Crowne Health Care of Eufaula

Inspectors wroteBased on interviews, residents record review, review of a facility policy titled ABUSE POLICY, review of Facility Reported Incidents (FRI), and review of the facility's investigative files, the facility failed to ensure residents in the facility were free from abuse perpetrated by employees of the facility and other facility residents. Specifically, 1) On 09/20/2024 Certified Nursing Assistant (CNA) #4, who was assigned to provide care for Resident Identifier (RI) #10, verbally and mentally abused RI #10 when other facility staff witnessed CNA #4 tell RI #10 not to shit in his/her brief or she would leave his/her big ass to sit in it. This deficiency was cited as the result of the investigation of complaint/report number AL00049007. [...]

Inspectors wroteBased on interviews, review of a facility policy titled, ABUSE POLICY, review of the facility's investigative file and review of a Facility Reported Incident (FRI) received by the State Agency, the facility failed to ensure an allegation of verbal abuse involving Certified Nursing Assistant (CNA) #4 and Resident Identifier (RI) #10 was reported to the Administrator (ADM) immediately and within two hours of the incident after the incident occurred on 09/20/2024. This deficient practiced affected one of 11 FRIs reviewed, and one of 18 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00049007.

Inspectors wroteBased on interviews, residents record reviews, review of a facility policy titled Abuse Policy, review of Facility Reported Incidents (FRI), and review of the facility's investigative files, the facility failed to protect residents' right to be free from abuse perpetrated by other residents. 1) On 04/12/2024 Resident Identifier (RI) #15 was physically abused when RI #14 hit him/her with a broom handle causing bruising to his/her wrist and legs. 2) On 04/25/2024 RI #1 was physically abused when he/she was slapped in the face by RI #17. 3) On 07/14/2024 RI #1 was physically abused when RI #4 hit him/her in the forehead. 4) On 08/30/2024 RI #4 was physically abused when RI #9 slapped him/her in the face. [...]

Inspectors wroteBased on resident record reviews, interviews, review of facility investigative files, and a facility policy titled Abuse Prevention Policy, the facility failed to report allegations of abuse within two hours to the State Agency. 1) On 07/30/2024 at 6:00 PM Certified Nursing Assistant (CNA) #17 heard a slap in Resident Identifier (RI) #1 and RI #3's room and the alleged physical abuse was not reported to the State Agency until 07/30/2024 at 8:30 PM, two and a half hours later. 2) On 08/20/2024 at 9:45 PM RI #1 was found to have injuries as a result of a tussle with roommate (RI #2). The incident of alleged physical abuse was reported to the State Agency the next morning on 08/21/2024 at 10:42 AM, over 12 hours later. 3) On 09/13/2024 at 3:00 PM RI #20 alleged physical abuse of being hit in the back by RI #1. [...]

Inspectors wroteBased on interviews, record reviews, review of a facility document titled, Maintaining Patient Trust Receipts, review of a facility document titled, Resident Trust Audit, and review of two unnamed facility documents, the facility failed to ensure residents' trust accounts were safeguarded when staff failed to follow facility procedure for issuing money from Resident Trust Accounts. [...]

Inspectors wroteBased on interviews, record review, facility's investigation, and a review of facility's policy titled, Abuse Policy, the facility failed to protect resident's funds from misappropriation when Employee Identifier (EI) #2 former Business Officer Manager stole $700 from Residents Trust Accounts. This deficient practice affected RI (Resident Identifier) #3, #15, #41, #48, #57 #62, #74, #83, #101, #103, #122, #132, #138, #139 and #142; fifteen of 73 sampled residents reviewed for misappropriation of residents' funds.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) assistance according to the resident's bathing preference for one of four residents sampled for ADLs, Resident #3.

Inspectors wroteBased on observation, interview and policy review the facility staff failed to implement the Infection Control Policy designed to prevent transmission of infections during meal service in the dining room of the Memory Care Unit. This failure could result in cross-contamination between residents during meal service and had the potential to affect residents receiving meals on the Memory Care Unit.

Inspectors wroteBased on observations made in the kitchen on 04/29/19 and 05/01/19, interviews with facility staff and a review of the facility's Food Storage and Personal Food Storage policies and a facility document titled Resource: Food Safety for Your Loved One, dietary staff failed to consistently label frozen meat and vegetables removed from their original packaging with an open and use by date. In addition, Nursing staff failed to label residents' food items brought in by family members and stored at each of the three nursing stations, with date of storage and use-by date to ensure timely disposal. This had the potential to affect all 159 residents for whom meals were prepared and served, as well as residents' refrigerated storage on 3 of 3 nursing stations. Findings Included: 1) DIETARY FOOD STORAGE The facility's Food Storage policy (dated 2013) specifies the following: . Procedure: . 15. [...]

Inspectors wroteBased on interviews, Minimum Data Set (MDS) assessments and a review of CMS's (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to ensure RI #4's Significant Change (SC) MDS and RI #7's Annual MDS assessments were submitted timely. This had the potential to affect 2 of 4 residents whose assessments were reviewed for being over 120 days late. Findings Include: A review of CMS's RAI Version 3.0 Chapter 5: Submission and Correction of the MDS Assessments . page 5-3 specifies, the assessment must be submitted within 14 days of the MDS Completion Date A review of RI #4's 2/25/2019 Annual MDS, section VO200C was signed and dated 3/18/19. The document should have been submitted by 4/1/19. A review of RI #7's 2/25/2019 SC MDS section VO200C was signed and dated 3/18/2019. The MDS should have been submitted by 4/1/2019. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Policy and Procedures for Aseptic Technique with Dressing Changes, the facility failed to ensure the licensed staff did not use the same gloves to clean a wound for Resident Identifier (RI) #106, then place the clean treatment and outer covering. This affected one of one resident observed for wound care. 1. A review of a facility policy titled Policy and Procedure for Aseptic Technique with Dressing Changes with a date of 7/18/05 revealed: . The goals for treating a wound are to prevent cross contamination and/or infection of an open area and to prevent additional trauma to area. RI #106 was readmitted to the facility on [DATE] with a diagnosis of Pressure ulcer of sacral region, stage 2. A review of RI #106's April 2019 Physician Orders revealed . [...]

Inspectors wroteBased on observation, interview, and a review of facility's policy titled, INFECTION CONTROL OXYGEN EQUIPMENT, the facility failed to ensure oxygen tubing and the humidifier bottle were replaced and dated appropriately for Resident Identifier(RI) #313. This affected 1 of 3 residents observed for oxygen therapy. Findings Include: A review of a facility policy titled, INFECTION CONTROL OXYGEN EQUIPMENT with a revised date of 8/2012, revealed: . Procedures . 4. Humidifiers are to be replaced weekly and dated. 5. Oxygen tubing, mask, and cannula's are to be replaced weekly and dated. RI #313 was admitted to the facility on [DATE] with a diagnosis of Hypoxemia and dependence of supplemental oxygen. A Physician orders, dated 04/18/19, revealed the order for oxygen (O2) at 2 liters per minute per nasal cannula as needed for shortness of breath and low O2 saturations. [...]

Inspectors wroteBased on observations, interviews, and review of facility a policy titled, Medication Administration - General Guidelines, the facility failed to ensure that licensed staff did not leave a medication cart unlocked and unattended while administering medications to Resident Identifier (RI) #2. This affected one of five nurses observed for medication pass. Findings Include: A review of the facility policy titled, Medication Administration - General Guidelines with a date of 01/12 revealed: .Procedures . 11. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. RI #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of: Encounter for attention to gastrostomy and Dementia in other diseases classified elsewhere. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Medication Administration Procedures Eye Drops the facility failed to ensure: 1. licensed staff washed her hands before administering eye drops for RI #122 and 2. licensed staff did not handle tablet medication with her bare hands, then touch the inside of a crush medication bag while preparing medication for RI #2. This affected one of one resident observed for eye drop medication and one of one resident observed for medication administered by tube. Findings Include: 1. A review of a facility policy titled, Medication Administration Procedures Eye Drops, with a date of 1/12 revealed: .Procedures .3. Wash your hand with soap and water . 9. Instruct the resident to look upward and place one drop .14. Wash your hands with soap and water . [...]