Crockett Health Care Associates, Inc.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 clean linen carts reviewed for infection control. The facility failed to store peri wash solution in a sealed container on the clean linen carts. This failure could place residents at risk of exposure to communicable diseases and infections. Findings Include: During an observation on 06/04/2025 at 9:30am, 2 out of 2 clean linen carts was observed having a pale of peri wash solution uncovered on each of them (solution identified by LVN D). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 4 residents (Residents #22) reviewed for ADL care. The facility failed to clean/groom Resident #22's fingernails that had a dark, brown substance underneath them on 6/2/2025 and 6/3/2025. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the DA wore a hairnet effectively to cover all of her hair on 5/6/2024. 2. The facility failed to ensure foods stored in the refrigerators, freezers and dry pantry were labeled, dated, and not kept past their expiration dates on 5/6/2024 3. The facility failed to ensure items were not stored on the floor in the dry pantry area on 5/6/2024. 4. The facility failed to ensure personal foods for staff were not kept in the refrigerators that were designated for the kitchen on 5/6/2024. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 5 of 14 staff (CNA B, CNA C, CNA D, CNA E and CNA F) reviewed for abuse policies. The facility failed to implement their own written policy and procedure for screening by not completing a Nurse Aide Registry (NAR) check for CNA B, CNA C, CNA D, CNA E and CNA F annually for 2023 and 2024. This failure could place residents in the facility at risk of Abuse, Neglect, or Exploitation.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 staff (CNA H) reviewed for infection control. The facility failed to ensure CNA H washed or sanitized her hands when passing out meal trays to residents on Hall 400 in rooms [ROOM NUMBER] on 5/6/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 15 residents (Resident #4 and Resident #13) reviewed for call lights. The facility failed to ensure Resident #4's emergency call button in the bathroom had a pull cord on 5/6/2024 and 5/7/2024. The facility failed to ensure Resident #13's call light was within reach while in bed on 5/6/2024 and 5/7/2024 These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 1 of 3 residents (Resident #188) reviewed for physical restraints. The facility failed to obtain physician order, informed consent, and pre-restraint assessment for Resident #188 before implementing bed alarm (position change alarm) on [DATE]. This failure could place residents in the facility at risk of decreased quality of life, injury and being subjected to restraints for purposes of convenience or discipline.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 of 13 residents (Resident #33 and Resident #188) reviewed for accuracy of assessments. The facility failed to accurately code the [DATE] MDS for a restraint (geri-chair with tray) used for Resident #33. The facility failed to accurately code the comprehensive MDS dated [DATE] for a bed alarm use for Resident #188 with a physician order summary report effective [DATE] for the use of the bed alarm. This failure could put residents at risk for lack of proper care and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 12 residents (Resident #188) reviewed for care plans. The facility failed to develop a comprehensive care plan for the use of a bed alarm for Resident #188 that was put into use on [DATE] This failure could place residents at risk of inappropriate care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 35 residents (Resident #16) reviewed for bed rails. The facility failed to obtain an order, complete an assessment, obtain informed consent, or attempt to use an alternative for the use of bedrails for Resident #16 who had full bed rails on both sides of her bed from 5/6/2024 to 5/8/2024. This failure could place residents at risk of entrapment or injury.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #3, Resident #7 and Resident #11) reviewed for beneficiary notice. The facility failed to ensure Resident #3, Resident #7 and Resident #11 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #11) reviewed for respiratory care. The facility failed to ensure Resident #11's oxygen nasal cannula tubing and prefilled humidifier was dated as specified in their policy. These deficient practices could place residents at risk of developing respiratory infections and complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (treatment cart) reviewed for labeling and storage. The facility failed to remove expired glucose control solution and ensure the glucometer strips had an open date located on the nurse medication cart used for treatments. This deficient practice could place residents at risk for receiving improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pureed meat and corn were prepared in a form designed to meet individual needs for 1 of 1 lunch meal reviewed for food form and preparation. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control. (Resident #21) CNA D did not wash or sanitize her hands when changing gloves while performing incontinent care for Resident #21. This failure could place residents at risk of exposure to communicable diseases and infections.