Crouse Community Center Inc

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not provide pharmaceutical services to meet the need of each resident for 4 of 4 residents (Residents #1, #88, #208, and #209) reviewed. Specifically, the facility used Resident #88's oxycodone (a narcotic pain reliever) to administer to Residents #1, #208, and #209 when they did not have the medication available.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure that it promoted and facilitated resident self-determination including the resident's right to make choices about aspects of daily life that are significant to the resident for 1 of 3 residents (Resident #4) reviewed. Specifically, there was no documented evidence Resident #4's informed consent was obtained prior to initiating a chair alarm (a device that detects pressure changes to alert staff of resident position changes) and the care plan was not revised to include the use of a chair alarm.

Inspectors wroteBased on observations, record review and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not consult with the physician when there was a significant change in the resident's physical status for 1 of 3 residents (Resident #30) reviewed. Specifically, Resident #30 had a continued, unplanned weight loss and the medical provider was not notified.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure resident rights to privacy and confidentiality of their personal and medical records for 2 of 2 residents (Resident #3 and 13) reviewed. Specifically, Residents #3 and #13 had their dietary status posted outside their rooms and was visible to the public.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 5 residents (Resident #25) reviewed. Specifically, staff identified a skin tear on Resident #25's left arm and there was not a timely investigation completed to rule out abuse or neglect. Additionally, the resident's skin tear was not assessed by a qualified professional and the medical provider was not notified of the injury.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 2 residents (Residents #43 and #57) reviewed. Specifically, Resident #43 did not have medication-specific interventions for the use of anticoagulants (blood thinner), and Resident #57 did not have a comprehensive care plan for the use of a chair alarm.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility failed to ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 2 of 3 residents (Residents #30 and #53) reviewed. Specifically, Resident #30 did not have pre and post pain evaluations completed when as needed pain medication was administered; and Resident #53's pain associated with transfers was not addressed.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 3/20/23- 3/23/23, the facility failed to ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 3 residents (Resident #13) reviewed. Specifically, staff identified a bruise on Resident #13 and there was no investigation completed to rule out abuse or neglect. Additionally, an assessment of the injury was not completed, and the medical provider and family representative were not notified.

Inspectors wroteBased on record review and interview during the recertification survey conducted 3/20/23 to 3/23/23, the facility failed to ensure each resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare and Medicaid Services (CMS)-specified Resident Assessment Instrument (RAI) for 1 of 1 resident (Resident #27) reviewed. Specifically, a Significant Change Minimum Data Set (MDS) assessment was not completed for Resident #27 following enrollment in a hospice program.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/20/23-3/23/23, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents (Resident #15) reviewed. Specifically, Resident #15's plan of care documented they were to have blue heel boots on both feet at all times to prevent skin breakdown and the resident was observed for 4 days not wearing the boots.

Inspectors wroteBased on observation and interviews during the recertification survey conducted 3/20/23 to 3/23/23, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 residents (Resident #15) reviewed. Specifically, Resident #15 was observed in a wheelchair that was in disrepair.

Inspectors wroteBased on record review, interview and observation during the recertification survey, the facility did not ensure residents with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident (Resident #70) reviewed. Specifically, during a wound dressing treatment for Resident #70, licensed practical nurse (LPN) #2 did not change gloves and placed unclean wound care supplies in a container with clean wound care supplies.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00273084) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #38) reviewed and the resident environment remains as free of accident hazards as is possible for 1 of 5 means of egress (courtyard door in hallway next to conference room) . Specifically, Resident #38 had known exit seeking behaviors and eloped through an unlocked door to an outside courtyard and there was no documented evidence of adequate supervision of the resident. Additionally, doors to a courtyard were not locked or monitored to prohibit unsupervised exit.