Crisp Regional NSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Crisp Regional NSG & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jun 13, 2023

  Based on record review and staff interviews, the facility failed to implement the plan of care for one resident (R) R#1 with a known history of elopement, to perform frequent location checks of exit seeking behavior from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. The noncompliance related to the IJ was identified to have existed on 5/16/23. An Acceptable IJ Removal Plan was received on 6/9/23. […]

• Immediate jeopardy, isolatedF689Jun 13, 2023

  Based on staff interviews, record review, and review of the facility policy titled, Elopement, the facility failed to provide adequate supervision and frequent monitoring of resident (R) #1 and failed to ensure one of three doors equipped with the Wander Guard system was functioning to prevent the elopement of one resident R#1 from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. […]

• No harm, potential for more than minimal, widespreadF814Sep 14, 2023

  Based on observations and staff interviews, the facility failed to maintain the garbage storage area in a sanitary manner by ensuring dumpster lids were closed, failed to ensure the surrounding area was free from trash and standing water, failed to ensure one of three dumpsters was in good condition by not leaking. This practice had the potential to attract insects/rodents, and the potential for transmission of disease through the harborage and feeding of pests and carrying microorganisms into the facility. Findings include: Observation on 9/12/2023 at 9:40 a.m., and again that afternoon at 5:00 p.m., revealed two of three dumpsters with large bags of garbage inside with the lid open and trash on the ground. The dumpsters were visible by the survey team from inside the conference room. […]

• No harm, potential for more than minimal, patternF761Oct 22, 2021

  Based on observations, staff interviews, and review of the facility policy titled Crisp Regional Health Services Medication the facility failed to ensure that two of four medication carts were locked and secured when not in use. Findings include: Review of the policy titled, Crisp Regional Health Services Medication, dated 6/11/2021, revealed under number 24., the medication cart should always be locked unless in use by the Unit Nurse. 1. Observation on 10/19/2021 from 12:41 p.m. until 12:48 p.m., RN NN entered room [ROOM NUMBER] to assist a resident. While the RN NN was in the room two surveyors observed medication cart #3 to be open. The light on the cart was orange and the drawers on the cart were able to be opened including the narcotics drawer. […]

• No harm, potential for more than minimal, patternF656May 20, 2021

  Based on record review and staff interviews, the facility failed to follow the pressure ulcer care plan intervention to provide skin care after each incontinent episode and as needed for two residents (R#2, R#3) of three sampled residents. Findings include: 1.Review of the medical record revealed R#2 was admitted to the facility with the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 3/29/2021 revealed an unstageable pressure ulcer to the sacrum. One of the resident's interventions was for skin care after each incontinent episode and as needed. During an observation on 5/19/2021 at 1:13 p.m. […]