Crook County Medical Services District Long Term C

In the surveyor’s words

From the most serious findings on record at Crook County Medical Services District Long Term C, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 4, 2021

  Based on observation, review of policy and procedure, resident and staff interview, and review of professional standards, the facility failed to implement infection control practices to prevent the spread of infectious disease including COVID-19. Specifically, the facility failed to ensure source control through face coverings and social distancing, and failed to ensure effective hand hygiene. It was determined these failures placed the residents in immediate jeopardy. The census was 27. On 3/2/21 at 12:55 PM the administrator was informed of an immediate jeopardy situation in the area of infection control related to the lack of source control, and insufficient hand hygiene. The facility submitted an action plan which included the following immediate changes: 1. […]

• Actual harm, isolatedF600Sep 5, 2024

  Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 2 sample residents (#1 and #2) reviewed for allegations of abuse. The findings were: 1. Review of an incident report dated 7/30/24 showed resident #2 assaulted his/her roommate, resident #1, with the metal clip of a pair of suspenders. Further review showed the clip caused a 1centimeter (cm) laceration to resident #1's left cheek and the resident required treatment in the emergency room (ER). The following concerns were identified: a. Review of medical record dated 7/31/24 showed resident #1 was transferred to the ER and received treatment of the wound with steristrips. […]

• Actual harm, isolatedF600Sep 2, 2022

  Based on medical record review, staff, resident and resident representative interview, review of facility incident reports, and policy and procedure review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (#1) reviewed for resident-to-resident altercations. This failure resulted in harm to resident #1 who experienced verbal abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The findings were: 1. Review of the 5/18/22 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE], had a BIMS score of 10/15 (moderate cognitive impairment), and had diagnoses which included moderate intellectual disabilities, unspecified psychosis not due to a substance or known physiologic condition, depression,… […]

• Actual harm, isolatedF656Sep 2, 2022

  Based on observation, resident, staff, and resident representative interview, medical record review, and policy and procedure review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 3 sample residents (#1, #2, #3) involved in resident-to-resident altercations. This failure resulted in harm to resident #1, who was not protected from another resident whose actions a reasonable person would find demeaning and humiliating. The findings were: 1. […]

• No harm, potential for more than minimal, widespreadF727Aug 14, 2025

  Based on staff schedule review, payroll based journal (PBJ) review, and staff interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days per week during 1 of 4 quarters reviewed (1st quarter of fiscal year 2025). The census was 27. The findings were: 1. Review of the PBJ Staffing Data Report for quarter 1 of fiscal year 2025 (October 1,2024 through December 31, 2025) showed there was no RN on duty for 8 consecutive hours for 2 days in November 2024, 11/9 and 11/23. Further review showed there was no RN on duty for 8 consecutive hours for 5 days in December 2024, 12/7, 12/14, 12/21, 12/22, and 12/29:2. […]