Crowley Ridge Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) out of four sampled residents was free of misappropriation of his/her property when Social Services Director (SSD) utilized the resident's banking information for his/her own personal use. The facility census was 50. The administration was notified on 06/10/25 of the Past Non-Compliance which occurred between 06/03/25 through 06/09/25. On 06/03/25, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 06/09/25, as the facility terminated employment of SSD, in-serviced all staff on the facility's policy and procedures on misappropriation and Resident #1 is to be refunded for the amount misappropriated. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission of hospice services for one resident (Resident #50) out of three sampled residents. The facility census was 48. The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #50's medical record showed: - admitted to hospice services on 02/26/25; - No significant change MDS dated on or after 02/26/25; - The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice. During an interview on 03/20/25 at 10:00 A.M., the MDS Coordinator said he/she would expect a significant change MDS to be completed if a resident was admitted to hospice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #47) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled residents The facility's census was 48. The facility did not provide a policy regarding trauma informed care. 1. Review of Resident #47's medical record showed: - admission date of 11/01/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 38 opportunities with three errors made, for an error rate of 7.89%, which affected three residents (Residents #37, #38, and #39) out of seven sampled residents. The facility census was 48. The facility did not have a policy for insulin administration. Review of the insulin aspart (medication to lower blood sugar), Novolog (medication to lower blood sugar) insulin, and insulin lispro (medication to lower blood sugar) Pen's Manufacture Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed: - Turn the dose selector to select two units; - Hold the pen with the needle pointing up; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of four resident's (Residents #1, #2, #3, and #4) narcotic medication. The facility census was 46. The administrator was notified on 02/03/25 of the Past Non-Compliance which occurred on 01/28/25. On 01/28/25, facility staff started an investigation, completed disciplinary action and began in-servicing all involved licensed nurses on the narcotic count and documentation policies and procedures. Facility staff also notified Department of Health and Senior Services on 01/28/25 and local law enforcement on 01/28/25. The noncompliance was corrected 01/31/25. Review of the facility's Medication Administration Guidelines, undated, showed: - Residents receive their medications on a timely basis and in accordance with established policies; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 43. Review of the facility's policy titled, Storage of Dry Food and Supplies, dated April 2011, showed: - The Dietary Department will store dry food and supplies according to facility guidelines and state regulations; - The storeroom must be neat and orderly; - Open boxes are to be effectively resealed. Bulk crackers, cereal, cookies, pasta, are to be stored and properly labeled in sealed containers; - Severely dented, rusted, leaking, and bulging cans must be placed in a separate, labeled holding area for return to the distributor. Observation on 04/03/24 at 10:34 A.M., of the dry food storage room showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Resident #8, and #16) received a Level II Preadmission Screening and Record Review (a comprehensive evaluation required as a result of a positive Level I screening and to determine whether placement or continued stay in a nursing facility to be appropriate) (PASARR) out of four sampled residents. The facility census was 43. The facility did not provide a policy. 1. Record review of Resident #8's significant change Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff), dated 01/22/24, showed: - admitted to the facility on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standard precautions to prevent the spread of infection. This had the potential to affect all residents. The facility census was 43. Review of facility policy titled, Medications, Storage of from the Nursing Guidelines Manual states: - Drugs must be stored in an orderly manner in cabinets, drawers, or carts. - Each resident must have a space assigned to them that prevents the possibility of a drug for one resident being administered to another. Review of facility policy titles, Infection Prevention and Control Program dated 10/13/22 states: - Medical staff supports the infection prevention/control program by adhering to all policies and procedures related to infection prevention. - Employees support resident safety by adhering to all guidelines related to infection prevention. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competencies of Abuse Prevention and Dementia Care for two out of two nurse aides sampled. The facility census was 43. The facility did not provide a policy regarding Abuse Prevention and Dementia Care training. 1. Review of the facility's April 2023 through March 2024 in-service records showed: - Certified Nursing Assistant (CNA) C with a hire date of 04/26/14; - CNA C attended a total of 16.5 hours of in-services; - CNA C did not attend an annual competency in-service on Abuse Prevention; - CNA C did not attend an annual competency in-service on Dementia Care. 2. Review of the facility's April 2023 through March 2024 in-service records showed: - CNA D with a hire date of 01/20/22; - CNA D attended a total of 12 hours of in-services; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP), a professional who assures healthcare workers and residents are doing everything possible to prevent infection, position. This had the potential to affect all residents in the facility. The facility census was 41. The facility did not provide records indicating any staff member had been enrolled in the specialized training for the IP position. During an interview at 11/03/22 at 1:21 P.M., the Director of Nursing (DON) said she had been keeping track of the antibiotic stewardship and would be signing up for the IP class that day. During an interview on 11/04/22 at 12:52 P.M., the Administrator said the DON and Registered Nurse (RN) D both shared the responsibility of the IP. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for oxygen (O2) use for one resident (Resident #138 ) out of 12 sampled residents. The facility census was 41. Record review of the facility's Physician's Orders policy, dated April 2006, showed: - Oxygen orders must specify the rate of flow, route and rationale. 1. Record review of Resident #138's medical record showed: - An admission date of 10/28/22; [...]