Crowne Health Care of Montgomery

In the surveyor’s words

From the most serious findings on record at Crowne Health Care of Montgomery, in the surveyor’s own words.

• Immediate jeopardy, isolatedF607Apr 16, 2021

  Based on interviews, review of the facility's Abuse Policy, the facility's investigation file, and other facility documents, the facility failed to ensure Resident Identifier (RI) #28 and other residents were protected from potential abuse after RI #28 reported to two Certified Nursing Assistant (CNAs) that EI #4, a CNA had hit him/her. The two CNAs reported the allegation of physical abuse to the Licensed Practical Nurse (LPN) who was on duty at the time of the incident. The LPN reported the allegation of physical abuse to the Registered Nurse (RN) Supervisor. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2021

  Based on observation, interview and review of facility policies titled Labeling & Dating, Use and Storage of Food Brought in by Family and Visitors, Policy-Expired Foods in Refrigerator, and a facility document titled Labeling & Dating Rules, the facility failed to ensure: 1. that Bacon and Sausage Links in the walk-in cooler were dated with open date and in a sealed package; 2. broken eggs were not placed on top of unbroken eggs and 3. the air conditioning exhaust vent above clean trays and cups used for resident meals was not covered with a thick layer of dust. The facility further failed to ensure all food items in the unit refrigerators contained a name and date and that refrigerators were clean. […]

• No harm, potential for more than minimal, isolatedF842Jun 30, 2021

  Based on record reviews, interviews, and a review of the facility policy Tube Feeding Administration, the facility failed to ensure licensed staff did not initial the Medication Administration Record (eMAR) for bolus tube feeding for Resident Identifier RI #1. This deficient practice was cited as a result of the investigation of complaint # AL 405 and affected RI #1, one of one resident's sampled for tube feeding. Findings Include: A review of an undated facility policy titled Tube Feeding Administration, revised on 5/21, revealed . Procedure: 1. Check the physician's order on the eMAR prior to gathering supplies.9. Feedings will be given by one of the methods below. Bolus Feeding Method . J. Document procedure on eMAR. Closed System via Infusion Pump . R. […]

• No harm, potential for more than minimal, isolatedF695Apr 16, 2021

  Based on observations, interviews, record review, and review of a facility policy titled Policy and Procedure for Oxygen Administration the facility failed to ensure the oxygen tubing for Resident Identifier (RI) #4 was changed weekly. This affected one of one resident sampled for respiratory care. Findings Include: A review of a facility policy titled Policy and Procedure for Oxygen Administration with a date of 07/2016 revealed, .Procedure: . Change the . cannula/mask tubing at least weekly, date and initial the bottle on 3-11 PM and as needed (PRN) whenever it is changed. Resident Identifier (RI) #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF880Apr 16, 2021

  Based on observation, interviews, and review of facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes the facility failed to ensure Employee Identifier (EI) #16 , Certified Nursing Assistant (CNA) changed gloves after removing the soiled brief and before applying a clean brief while providing incontinent care to Resident Identifier (RI) # 58. This affected RI #58, one of one sampled residents reviewed for bladder and bowel incontinence. Findings include: A facility document titled Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012 revealed . PROCEDURE: .2. Apply gloves . 4. Female- clean entire perineal area . 9. Remove and dispose of gloves, wash hands. Apply new gloves. 10. Apply new dry incontinence pad . 12. […]