Crown Haven Health and Rehabilitation

Inspectors wroteBased on record review, and staff, resident, family member, Medical Director and Adult Protective Services (APS) Social Worker (SW) interviews, the facility failed to provide a safe and orderly discharge for 1 of 3 residents reviewed for discharge (Resident #88). Resident #88 was being treated in the facility with Chlordiazepoxide HCl (a medication used to treat the symptoms of alcohol withdrawal also known as Librium) for a known history of alcohol abuse and received a dose a short time before exiting the facility on 5/18/25 at approximately 10:51 AM. The Medical Director wrote orders for Resident #88 to be monitored every shift for symptoms of alcohol withdrawal syndrome, such as tremors, shaking, anxiety, nausea, vomiting, headaches, elevated heart rate, sweating, irritability, confusion, insomnia, nightmares and high blood pressure the same day the Chlordiazepoxide HCl was initiated. [...]

Inspectors wroteBased on record review, and resident, Medical Director and staff interviews, the facility failed to have documentation that the resident was informed in advance of the risks and benefits for the use of Chlordiazepoxide HCl (a psychotropic medication used to treat the symptoms of alcohol withdrawal) for 1 of 6 residents (Resident #88) reviewed for psychotropic medications.

Inspectors wroteBased on record review and staff, resident, family member, and Medical Director interviews, the facility failed to allow a resident's choice regarding leave of absence (LOA) for 1 of 1 resident (Resident #88) reviewed for self-determination.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan in the areas of dialysis, Activity of Daily Living (ADL), insulin use, (Resident #23) for 1 of 20 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observations, record review, and staff and physician interviews, the facility failed to transcribe an order of lorazepam gel (a medication used to treat anxiety) from the hospital discharge record to the electronic medical record (EMR) for Resident #23. Additionally, the failed to report a low heart rate of 46 (normal heart rate is 60 to 100 beats per min) to the medical provider prior to surveyor stopping Nurse #9 from administering Metoprolol (medication that lowers heart rate and blood pressure) to Resident #41. The facility also failed to follow an order to remove a lidocaine (topical pain medication) patch at bedtime for Resident #79. This was for 3 of 5 residents reviewed for professional standards of practice.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to implement the smoking policy for storage of smoking supplies (cigarettes/lighter) for 2 of 3 residents sampled for supervision to prevent accidents (Resident #85 and Resident #13).

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to implement their abuse policy in the areas of investigating, and protection following an allegation of sexual assault. A thorough investigation was not conducted, and protection was not implemented to prevent further potential abuse. This deficient practice was for 1 of 5 residents (Resident #4) reviewed for abuse.

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, the facility failed to don appropriate Personal Protective Equipment (PPE) before entering residents' room under transmission-based precautions for 1 of 3 residents reviewed for infection control (Resident #1).

Inspectors wroteBased on record reviews, staff and Resident interviews the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed for abuse (Resident #8). Resident #8 reported Resident #7 slapped Resident #8's face with his open hand, continued slapping at her face multiple times and hit her like a girl while yelling at her when Resident #7 exited the smoking courtyard and Resident #8 entered.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to implement their abuse policy in the areas of reporting, investigating, and protection following an allegation of resident to resident abuse. The allegation was not reported to the state or Adult Protective Services (APS), an investigation was not conducted, and protection was not implemented to prevent further potential abuse. This deficient practice was for 1 of 3 residents (Resident #8) reviewed for abuse.

Inspectors wroteBased on observations, record review, resident interview, and staff interviews, the facility failed to provide incontinence care when Resident #2 requested incontinence care before attending an activity. This failure caused Resident #2 to miss the activity when she remained in her room in a soiled and wet brief. This made the Resident feel very upset, angry and cry. This occurred for 1 of 2 sampled residents reviewed for dignity and respect.

Inspectors wroteBased on observations and staff interviews the facility failed to provide a clean homelike environment when they failed to clean tube feeding formula off the feeding tube pole and floor in 1 of 3 resident rooms that had tube feeding formula (room [ROOM NUMBER]).

Inspectors wroteBased on observations, record review, resident interview, and staff interviews, the facility failed to provide incontinence care when requested to 1 of 2 dependent residents (Resident #2) reviewed for activities of daily living.

Inspectors wroteBased on observations, record review, staff, and Medical Director interviews the facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for 1 of 3 residents reviewed with tube feeding orders (Resident #3).

Inspectors wroteBased on observations, record review, staff, and Medical Director interviews the facility failed to change the dressing to a peripherally inserted central catheter (PICC line or an intravenous line) as ordered by the physician for 1 of 1 residents receiving intravenous medication (Resident #3).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to ensure that a tracheostomy (surgical airway in the front of the neck) dependent residents' oxygen was delivered at the prescribed rate, failed to clean the oxygen concentrator and oxygen concentrator filter for 1 of 3 residents reviewed for respiratory services (Resident #3).

Inspectors wroteBased on record review and staff interviews the facility failed to maintain a complete an accurate medical record when Nurse #2 documented that she changed a peripherally inserted central catheter line (intravenous line) dressing on two occasions when the dressing was not changed as ordered for 1 of 1 residents reviewed who required intravenous medications (Resident #3).

Inspectors wroteBased on an observation, staff interviews and record review, the facility failed to wash dishes in hot water and sanitize dishes per manufacturer recommendations in a quaternary sanitizing solution of at least 100 parts per million (ppm). This had the potential to affect 89 of 89 residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 8/31/21, the complaint investigation survey completed on 1/19/22, the recertification and complaint investigation survey completed on 7/15/22, and the complaint investigation survey completed on 5/25/23. This failure occurred for four repeat deficiencies cited for resident, family, group and response, accuracy of assessments, food procurement, and increase, prevent decrease in range of motion and mobility that was subsequently recited on the current recertification and complaint investigation survey of 2/12/24. [...]

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to provide updates or resolutions to group grievances (evening snacks, better meal choices, transportation to outings, and cold food) that were brought to Resident Council meetings for 4 of 4 months reviewed (October, November, December of 2023 and January 2024).

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to record opening date for 1 opened vial in 1 of 5 medication cart (100 Hall medication cart), failed to remove expired medication in accordance with the manufacturer's expiration date for 1 of 5 medication cart (100 Hall medication cart), and failed to store drugs in clean and sanitary environment for 1 of 2 medication room refrigerators (north side medication room refrigerator) during medication storage checks.

Inspectors wroteBased on an observation of the lunch meal tray line, staff interviews and record review, the facility failed to provide the correct portion size of pureed food and large portions according to the planned menu for 1 of 1 meal observations. This practice had the potential to affect 2 residents on pureed diets and 12 residents who received large portions.

Inspectors wroteBased on resident interviews and staff interviews, the facility failed to offer and deliver evening snacks to 10 of 12 residents (#78, #6, #69, #84, #60, #81, #34, #7, #25, #27) reviewed for evening snacks.

Inspectors wroteBased on record reviews and staff interviews the facility failed to administer the Influenza vaccination ( Resident #63) and failed to offer and administer the Pneumococcal vaccination (Resident #15, Resident #59 and Resident #68) to 4 of 5 residents reviewed for immunizations.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Gradual Dose Reduction for 2 of 5 residents (Resident #15 and Resident #20) reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to implement nutrition care plan interventions to monitor and document food/fluid intake at each meal for 2 of 2 sampled residents reviewed for nutrition care plans (Resident #142 and Resident #80).

Inspectors wroteBased on observations, record review, a family interview, interviews with the Physician, Nurse Practitioners and staff, the facility failed to obtain a STAT (immediately) chest X-Ray, transcribe an as needed order for Tylenol in response to a fever, follow a recommendation to monitor vital signs, and provide STAT lab results to the Nurse Practitioner for 1 of 3 sampled residents reviewed for hospitalization (Resident #142).

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to reschedule and transport a resident to a consultation with an eye doctor for 1 of 1 resident reviewed for vision services (Resident #28).

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to identify and develop a treatment plan for a resident with a right-hand contracture. This was evident for 1 of 3 residents (Resident #63) reviewed for range of motion.

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to ensure that a smoking materials were secured by staff in accordance with their smoking policy for 1 of 3 residents observed for supervision to prevent accidents (Resident #18).

Inspectors wroteBased on observations, record reviews, staff and Resident interviews, the facility failed to secure a urinary catheter tubing to prevent tension or trauma for 1 of 2 residents (Resident #28) reviewed for urinary catheter.

Inspectors wroteBased on observations, interviews and record review, the facility failed to serve a prescribed double portion protein therapeutic diet to Resident #80, a Resident at risk for nutritional decline, for 1 of 2 sampled residents reviewed for physician ordered therapeutic diets.

Inspectors wroteBased on record reviews and responsible party, staff, and Medical Director interviews, the facility failed to notify Resident #1's responsible party (RP) that Resident #1 had low blood sugar levels from insulin administration and the insulin was discontinued on 07/21/23. The insulin was prescribed for Person #2 (potential new admission from the same skilled nursing facility with same first and last name as Resident #1). Resident #1's RP stated if he had been notified in July about the administration of the insulin he would have asked to speak to the Administrator and the Medical Director and informed them Resident #1 did not have a diagnosis of diabetes. Had Resident's #1's RP been notified there was the high likelihood further significant medication errors would not have occurred until September. This deficient practice occurred for 1 of 2 residents reviewed for notification of change.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to implement their Admissions Policy and Procedure and verify the identity of a cognitively impaired resident when he was admitted to the facility with paperwork from the discharging skilled nursing facility for Person #2 (potential new admission with same first and last name as Resident #1). As a result, Resident #1, who did not have a diagnosis of diabetes, was administered 3 doses of long-acting insulin, and experienced 3 three low blood sugar levels before the insulin was discontinued. In addition, Resident #1 received an anticoagulant, aspirin, a diuretic, and a medication used to treat hypothyroidism from 07/17/23 until 09/15/23 prescribed for Person #2. This deficient practice occurred for 1 of 2 residents reviewed for medication errors and had a high likelihood of serious harm (Resident #1).

Inspectors wroteBased on record reviews and family member, staff, Nurse Practitioner and Medical Director interviews, the facility failed to prevent significant medication errors when a. Resident #1 was administered medications prescribed for Person #2 (potential new admission with same first and last name as Resident #1). Person #2's information and medication orders were entered for Resident #1 in error on 7/17/23 and this was not discovered until 9/15/23. Resident #1 did not have a diagnosis of diabetes and was administered 3 doses of long-acting insulin and had three low blood sugar levels before the insulin was discontinued on 07/21/23. In addition, Resident #1 was administered an anticoagulant, aspirin, diuretic, and a medication used to treat hypothyroidism for which he had no diagnoses to treat. b. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 08/31/21. The area of infection control and prevention was originally cited during a recertification and complaint survey dated 08/31/21. The area was subsequently recited during the onsite revisit and complaint survey dated 12/13/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to implement their hand hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene prior to beginning treatments, or prior to donning gloves to remove soiled coverings with drainage from several wounds on a resident's (Resident #9) left leg and foot wound, and right inner thigh wound. The Treatment Nurse doffed her gloves after removing the coverings and donned new gloves without sanitizing her hands and proceeded to apply the treatment to the wounds and covered them with border gauze dressings. This occurred for 1 of 2 residents reviewed for wound care.

Inspectors wroteBased on record reviews and staff, family member and Wound Physician interviews, the facility failed to identify a skin impairment on a resident during weekly skin assessments for 1 of 1 resident reviewed for pressure ulcers (Resident #21). This failure resulted in Resident #21 being admitted to the hospital and requiring care in the Intensive Care Unit for severe sepsis due to a necrotic (dead tissue) heel wound and osteomyelitis (bone infection).

Inspectors wroteBased on record review, observation, resident, and staff interviews, the facility failed to apply bilateral lower leg splints for 1 of 1 resident reviewed for contractures/limited range of motion (Resident #5).

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to maintain a medication administration error rate of less than 5% as evidenced by a medication error rate of 22.22% (7 out of 27 opportunities) (Resident #66).

Inspectors wroteBased on record review and staff interviews the facility failed to provide the resident with a care planning conference to participate with the interdisciplinary team in the development of a comprehensive care plan for 1 of 1 resident (Resident #42) reviewed for care plans.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to check residual prior to administering gastrostomy tube (G-tube) medication and failed to flush the G-tube before medication administration for 1 of 1 resident reviewed for G-tube medication administration (Resident #66).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a call light was functioning for 1 of 6 resident rooms (room [ROOM NUMBER]) on 1 of 4 halls.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately record the weight on a Minimum Data Set (MDS) assessment for 1 of 4 sampled residents reviewed for MDS accuracy (Resident #31).