Munson Healthcare Crawford Continuing Care Center

Inspectors wroteThis deficient practice pertains to Intake 2985836. Based on interview and record review, the facility failed to prevent an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.

Inspectors wroteBased on interview and record review, the facility failed to document collaboration among the interdisciplinary team (IDT) and to offer and provide inclusion of resident's or their representatives in the quarterly review of the comprehensive care plan for three Residents (#5, #7 and #13) of 12 residents reviewed and affecting all 19 residents receiving long-term care of a total of 27 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychoactive medications for one Resident (R10) of five residents reviewed for psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of transfer or discharge and the facility bed hold policy for three Residents (#3, #6 and #32) of three residents reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor and maintain nutritional status of one Resident (R7) of two residents reviewed for nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (R28, R30 and R36) of four residents reviewed for dining assistive devices.

Inspectors wroteThis deficient practice pertains to intake 2588223. Based on interview and record review, the facility failed to prevent and readily detect an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures to ensure a safe and sanitary environment for five Residents (#5, #10, #23, #15, and #13) of eight residents reviewed for infection prevention and control.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#185) of one resident reviewed for end-of-life care (EOLC) had a care plan and physician's order for terminal care, and appropriate activation of patient advocate/durable power of attorney prior to placing a resident on EOLC.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate assessments and documentation warranting the use of a physical restraint for one Resident (#10) of one resident reviewed for restraints, resulting in the potential for feelings of helplessness, agitation, decreased physical functioning and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for two Residents (#3, #23) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side-effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of target behaviors/symptoms with attempted use of non-pharmacological interventions prior to the administration of as needed (prn) anti-anxiety medication for two Residents (#3, #10) of five residents reviewed for unnecessary medications, resulting in the potential for adverse side effects and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 26 residents.

Inspectors wroteBased on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 26 residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of performance indicators, identification of quality issues, and the conducting of distinct performance improvement projects to correct quality deficiencies and maintain sustained compliance. This failure had the potential to affect all 26 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. This deficient practice resulted in the potential for ineffective interdisciplinary communications regarding facility process with the potential to affect all 26 residents residing in the facility.

Inspectors wroteThis citation will have two deficient practice statements: A and B A. Based on interview and record review the facility failed to implement a system for recording and tracking communicable disease during an outbreak of respiratory illness (Covid-19), resulting in the potential for further spread of the virus to 23 un-infected residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist worked at least part-time at the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program resulting in the lack of outbreak surveillance and investigation and tracking of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing with the reason for a transfer out of the facility for three Residents (R82, R186, R27) of three residents reviewed for transfers.

Inspectors wroteBased on observation, interview and record review the facility failed to safely provide assistance with wheelchair mobility for three Residents (R6, R14, R186) and failed to investigate the root cause of self-injurious behavior for one Resident (R3) of four residents reviewed for accidents and supervision. This deficient practice resulted in the potential for injury related to unsafe wheelchair mobility assistance and the potential for continued self-injurious behavior.

Inspectors wroteBased on interview and record review, the facility failed to implement the abuse policy and investigate allegations of abuse for one Resident (R8) of two residents reviewed for abuse, resulting in the potential for continued abuse, fear, anger, and mental anguish.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address safety concerns for one Resident (R3) of 12 residents reviewed for care planning, resulting in the potential for unmet safety needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer supplemental oxygen per physician orders for one Resident (#186) of one residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and manage pain for one Resident (#2) of one resident reviewed for pain management. This deficient practice resulted in untreated pain and unnecessary suffering.

Inspectors wroteBased on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for a psychotropic medication for one Resident (R23) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than five percent, with two errors identified out of 31 opportunities, affecting one Resident (R182) of four residents observed for medication administration, resulting in a medication error rate of 6.45 percent.