Crowley County Nursing Center

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Services Deficiencies

Meet other general requirements that are deficient.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Egress Deficiencies

Install resident room doors of proper design and width.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90.The facility is one story, Type V (111), slab-on-grade construction. The facility is protected by a National Fire Protection Association (NFPA) 1.. Through documentation review, it was determined that the facility failed to meet the emergency light requirements in accordance with NFPA 101.This requirement was NOT MET by the following: 1) No documentation was provided for M.. Through documentation review, it was determined that the facility failed to meet the Exit Signange requirements in accordance with NFPA 101.This requirement was NOT MET by the following: 1) No documentation was provided for th.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in accordance with NFPA 101.This requirement was NOT MET by the following:First Shift missed a Fire Drill in the secon.. Through observation during the survey, it was determined that the facility failed to meet the Building Service- Other requirements in accordance with NFPA 101 and NFPA 80. This requirement was NOT MET by the following:1) There is .. Through observation during the survey, it was determined that the facility failed to meet the Cooking Facility requirements in accordance with NFPA 101. This requirement was NOT MET by the following:1) Near the dishwasher, .. Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101.This requirement was NOT MET by the following:1) When exiting the fitne.. Through observation during the survey, it was determined that the facility failed to meet the Egress Door requirements in accordance with NFPA 101.This requirement was NOT MET by the following:The two delayed egress .. Through observation during the survey, it was determined that the facility failed to meet the Fire Alarm Testing and Maintenance requirements in accordance with NFPA 101, and NFPA 72. This requirement was NOT MET by the f.. Through observation during the survey, it was determined that the facility failed to meet the Gas Transfill requirements in accordance with NFPA 101 and NFPA 99. This requirement was NOT MET by the following:1) In the O.. Through observation during the survey, it was determined that the facility failed to meet the Hazardous Areas- Enclosure requirements in accordance with NFPA 101. This requirement was NOT MET by the following:1)The chapel i.. Through observation during the survey, it was determined that the facility failed to meet the Subdivision of Building Spaces – Smoke Barrier Construction requirements in accordance with NFPA 101. This requirement was NOT MET by t.. Through observation during the survey, it was determined that the facility failed to meet the Utilities- Gas and Electric requirements in accordance with NFPA 101, NFPA 54, and NFPA 70. This requirement was NOT MET by the fol..

A recertification survey was conducted from 2/21/24 to 2/27/24. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 2/21/24 to 2/27/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#25 and #30) of five residents reviewed for unnecessary medication of out 17 sample residents.Specifically, the facility failed to ensure consents were obtained for the usage of psychotropic medications for Resident #25 and Resident #30.Findings include: I. Facility policy and procedureThe Psychotropic Medicatio.. Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#25) of three residents reviewed for PASRR out of 17 sample residents. Specifically, the facility failed to arrange and incorporate recommendations.. Based on observation, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#23) of 12 residents reviewed for activities of daily living (ADL) out of 17 sample residents. Specifically, the facility failed to revise Resident #23' s person-centered, resident-s.. Based on observation, record review and staff interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to:-Ensure a backflow prevention device was installed on the hand held shower hose in the shower room on B hall, increasing the risk of contamination to the facility' s main water supply; and, -Ensure necessary kitchen equipment was maintained i.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four certified nurse aides (CNAs) reviewed. Specifically, the facility failed to:-Provide inservice education plans based on the outcome of the performance reviews for CNA #2, #3, #4, and #5; and,-Ensure CNAs received 12 hours of.. Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for four of four CNAs reviewed.Specifically, the facility:-Failed to ensure CNAs #2, #3, #4, and #5 received annual dementia management training; and,-Failed to ensure CNAs #2, #3, and #4 received annual abuse training. Findings include:I. CNA trai.. Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#38) of two residents receiving hospice services. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures.Findings include:I. Facility policyThe Hospice Program policy, revised July 2017..

A complaint survey, prompted by #CO31606 was conducted on 4/13/23. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three rooms out of 26 occupied rooms. Specifically the facility failed to ensure power strips were not plugged into another powerstrip/surge protector.Findings include: I. Facility policyThe Electrical Safety for Residents policy, revised January 2011, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:02 p.m. included,"Power strips shall not be used as a substitute for adequate electrical outlets in the facility. Power strips may be used for a computer, monitor, and printer."II. ObservationsThe room 4A at 10:05 a.m. on 4/13/23 had a dark gray power strip plugged into the wall outlet next to the bedside with two cords plugged into it. One of the cords led to another light gray power strip attached to the bed frame. The light gray power strip had three items plugged into it.The room 5B at 10:15 a.m. had a six plug outlet cover plugged into the wall next to the bedside. The six plug outlet had four outlets being used to include a gray power strip with two outlets being used.The room 9C had a power strip plugged into the wall next to the bedside. The power strip had one outlet being used by another power strip. The second power strip did not have any outlets being used.III. InterviewsThe maintenance director (MTCE) was interviewed on 4/13/23 at 11:05 a.m. He said he was new to the position and was in the process of scheduling safety inspections. He said it was not safe to plug one power strip into another power strip power surge protector. He said he was not aware of the identified rooms and would do an audit immediately to fix and ensure there were no others. The NHA was interviewed on 4/13/23 at 12:20 p.m. She said the facility had just completed an audit and took out the power strips. She said it was not safe to have power strips plugged into each other. She said going forward the power strip use would be audited and included in safety inspections.