Inspection Reports for
Crouse Community Center Inc
101 South Street, Morrisville, NY, 13408
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jan 13, 2025
Visit Reason
The survey was a recertification annual inspection conducted from 1/6/2025 to 1/13/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination regarding alarm use, failure to notify physicians of significant weight loss, breaches of resident privacy, inadequate investigation of injuries of unknown origin, incomplete care plans, inadequate pain management documentation, and improper pharmaceutical practices including borrowing controlled medications.
Deficiencies (7)
F 0561: The facility did not ensure resident self-determination for use of chair alarms; Resident #4's informed consent was not obtained and care plan was not revised to include chair alarm use.
F 0580: The facility failed to notify the physician of significant weight loss for Resident #30 and did not document timely communication or follow-up.
F 0583: The facility did not protect resident privacy by posting dietary status (NPO) outside rooms of Residents #3 and #13, visible to the public.
F 0610: The facility failed to thoroughly investigate a skin tear injury of unknown origin for Resident #25, did not notify the medical provider timely, and did not rule out abuse or neglect.
F 0656: The facility did not develop and implement comprehensive care plans for Residents #43 and #57; Resident #43 lacked medication-specific interventions for anticoagulants and Resident #57 lacked care plan for chair alarm use.
F 0697: The facility failed to provide adequate pain management documentation for Residents #30 and #53; pre and post pain evaluations were not completed and pain associated with transfers was not addressed.
F 0755: The facility did not provide pharmaceutical services to meet resident needs; Resident #88's oxycodone was borrowed to administer to Residents #1, #208, and #209 without proper prescriptions or medication availability.
Report Facts
Weight loss percentage: 13.1
Weight loss percentage: 8.9
Medication borrowing count: 20
Medication borrowing count: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Provided interview regarding resident rounds and alarm use for Resident #4. | |
| Licensed Practical Nurse #5 | Provided interview about alarm use policies and Resident #4's care. | |
| Registered Nurse Unit Manager #6 | Interviewed about alarm use, privacy violations, and medication borrowing. | |
| Director of Nursing | Interviewed regarding alarm use, weight loss notification, privacy, injury investigation, and medication borrowing. | |
| Dietetic Technician #12 | Provided nutritional assessments and noted failure to notify physician of weight loss for Resident #30. | |
| Registered Nurse Unit Manager #7 | Responsible for weight change reviews and injury investigation for Resident #25. | |
| Certified Nurse Aide #16 | Observed Resident #30 and commented on pain and assistance needs. | |
| Licensed Practical Nurse #2 | Documented skin tear on Resident #25 and commented on pain management and transfer pain for Resident #53. | |
| Certified Nurse Aide #25 | Reported Resident #53's complaints of pain during transfers. | |
| Registered Nurse Unit Manager #23 | Discussed care plan responsibilities and chair alarm use for Resident #57. | |
| Director of Education/Infection Control Nurse #22 | Discussed care plan and chair alarm use for Resident #57. | |
| Pharmacist #42 | Discussed emergency medication supply system and medication borrowing risks. | |
| Medical Director | Interviewed about injury investigations and medication borrowing policies. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Jan 13, 2025
Visit Reason
Inspection identified multiple level 2 standard health and life safety code deficiencies related to quality of care and safety features, all corrected by follow-up dates.
Findings
Inspection identified multiple level 2 standard health and life safety code deficiencies related to quality of care and safety features, all corrected by follow-up dates.
Deficiencies (17)
Develop/implement comprehensive care plan
Investigate/prevent/correct alleged violation
Notify of changes (injury/decline/room, etc.)
Pain management
Personal privacy/confidentiality of records
Pharmacy srvcs/procedures/pharmacist/records
Self-determination
Cooking facilities
Corridor - doors
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Emergency lighting
Fire drills
Gas and vacuum piped systems - inspection and
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 23, 2023
Visit Reason
The inspection was a recertification survey conducted from 3/20/23 to 3/23/23 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate injuries of unknown origin for a resident, failure to complete a significant change assessment for a resident enrolled in hospice, failure to implement a comprehensive care plan for a resident, and failure to maintain safe and functional equipment such as a wheelchair for a resident.
Deficiencies (4)
F 0610: The facility failed to ensure injuries of unknown origin were thoroughly investigated for Resident #13. No incident report, assessment, or notification to medical provider and family was completed for a bruise found on 3/17/23.
F 0637: The facility failed to complete a Significant Change Minimum Data Set assessment for Resident #27 after enrollment in hospice services on 2/24/23.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident #15, who was observed not wearing prescribed blue heel boots for 4 days to prevent skin breakdown.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment for Resident #15 by allowing use of a wheelchair in disrepair with worn padding, frayed tape, and protruding foam.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Documented bruise on Resident #13 and involved in injury reporting |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Observed Resident #13's bruise and involved in injury assessment and reporting |
| RNS #7 | Registered Nurse Supervisor | Notified of Resident #13's bruise but did not assess |
| ADON | Assistant Director of Nursing | Interviewed regarding injury reporting procedures and deficiencies |
| SW #12 | Social Worker | Documented hospice referral for Resident #27 |
| CNA #14 | Certified Nursing Assistant | Interviewed about Resident #15's care plan and wheelchair condition |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Interviewed about Resident #15's care plan and wheelchair condition |
| LPN #13 | Licensed Practical Nurse | Interviewed about Resident #15's care plan compliance |
| Director of Rehabilitation Services | Interviewed about wheelchair condition for Resident #15 |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 9
Date: Mar 23, 2023
Visit Reason
Inspection found multiple level 2 standard health and life safety code deficiencies related to quality of care and safety, all corrected by follow-up dates.
Findings
Inspection found multiple level 2 standard health and life safety code deficiencies related to quality of care and safety, all corrected by follow-up dates.
Deficiencies (9)
Comprehensive assessment after signifcant chg
Develop/implement comprehensive care plan
Investigate/prevent/correct alleged violation
Safe/functional/sanitary/comfortable environ
Corridor - openings
Fire alarm system - testing and maintenance
Gas and vacuum piped systems - information an
Hazardous areas - enclosure
Illumination of means of egress
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 29, 2021
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards, including pressure ulcer care and resident safety related to elopement risks.
Findings
The facility failed to ensure appropriate pressure ulcer care for one resident by not following proper infection control procedures during wound dressing changes. Additionally, the facility did not provide adequate supervision and environmental controls to prevent elopement for another resident with known exit-seeking behavior, resulting in safety risks.
Deficiencies (2)
F 0686: The facility did not ensure residents with pressure ulcers received treatment consistent with professional standards. Specifically, a licensed practical nurse failed to change gloves and mixed clean and unclean wound care supplies during a dressing change for Resident #70.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Resident #38 who had known exit-seeking behaviors and eloped through an unlocked courtyard door. The courtyard doors were unlocked during the day and alarms did not sound when opened.
Report Facts
Residents Affected: 1
Residents Affected: 1
Safety check intervals: 15
Safety check intervals: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in pressure ulcer care deficiency for improper glove use during dressing change |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Interviewed regarding proper dressing change procedures |
| Infection Control RN #6 | Infection Control Registered Nurse | Interviewed regarding wound care and infection control procedures |
| RNS #14 | Registered Nurse Supervisor | Named in resident elopement incident and investigation |
| Housekeeper #13 | Housekeeper | First staff to observe Resident #38 after elopement incident |
| LPN #11 | Licensed Practical Nurse | Interviewed about safety check documentation for Resident #38 |
| CNA #10 | Certified Nursing Assistant | Interviewed about Resident #38 wandering and safety checks |
| Director of Education/IC RN | Director of Education/Infection Control Registered Nurse | Interviewed about safety check documentation and resident care |
| Director of Nursing | Director of Nursing | Interviewed about elopement risk screening and safety check documentation |
| CNA #19 | Certified Nursing Assistant | Interviewed about Resident #38 wandering and safety check communication |
| LPN #15 | Licensed Practical Nurse | Interviewed about Resident #38 wandering and door exit attempts |
| RNS #17 | Registered Nurse Supervisor | Interviewed about Resident #38 wandering and safety checks |
| Director of Maintenance | Director of Maintenance | Interviewed about courtyard door visibility and locking practices |
| Administrator | Administrator | Interviewed about courtyard door locking and alarm system |
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