Every finding on record at Three Crowns Park

Based on interview and record review, the facility failed to ensure that 1 of 3 (R1) residents reviewed for abuse in the sample of 3 remained free from physical abuse. This failure resulted in a staff member striking R1's arm and hand and staff member screaming at the resident, causing R1 to cry out in physical pain and emotional distress verbalizing that she was being hurt and abused. Findings include:R1 is cognitively intact [AGE] year old with diagnoses including but not limited to Parkinson's Disease, Spinal Stenosis and Scoliosis and requires staff assistance for all activities of daily living. On 10/24/25 at 8:30 PM, R1 screamed to the hallway staff stating Help! Help! Someone help me she is hurting me! V3, Registered Nurse (RN) responded to the screams and observed V4, Certified Nursing Assistant (CNA) at the bedside providing care. R1 reported that V4 hit her arm and hand multiple times while performing care causing immediate pain. During resident interview on 12/5/25 at 11:45 AM, R1 stated, Yes I remember what happened, she (V4 CNA) hit me in the arm and my hand hard. I told her she was hurting me and she didn't stop. She was placing me on the sit-to-stand machine and putting this circular thing to go around my waist and when she was hoisting me up, it was hurting me because is was squeezing me in the wrong area and I told her to stop and she just kept going so I screamed stop, stop, stop! So instead of stopping she slapped my arm and hand several times and told me to stop screaming. She was angry with me and that frightened me. That's when the nurse finally came in and told her to move away from me and she (V4) left the room and somebody else came in and helped me. I've had some minor issues with the same CNA, but I just overlooked it before but this time she really hurt me so I had enough. Surveyor asked what minor issues she had with V4, R1 indicated it was the way V4 rushed through things to finish caring for her and that at times she was rough but that she just ignored it until she could no longer. On 12/5/25 at 11:59 am, V2 (Director of Nursing), indicated that the nurse V3 RN called her and gave the reason that she wanted to rearrange the CNA's because one of the CNA's (V4) was giving her a hard time. I told V3 RN that V4 (CNA) needs to be sent home immediately because she just wanted to rearrange the schedule instead of sending the CNA home. I did say to her if the resident said abuse and she said yes so I told V3 that what we are dealing with is allegation of abuse. I texted the executive director (V7) but she did not text me back. I called back and talked to V3 again to ensure that V4 (CNA) left the building. Surveyor asked about R1, V2 indicated that the resident is cognitive and is not confused and did not have any history of similar allegations. Interview with V3 RN on 12/5/25 at 12:51 PM indicated she heard R1 screaming and heard, Help! Help! She is hurting me! so she went to R1's room immediately and observed V4 trying to put R1's socks on the resident. V3 asked R1 what happened and R1 had explained that she did not want V4 to be her aide anymore and that V4 hit her multiple times on the hands and arm and told her to quiet down which frightened her. V3 said that she asked V4 to leave until she called the director of nursing to inform her of the issue. V3 indicated she had called the V7 executive director first but there was no answer or call back. Surveyor asked if she had called the director of nursing for reassignments of her CNA's, V3 affirmed that she did, but that the director of nursing instructed her to go back to the resident to ask if she was abused or not. Surveyor asked when the last time she was trained on abuse prevention, V3 said she could not recall but that she received one after the incident happened. V4 CNA could not be contacted for interview and was terminated from employment for not meeting service standards. V7 executive director was requested for interview but failed to honor surveyor requests during the investigation.V8 interim administrator who created the internal investigation is no longer with the facility. Facility policy on abuse reads in part, The facility prohibits any form of resident abuse, neglect, or exploitation. Facility shall supervise staff in such manner as to attempt to identify inappropriate behaviors such as rough handling of residents, identifying escalating aggressive behaviors from residents, or imposed seclusion. Staff members shall use the care plan or resident assessment to monitor and identify resident needs and behaviors that have the potential for abuse. All employees are obligated to report knowledge of potential for abuse, neglect, or exploitation of a resident to their immediate supervisor. Physical abuse is the infliction of physical of pain or injury to the resident which includes, but is not limited to, hitting, slapping, pinching, and kicking.

Based on interview and record review, the facility failed to conduct a thorough and accurate investigation into an allegation of abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. The nurse on duty (V3) did not provide immediate protection by removing the alleged perpetrator (V4) from resident contact as required. Instead, the nurse attempted to reassign the CNA to a different resident until she was specifically directed by the Director of Nursing (V2 DON) to remove the CNA from the building. Additionally the facility failed to evaluate relevant evidence, and concluded that the allegation was unsubstantiated. These failures created a facility-wide potential for residents to be placed at risk for unrecognized and/or inadequately investigated allegations of abuse. Findings include:R1 is cognitively intact [AGE] year old with diagnoses including but not limited to Parkinson's Disease, Spinal Stenosis and Scoliosis and requires staff assistance for all activities of daily living. On 10/24/25 at 8:30 PM, R1 screamed to the hallway staff stating Help! Help! Someone help me she is hurting me! V3, Registered Nurse (RN) responded to the screams and observed V4, Certified Nursing Assistant (CNA) at the bedside providing care. R1 reported that V4 hit her arm and hand multiple times while performing care causing immediate pain. On 10/23/25 at 8:30 PM R1 yelled Help me, help me, she is hurting me! prompting V3 RN to respond. V3 found R1 distressed and removed V4 CNA from the situation and reported that V4 hit her several times which caused her pain. R1 explained to V4 that the sit-to-stand machine was improperly placed on her and that during the lifting process she was telling the CNA V4 she was in pain and to stop, yet she kept continuing the process and instead told the her to be quiet. During interviews on 12/5/25 at 11:45 AM , R1 consistently stated that V4 CNA struck her hand several times along with her arm. R1 stated, Yes I remember what happened, she (V4 CNA) hit me in the arm and my hand hard. I told her she was hurting me and she didn't stop. She was placing me on the sit-to-stand machine and putting this circular thing to go around my waist and when she was hoisting me up, it was hurting me because is was squeezing me in the wrong area and I told her to stop and she just kept going so I screamed stop, stop, stop! So instead of stopping she slapped my arm and hand several times and told me to stop screaming. She was angry with me and that frightened me. That's when the nurse finally came in and told her to move away from me and she (V4) left the room and somebody else came in and helped me. Witness statements and the resident's distress were not reconciled or analyzed using the regulatory definition of abuse which defines abuse by the willful infliction of physical pain, and does not require injury or malicious intent. On 12/5/25 at 11:59 am, V2 (Director of Nursing), indicated that the nurse V3 RN called her and gave the reason that she wanted to rearrange the CNA's because one of the CNA's (V4) was giving her a hard time. I told V3 RN that V4 (CNA) needs to be sent home immediately because she just wanted to rearrange the schedule instead of sending the CNA home. I did say to her if the resident said abuse and she said yes so I told V3 that what we are dealing with is allegation of abuse. I text the executive director (V7) but she did not text me back. I called back and talked to V3 again to ensure that V4 (CNA) left the building. Surveyor asked about R1, V2 indicated that the resident is cognitive and is not confused and did not have any history of similar allegations. Interview with V3 RN on 12/5/25 at 12:51 PM indicated she heard R1 screaming and heard, Help! Help! She is hurting me! so she went to R1's room immediately and observed V4 trying to put R1's socks on the resident. Surveyor asked if she had called the director of nursing for reassignments of her CNA's, V3 affirmed that she did, but that the director of nursing instructed her to go back to the resident to ask if she was abused or not. Surveyor asked when the last time she was trained on abuse prevention, V3 said she could not recall but that she received one after the incident happened. The facility's investigation did not evaluate the resident's distress and immediate outcry as evidence; did not compare the CNA's denial against resident credibility assessment; and did not apply the federal definition of physical abuse, and justified the unsubstantiated finding with clear evidence. As a result, the facility reached a conclusion inconsistent with the regulatory criteria of abuse. V4 CNA could not be contacted for interview and was terminated from employment for not meeting service standards. V7 executive director was requested for interview but failed to honor surveyor requests during the investigation.V8 interim administrator who created the internal investigation is no longer with the facility. Facility policy and procedures for abuse prohibition reads in part but not limited to, Abuse is any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm. This includes mental abuse, physical abuse, verbal abuse, or any other actions within this definition. Mental abuse is the infliction of mental/emotional suffering. 'It includes, but is not limited to humiliation, harassment, intimidation. Physical abuse is the infliction of physical pain or injury to the resident. It induces, but is not limited to hitting, slapping, and also includes controlling behavior through corporal punishment, or the misuse of physical restraints. Verbal abuse is the use of oral or gestured language that willfully includes disparaging terms to residents within their hearing distance. Examples of verbal abuse include, but not limited to, threats of harm or saying things to frighten a resident. Mistreatment means inappropriate treatment of a resident.

Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of property as evidenced by R1's wallet being stolen while in the facility. This failure affected one (R1) of four residents reviewed for misappropriation of resident property. Findings include:Facility reported incident (FRI) dated 6/27/2025 documents: R1's wallet was returned to the facility's front desk by the postman who found it on the sidewalk several blocks away around 6 PM on 6/27/2025. R1 had not been out of the facility. R1's Family member was notified by the credit card company of unusual activity at a gas station, a telephone company, and a chicken restaurant. The card was then cancelled.R1's face sheet dated 7/17/2025 documents that R1 is an [AGE] year-old resident with diagnoses including but not limited to: Heart failure, heart valve replacement, hypertension, neoplasm of the breast, and hearing loss.R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a Brief Interview for Mental Status (BIMS) score of 15/15, which suggests that R1 is cognitively intact.On 7/17/2025 at 12:20 PM, R1 said, I found out that I did not have my credit card when my wallet was found outside the building, and someone found it and returned it to me. I did not call the police, but someone in the building called the police. I never had any personal items lost or taken in the past; this is the first time. I just trusted that the facility would hire good people to care for us.Police report number obtained and read: R1, stated that her wallet was stolen while she was at a retirement home. She advised that the incident occurred earlier in the day at approximately 0900 hours. According to R1, she had purchased on Amazon using a credit card and then placed her wallet back into her purse. At the time, R1 was in a room where only one employee was present. R1 later discovered her wallet outside on the street near the facility. Upon recovering it, R1 found that only her credit card was missing; all other contents remained inside. R1 described the suspected employee as a female Black, possibly between 30 to [AGE] years old, but could not provide any further identifying information.On 7/17/2025 at 3:06 PM, V1 (Administrator/Abuse coordinator) said, the postman found a wallet outside the facility and brought it in on 6//27/2025 and gave it to the front desk. Someone took the wallet of R1, and I don't know who took it. R1 said that she was ordering something and requested the assistance of a staff member to read her card. I don't know who that staff was. R1 said that on the same day, her card went missing. R1 doesn't leave the building. R1 described that an African American stout female assisted her with care that day. V14 Certified Nursing Assistant was assigned to care for R1, but I cannot accuse anyone. V14 was prohibited from coming to work in the facility, and I called the staffing agency and notified them of the incident. The police were called, and they started the investigation, came to the building, checked the video footage, and said that they know V14 but don't have any criminal background for her. V1 said, Taking residents' belongings is considered misappropriation, that is why I reported it, and I implemented that all the agency staff read and sign the abuse policy before they start the shift. The new process started on 6/28/2025, and we are offering a safe for residents who want to keep their valuables here, but we are recommending that families bring their valuables home. On 7/17/2025 at 3:34 PM, V1 provided policy titled, Abuse Prevention Program, review date 10/15/2022. Which reads in part (but not limited to),Policy: The facility of Covenant Living Communities and Services has zero tolerance for any form of abuse, neglect, or exploitation.Exploitation or Misappropriation of Resident Property- the deliberate misplacement, exploitation, or wrongful, temporary use of a resident's belongings or money without the resident's consent. Examples include theft of the resident's television, false teeth, clothing, jewelry, money, using the resident's telephone, etc. E. Immediate reporting of suspected abuse or crimeI. If you reasonably suspect that crime, abuse, neglect, or mistreatment, including injuries of unknown source and misappropriation of the resident's property, has occurred against a resident or a person receiving care at the name of campus, you must report that allegation to the State Survey Agency.

Based on observation, interview, and record review, the facility failed to follow contact isolation protocols by failing to place correct signage on resident room door regarding isolation precautions, they failed to ensure that a resident on contact isolation was placed in an appropriate room, and they failed to ensure that a resident's breathing mask was properly contained in accordance with infection control protocols. These failures applied to two (R3 and R4) of six residents reviewed for infection control. Findings include: R4 is [AGE] years old and have resided at the facility since 2019. Face sheet listed the following medical diagnosis among others: Local infection of the skin and subcutaneous tissue, abnormal posture, personal history of malignant neoplasm of the bladder, dependence on renal dialysis, methicillin resistant staphylococcus aureus infection as cause of disease classified elsewhere, methicillin resistant staphylococcus aureus infection unspecified site, pressure induced deep tissue damage of contagious site of back, buttock, and hip etc. 04/22/25 1:15AM, R4 was observed in his room with another resident (R3) sharing the same room. An enhanced barrier precaution signage was noted at the door and some personal protective equipment (PPE) was noted behind the door. R4 was sitting on a motorized wheelchair, awake, alert and oriented and stated that he is doing okay. R4 said that he gets wound care at night, they do it when he lays down and it is okay with him. R4 added that he gets breathing treatment and normally does it himself after breakfast or before, he also takes his two inhalers after the breathing treatment. A breathing machine was noted at the bedside with the breathing mask open to air and not contained. R4 was observed during the survey moving around the facility in his motorized wheelchair and even attended the resident council meeting held by a surveyor. R3 is [AGE] years old, admitted to the facility on [DATE], medical diagnosis includes, but not limited to presence of urogenital implants, unspecified dementia, unsteadiness on feet, type 2 diabetes, retention of urine, presence of aortocoronary bypass graft, etc. Review of facility list for residents on isolation dated February 2025 listed R4 as being on contact isolation for MRSA of wound and C-diff. Isolation was started on 2/24/2025 and the end of isolation was documented as on going. Care plan initiated 3/1/2025 states: R4 is on contact isolation d/t MRSA/ C diff. Goal states: R4 will remain in his room while on contact isolation. Staff will adhere to the contact isolation while providing care to prevent spread of infection. Interventions include Provide education to the resident as able and family on Contact Isolation protocol and rationale, Staff to wear PPE's when providing care per facility protocol. Mask/eye shield as indicated for potential splashing/contamination, etc. 04/23/25 11:30AM, V3 (infection prevention nurse) said that R4 used to be on contact isolation for MRSA of the wound, he went to the hospital and the isolation was discontinued at the hospital. Resident is just on enhanced barrier precaution now, the admitting nurse called the hospital who told her that that the isolation was discontinued, V3 told the nurse to document the information from the hospital. Review of resident's record did not show any physician order or progress note stating that R4's contact isolation was discontinued. Surveyor requested for the information from facility, but none was provided. On 4/24/2025 at 12:16PM, V2 (DON) said that they could not fid any documentation that R4's contact isolation was discontinued. V2 added that R4 should have been in a private room and the contact isolation precaution sign should have been placed on the door. V2 also said that residents breathing masks should be contained after use. Transmission based precaution policy provided by V2 (DON) revised September 2022, states that transmission-based precaution are initiated when a resident develop signs and symptoms of transmissible infection, arrives for admission with symptoms of infection or have laboratory confirmed infection ad is at risk of transmitting the infection to other residents. Under contact precaution, the policy states in part that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact precautions are also used in situations when a is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen even before a specific organism has been identified. Under discontinuation of isolation the policy states that transmission-based precaution is discontinued when it is determined that the resident's condition no longer indicate such precaution. Residents remains on appropriate transmission-based precaution until discontinued by the attending physician or the infection preventionist.

Based on interview and record review the facility failed to transfer a resident in a safe manner. This failure resulted in R1 falling and sustaining lacerations to her right foot 3rd, 4th and 5th toes requiring sutures. Findings include: R1's Physician Order Sheet dated 1/25 show R1 has diagnoses that include chronic kidney disease, spinal stenosis and chronic pain. R1's careplan with initiated date of 9/26/24 show R1 is alert and oriented and able to verbalize her needs. High risk for falls due to impaired balance. R1's careplan under transfers show, - (R1) requires staff assistance with transfer due to decreased physical mobility, She requires staff assistance with transfers using sit to stand lift. She is at times able to transfer from wheelchair/c to bed with staff using gait belt and pivot. She can verbalize if she feel weak to pivot and can use sit to stand lift. The Facility Reported Incident (FRI) sent to the state agency as initial and final dated 12/16/24 show, blood was noted on the floor next to resident's bed by facility staff. It was observed that the resident (R1) had a laceration to her right foot. Resident sent to the emergency room (ER), received three sutures. Resident returned to the facility the same day in good condition. During the investigation, R1 stated the CNA lost her grip which caused her to slide down in the wheelchair. Foot rests were in place at the time. Laceration is clean and healing. Resident remains in good condition, medicated for pain as needed. The facility Incident Report dated 12/16/24 shows, Type-fall. Place-residents room. Activity-transfer. Injury-leg, right toe lacerations to 3 of her toes on the 3rd toe, 4th toe and 5th toe. Lacerations measuring: 1.5 centimeters (cm) x 0.8 cm, 1 cm x 2 cm, 2 cm x 0.6 cm, distal part of the 3rd, 4th, and 5th right toes. On 1/3/24 at 10:45 AM, R1 was in her room, sitting in her wheelchair alert and pleasant. R1 said last month she fell and injured her right foot's 3rd, 4th and 5th toes. R1 said the staff (V7, Certified Nursing Assistant) got her up from bed to put her in her wheelchair. I don't think she realized how heavy I was, she was not able to lift me, she was sort of grabbing me and I ended falling on the floor. Then I saw blood, that was when I was told I needed to go to the hospital, I had sutures in my right toes. (showed this surveyor her right 3rd, 4th and 5th toes that was previously injured). V2 (Director of Nursing) who was with this surveyor said V7 (agency CNA) should have used the mechanical stand lift or ask another staff for assistance to transfer R1 safely. On 1/3/24 at 1:26 PM V5 (License Practical Nurse) said she was R1's nurse on 12/16/24. At around 6:45 AM, V7 (agency CNA) informed me that R1 was on the floor. V7 said she was transferring R1 by herself from bed to wheelchair but R1 ended on the floor. V5 (LPN) said she went to check on R1 who was lying on the floor with blood noted on the floor. Body assessment done that show R1 sustained lacerations to her right leg toes. (3rd, 4th and 5th toes). Later R1 was sent to the hospital to have her lacerations to be sutured. R1's Hospital Emergency Department (ED) note dated 12/16/24 show, diagnosis-lacerations of right foot .evaluated in the ED today for lacerations to right foot Your lacerations were repaired in the ED with sutures. Remove sutures in 7 days. On 1/3/24 at 2PM both V1 (Administrator) and V2 (Director of Nursing) said V7 (agency CNA) does not work at the facility any longer. V7 had been on do not return status. The facility policy on Safe Lifting and transfers dated July 2017 show, In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.