Focused Care at Crane

Inspectors wroteBased on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 4 quarterly meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents (Resident #25, #32 and #37) reviewed for quality of care in that: 1. The facility failed to assess and care plan Resident #25 for safe vaping, 2. The facility failed to keep Resident #25's vape secure when it was not a supervised smoking time 3. CNA E and CNA D incorrectly transferred Resident #32 the shower chair to the bed by incorrectly applying the gait belt too loosely and hooking under Resident #32's arms. 3. CNA A and CNA B incorrectly transferred #37 from her wheelchair to the bed by grabbing her from the back of her pants and her under arms. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurateacquiring, receiving, labeling, dispensing, safe and secure storage of medications for 2 of 2 medication carts(200 hall and 300 hall) checked for storage of medications. - The 200 hall medication cart had a bottle of milk of magnesia with dried drippings on the lid of the bottle. - The 300 hall medication cart had an empty bottle of Pro Stat liquid collagen with dried drippings on the side of the bottle - The 300 hall medication cart had two open undated insulin pens for Resident #7 and Resident #14 These failures could affect residents that received medications at the facility by placing them at risk of cross contamination and receiving ineffective insulin therapy.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Residents #25) reviewed for care plans in that: Resident #25 did not have a Care Plan addressing his vape use/smoking. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #34) reviewed for nutrition. The facility failed to provide care and services to maintain acceptable parameters of nutritional status for Resident #34. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in 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 to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #21) of 3 residents reviewed for infection control. CNA B failed to change her gloves and wash her hands after they became contaminated during incontinent care while assisting Resident #21. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure allegation of abuse, the facility had evidence that alleged violation was thoroughly investigated but failed to report the results of investigation to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 resident (Residents #1) reviewed for investigating alleged violation of abuse. The facility failed to report evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A), and failed to report the results of the investigation when Resident #1 alleged abuse from CNA A which did not result in injury to Resident #1. These failures could place residents at risk for allegations of abuse and neglect not being thoroughly investigated by the facility and reported as required.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative when the resident had a change in his psychosocial status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to inform Resident #1's responsible party when he ran out of the medication Risperidone or of his ongoing aggressive behavior. The facility failed to inform Resident#1's physician that when he ran out of the medication Risperidone and get a new order for the medication at the family's request. This failure could place residents at risk for not having their representative notified or not receiving relevant medical information when there is a change of condition.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #1) of four residents reviewed for availability of medications. The facility failed to obtain and administer the antipsychotic Risperidone fifteen (15) times between 4/23/24 and 5/1/24 per physician's orders to Resident #1. This failure puts residents at risk of not receiving prescribed medications and experiencing behaviors or other symptoms of diagnosed conditions.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 4 halls (Hall 300, Hall 400, and Hall 500) reviewed for accidents and supervision. 1. The temperature reading for Hall 300 shower room sink was 119°F. 2. The temperature reading for Hall 400 shower room sink was 141.3°F and for the shower itself was 137.9°F. 3. The temperature for Hall 500 shower was 136°F. 4. The temperature readings for Hall 500 resident sinks were in temperature ranges from 130°F to 135° 5. The temperature of Hall 500 hot water heater was 140°F. An Immediate Jeopardy (IJ) situation was identified on 04/22/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents had the right to choose their schedule for 2 of 6 residents (Residents #12 and #63) reviewed for self-determination preferences. The facility failed to allow Resident's #12 and #63 to smoke more than one cigarette while on their smoke break. This failure could place residents at risk of diminished feeling of self-worth, depression, and or diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike environment for 3 of 17 (Resident #4, #22, and #32) resident rooms reviewed for resident rights. 1. The facility failed to ensure the hot water faucet worked in Resident #4's and #22's rooms. 2. The facility failed to ensure hot water in room was above 100? in Resident #32's room sink. 3. The facility failed to ensure hand washing sink drained water without resident holding up drain with hand by reaching into used water in Resident #32's room. 4. The facility failed to ensure closets had doors that would enclose resident's clothing. These failures could place residents at risk for infection and diminished clean, homelike environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for residents who are incontinent of bladder, for 2 of 18 (Resident #17 and Resident #38) residents reviewed for incontinent care. The facility failed to ensure no cross-contamination occurred when CNA B failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #17. The facility failed to ensure no cross-contamination occurred when CNA C failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #38. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #26, Resident #59, and Resident #68) reviewed for bed rails. 1. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. 2. The facility failed to obtain informed consent prior to installation of bed rails. These failures could place residents at risk for injury and restricted movement.

Inspectors wroteBased on interview and record review, the facility failed to review the work of each Certified Nurse Aid (CNA) every 12 months for 4 (CNA-D, CNA-E, CNA-F and CNA G) of 5 CNAs reviewed for nursing services. The facility failed to provide CNA competency evaluations at least every 12 months after hire. This failure could result in inadequate CNA performance while providing care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 6 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52) of 11 residents reviewed for pharmacy services. The facility failed to ensure Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52 had stop dates for PRN Lorazepam (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Resident #45 Review of Resident #45's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, depression, dementia, and Alzheimer's. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services in that: The facility failed to ensure the dry food storage was not past their use by dates. This failure placed residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 11 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34) of 11 residents reviewed for hospice services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 5 (CNA-D, CNA-E, CNA-F, CNA-G) employees whose in-service records were reviewed had received the required minimum 12 hours annual in-service. The facility failed to provide the required annual performance care training to CNA-D, CNA-E, CNA-F, and CNA-G. This failure placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure 1 medication cart (used by nurse for treatments performed on 200 and 400 halls was locked when unattended. This failure could place residents at risk of having access to unauthorized medications, wound care, and medical supplies leading to possible harm or drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were maintained with accepted professional standards and practices for completeness and accurately documented for 1 of 17 residents (Resident #64) reviewed for resident records. The facility failed to obtain physician's order prior to placing Resident #64 in secure unit. The facility failed to obtain consent from resident or representative prior to placing Resident #64 in secure unit. These failures could place residents at risk of being separated against their will , without orders or the representative's consent.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 6 of 6 dumpster and 1 of 1 oil fryer container reviewed for food safety requirements. 1. Garbage and refuse were observed on the ground near the dumpsters in the back of the facility. 2. 2 dumpsters were observed uncovered with garbage inside and one fry oil container was uncovered with used fry oil in it. This failure could affect residents by placing them at risk of illnesses, or be provided a unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment for 2 of 4 shower rooms (200 hall and 400 hall) reviewed for environment. 1. The facility failed to ensure shower room in 200 and 400 hall was free from black mold. 2. Resident #55 and Resident #76 voiced concerns with dirty shower rooms. This failure could place residents at risk for infection and a diminished clean, homelike environment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; which included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat residents medical symptoms for 5 of 19 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) reviewed for abuse. A. 5 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) were residing in the secure memory unit without physician orders and medical symptoms. These failures could place residents at risk of being separated against their will, without orders or the representatives consent.

Inspectors wroteBased on observation, interviews and record review, the facility failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 1 out of 4 (400 hall) narcotic count sheets and 1 out of 1 medication storage room reviewed for controlled medications in that: -Narcotic count sheet for 400 hall was missing staff signatures for 3 days (2/20, 2/21 and 2/22). -An unemptied open vial of Haldol medication was found inside the medication storage room and had not been wasted. This deficient practice could result in inaccurate count and destruction of controlled medications which could lead to a decline in health to residents receiving controlled medications.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services, in that: 1. Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. 2. Staff were not wearing hairnets properly or not at all while in the kitchen. 3. Sanitation Bucket Log (Is used to check the part per million of cleaning solution mixed with the water to make it is disinfecting) was not filled out every day. This these failures could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that are complete, accurately document and readily accessible for 11 of 16 residents (Resident #180, 62, 50, 71, 42, 62, 47, 15, 53, 41, and 8) reviewed for medical records. A. The facility failed to maintain physician orders that were complete and accurately documented for Resident # 180, 62, 50, 71, and 42. B. The facility failed to have history and physicals readily accessible for Resident #39, 38, 52, 180, 62, 47, 15, 53, 41, and 8. C. Resident #68 was receiving oxygen with no physician order. These failures placed residents at risk of not receiving necessary care due to inaccurate and or incomplete medical records.

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. A. The facility failed to ensure Nasal Cannulas were placed in a bag when not in use for Resident #130, 11, 13, 70, 24, and 12. B. The facility failed to ensure clean linen was distributed in a covered linen cart, all four edges were torn exposing clean linen. C. The facility failed to keep urinals clean. D. The facility failed to ensure soiled linens were properly handled. These failures could place residents at risk of cross contamination.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for environment. The facility failed to ensure housekeeping and maintenance services were provided for resident living areas. This failure could affect residents placing them at risk of living in an unsafe, uncomfortable environment, infection and disease, and decreased quality of life due to poor conditions of the facility interior and exterior.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid including referring residents with newly evident or possible serious mental disorders for level II resident review upon a significant change in status assessment for one (Resident #10) of 6 resident reviewed for PASARR, in that: Resident #10 was admitted with a Level 1 PASARR indicating resident did not have a mental illness and or intellectual disability or related condition resulting in the facility failing to coordinate a Level II PASARR during resident screening. This failure could place residents at risk of not receiving specialized services that may assist them in attaining and or maintaining their highest practicable level of psychosocial functioning. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission for 1 of 8 residents (Resident #181) reviewed for baseline care plans. The facility failed to develop a baseline care plan within 48 hours of Resident #181 admission. This failure could place recently admitted residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences in 1 resident (Resident #68) out of 8 reviewed for oxygen care in that: -Nursing staff administered oxygen to Resident #68 without a physician's order. This deficient practice could cause a decline in health for residents receiving O2 without a physician order and who are not being monitored accurately.

Inspectors wroteBased on observation, interviews and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 drugs/biologicals reviewed for labeling in that: -Resident #10's tube feeding was unlabeled with feeding rate and time it was hung. This deficient practice could cause a decline in health in residents due to labeling errors/issues.