . 4. Humidifiers are to be replaced weekly and dated. 5. Oxygen tubing, mask, and cannula's are to be replaced weekly and dated. RI #313 was admitted to the facility on [DATE] with a diagnosis of Hypoxemia and dependence of supplemental oxygen. A Physician orders, dated 04/18/19, revealed the order for oxygen (O2) at 2 liters per minute per nasal cannula as needed for shortness of breath and low O2 saturations. On 04/29/19 at 3:18 PM, the surveyor observed RI #313 resting in bed, wearing oxygen. No dates were observed on either the oxygen tubing or the humidifier…

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, and review of facility a policy titled, Medication Administration - General Guidelines, the facility failed to ensure that licensed staff did not leave a medication cart unlocked and unattended while administering medications to Resident Identifier (RI) #2. This affected one of five nurses observed for medication pass. Findings Include: A review of the facility policy titled, Medication Administration - General Guidelines with a date of 01/12 revealed: .Procedures . 11. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. RI #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of: Encounter for attention to gastrostomy and Dementia in other diseases classified elsewhere. On 4/30/19 at 5:00 PM, Employee Identifier (EI) #5 a Licensed Practical Nurse (LPN) was observed preparing medication for RI #2. EI #5 prepared the following medications: Carafate, Ceftin, and Maxitrol eye…

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, interview, record review and review of a facility policy titled, Medication Administration Procedures Eye Drops the facility failed to ensure: 1. licensed staff washed her hands before administering eye drops for RI #122 and 2. licensed staff did not handle tablet medication with her bare hands, then touch the inside of a crush medication bag while preparing medication for RI #2. This affected one of one resident observed for eye drop medication and one of one resident observed for medication administered by tube. Findings Include: 1. A review of a facility policy titled, Medication Administration Procedures Eye Drops, with a date of 1/12 revealed: .Procedures .3. Wash your hand with soap and water . 9. Instruct the resident to look upward and place one drop .14. Wash your hands with soap and water . RI #122 was admitted to the facility on [DATE] with a diagnosis of Unspecified Glaucoma. A review of RI #122's April 2019 Physician Orders revealed: . 3/06/19 Dorzolamide .Eye Drops Instill 1…

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.