Crowell Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer and pantry food items were properly stored, labeled, and dated. The facility also failed to ensure refrigerator and freezer temperatures were monitored and logged daily. These failures had the potential to place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 out of 3 residents that received pureed food (Resident #30), in that:The facility served residents receiving a pureed diet with a different and less comparable breakfast than residents receiving a regular diet. This failure could negatively impact the self-esteem, self-worth, and identity of residents who require a pureed diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #35) of 17 residents reviewed for accidents and hazards. Resident #35 was allowed to have the code for the door when going out to smoke. This failure could place residents at risk for injury or elopement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for 1 of 17 residents (Resident #39) reviewed for pharmacy services. Resident #39's clinical record identified an allergy to cephalexin; however, the resident was administered a 14-day course of cephalexin for a urinary tract infection (UTI). This failure had the potential to place residents at risk for substandard care, failure to meet identified needs, and increased risk of adverse outcomes, including allergic reaction, anaphylaxis, or death. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 3 out of 3 residents that received pureed food (Residents #7, # 16, #30), in that: The facility failed to ensure Residents #7, #16, #30 received pureed applesauce prepared according to the facility recipe, instead they were served plain applesauce directly from the original container. This failure could place residents at risk for inadequate nutritional intake, reduced meal acceptance, potential weight loss and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 (Resident #26) of 3 residents observed for infection control. -CNA C did not wash her hands while performing incontinent care for Resident #26. This deficient practice could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure quality of care is a fundamental principle that applies to all treatment and care provided to facility residents based on the comprehensive assessment of a resident, to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 (Resident #38) of 13 residents reviewed for quality of care. The facility failed to document physician ordered weekly skin assessments to include a lesion on Resident #38's right cheek. The facility failed to revisit the option of treatment of the lesion on Resident #38's right cheek with her responsible party as the lesion progressed. These failures could place residents at risk of harm due to health issues not being recognized and treated timely. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 (Resident #26, Resident #31, and Resident #38) of 13 residents reviewed for environment. The facility failed to clean expired and unlabeled food out of Resident #26's personal refrigerator. The facility failed to ensure Resident #31 and Resident #38 kept their personal snacks in sealed containers. The facility failed to ensure Resident #38's personal refrigerator had a thermometer inside with which to monitor temperature of the refrigerator as per facility policy. These failures could place residents at risk of pests and/or food borne illness. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #3 and Resident #38) of 13 residents reviewed for accuracy of assessment. 1. Resident #3 was a smoker and his annual MDS assessment did not indicate his use of tobacco. 2. Resident #38 had a lesion on her right cheek which was not noted in her quarterly MDS assessment. These failures could place residents at risk of not receiving necessary care and treatment. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible for one (Resident #3) of 2 residents reviewed for accident hazards. -Resident #2's last smoking evaluation was completed 9-27-2024. This failure could affect residents that smoke at the facility by placing them at risk for accidents that lead to injuries such as burns, tissue damage, and feeling of isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #38) of 13 residents reviewed for accuracy of medical records. The facility failed to correctly enter an order for barrier cream into Resident #38's EHR. The order was entered for her left cheek and the lesion was located on her right cheek. This failure could place residents at risk of receiving unnecessary treatment or not receiving necessary treatment. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 (ST) of 15 employees reviewed for staff training. The facility failed to train ST on Abuse, Neglect, and Exploitation. These failures could place residents at risk of injury or harm due to being cared for by untrained staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. 4. The facility failed to ensure that proper hand hygiene was practiced during distribution of food. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on interview and record review the facility failed to implement written policies to prohibit and prevent abuse, neglect, and exploitation of residents for 6 (DM, DT E, CNA F, RN G, DON, and RN H) of 12 staff reviewed for EMR/NAR registry. The facility did not complete EMR/NAR background checks for DM, DT E, CNA F, RN G, DON, and RN H. This failure could place residents in the facility at risk for abuse, neglect, or exploitation.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff for dementia care for 3 (DT E, HK I, and AD) of 12 employees evaluated for required trainings. DT E was hired 5-30-23 and not training had been provided for Dementia Care on hire. HK I was hired 7-21-2023 and no training had been provided for Dementia Care on hire. AD was hired 11-6-2023 and no training had been provided for Dementia Care on hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care. This failure could result in deterioration in resident condition and exacerbation of the disease process.