Crest View Lutheran Home

Inspectors wroteBased on interview, and document review, the facility failed to protect a resident's right to be free from physical abuse for 1 of 3 residents (R1) reviewed for abuse. This resulted in actual harm when R2 struck R1 in the face resulting in swelling to the eyebrow, nose fracture, and a laceration to the lip that required hospitalization. The facility had implemented actions on 3/16/26 to prevent recurrence prior to the survey; therefore, the citation was issued at past non-compliance (PNC).

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs, and care plan to eliminate/reduce the risk of an accident during a bed bath for 1 of 3 residents (R1). This resulted in actual harm to R1 when staff repositioned her without a drawsheet and with too much force caused R1 to slide out of the bed to the floor. As a result, R1 sustained a fracture to the left femur that required surgical intervention. The facility had implemented actions to prevent reoccurrence prior to the survey on 12/8/25, therefore, the citation was issued at past non-compliance.

Inspectors wroteBased on observation, and interview, the facility failed to maintain the appearance and integrity of the walls in the memory care unit, including the medication room, to provide for a surface which could be cleaned and homelike appearance. The facility failed to maintain furniture which was clean, with intact, washable surfaces in the memory care day room. The facility failed to ensure room blinds were kept in a state of good repair to provide visual privacy in 3 of 4 resident rooms (rooms [ROOM NUMBER]) observed to have blinds in disrepair. The facility failed to ensure shower rooms were kept in good repair in 3 of 4 shower rooms toured during survey. These concerns had potential to affect any resident who used the three shower rooms. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to assure medications were properly labeled with the correct dose for 1 of 1 resident, (R20), who received a liquid medication during observation of medication administration. The facility also failed to assure over the counter (OTC) medications were dated when opened in 2 of 3 medication carts reviewed. The facility also failed to consistently date, and/or remove inhalers which were beyond the dates of recommended use, in 1 of 3 medication carts. In addition, the facility failed to remove vaccines which had either an illegible label, or lacked a label, in 2 of 2 medication rooms reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for dining, assuring food was offered to residents and assistance was received as needed in a timely manner. This had the potential to affect all 18 residents served in the memory care dining room.

Inspectors wroteBased on observation, interview and document review the facility failed to appropriately store nutritional supplements in two of two medication rooms reviewed during medication room storage observation. This had the potential to impact all residents who routinely received, or may received nutritional supplements on those units. In addition, the facility failed to ensure the ice machine was in good repair. This had the potential to affect residents, staff and visitors who obtained ice from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the kitchen was kept clean, sanitary and in good repair which had the potential to affect all residents, staff and visitors who received meals from the kitchen.

Inspectors wroteDuring observation and interview, the facility failed to ensure hand rails were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rights were maintained for 2 of 4 residents (R15 and R43) reviewed for dignity. Findings Include: R15R15's annual Minimum Data Set (MDS) dated [DATE], identified R15 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure parameter mattress (a type of mattress cover or encasement designed to create a gentle barrier around the edge of the bed, preventing falls) was not used in a manner to restrain resident while in bed for 1 of 1 resident (R4) reviewed for restraints.

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 3 residents (R43) reviewed for hospitalizations.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and implemented to include post-traumatic stress disorder (PTSD) triggers and interventions for 1 of 1 resident (R47) who had a diagnosis of PTSD.

Inspectors wroteBased on interview, observation and document review, the facility failed to update the care plan with specific interventions for 1 of 1 resident (R43) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide supervision, cues, and hands on assistance as needed to eat during meals, and with snacks, for 1 of 1 residents (R5) whom required staff direction for eating.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently meet the identified needs and preferences of 3 of 4 residents (R7, R19, and R76), reviewed for activities.

Inspectors wroteBased on observation, interview and document review the facility failed to promote and provide positioning assistance to 1 of 3 (R72), residents reviewed for positioning. Further, the facility failed to implement interventions 1 of 3 residents (R19) reviewed for vision.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids/devices were available to maintain hearing/communication needs for 1 of 1 resident (R76) reviewed for hearing. Findings Include: R76's quarterly MDS dated [DATE], identified R76 had severe cognitive impairment and required assistance with all ADL's. R76's diagnoses included non-traumatic brain dysfunction (brain damage that occurs due to internal factors, rather than external trauma), Alzheimer's disease with late onset, diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), anxiety disorder and depression. MDS indicated R76's hearing was moderate difficulty needed hearing aids. R76's care plan, reviewed 6/26/25, identified R76 had an alteration in communication related to hard of hearing and had two hearing aids. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed for residents who wished to smoke for 1 of 1 resident (R19) reviewed for smoking.

Inspectors wroteBased on interview and document review, the facility failed to properly assess and obtain orders for 1 of 1 resident (R43) reviewed for use of oxygen therapy.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R47) resident reviewed who had a history of past traumatic experiences.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure results of complaint investigations were available for review. This had the potential to affect all 78 residents residing in the facility, as well as family, visitors, and staff.

Inspectors wroteBased on interview and document review the facility failed to develop a policy, without conflicting information, consistent with federal requirement for reporting allegations of abuse to the state agency immediately but no later than two (2) hours. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently perform hand hygiene with change of gloves while performing blood glucose monitoring. Additionally, the facility failed to clean the community glucose monitor after use. This had the potential to affect any of the 14 residents on the memory care unit who may require blood glucose checks, either routine or emergent. Further, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms (Evergreen and Willow) and 1 of 1 units (Aspen and [NAME]) reviewed. In addition, the facility failed to properly handle and store clean laundry and linens. This had potential to affect all 78 residents within the care center.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide medically related social services of clothing and shoes for 1 of 1 resident (R1) reviewed for clothing. This resulted in harm when R2 displayed a lack of engagement in social activities and diminished level of participation in social interactions because she felt unable to leave her room due to a lack of proper and adequate clothing and shoes.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement the comprehensive care plan for 2 of 3 residents (R1, R2) reviewed for pressure ulcer prevention.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure individualized activities were provided for 1 of 1 resident (R1) reviewed for activities. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE], understood others and made herself understood., had moderate cognitive impairment, sometimes felt socially isolated, and did not exhibit behaviors. R1's Interview for Activity Preferences identified it was somewhat important to her to do her favorite activities, go outside to get fresh air when the weather was good, participate in religious services or practices, and listen to music she liked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one of one resident (R1) reviewed for physician orders. The facility received an order for a cervical collar to be used by two licensed staff; one to stabilize the resident's cervical spine and one for care of the cervical collar and were observed not following the orders.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow the care plan for 1 of 3 residents (R1) reviewed for abuse, when R1 was transferred and personal cares were provided by one staff when the care plan directed two female staff for all cares and transfers.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure food was labeled, dated, and stored to prevent foodborne illness. The facility failed to maintain clean vents over clean dishes. In addition, the facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all residents and staff who eat from the main kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement transmission-based precautions (TBP) for 1 of 1 resident (R17) reviewed who had emesis and loose stools while there was an outbreak of confirmed rotavirus and norovirus cases (contagious viruses which causes vomiting and diarrhea and are spread through feces) in the facility, failed to implement TBP for 1 of 1 residents (R65) who had a history of MRSA (methicillin resistant staphylococcus aureus - a potentially dangerous type of staph bacteria that is resistant to certain antibiotics), and failed to implement enhanced-barrier precautions for 2 of 2 residents (R385, R53) and failed to ensure proper handling of linens observed for infection prevention practices.

Inspectors wroteBased on interview and document review, the facility failed to provide the resident with a written discharge notice and basis for discharge; and failed notify the Ombudsman Office for Long-Term Care (OOLTC) of transfers and discharges for 1 of 1 resident (R82) reviewed for facility initiated discharge, which has the potential to affect all residents who transfer or discharge.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 (R19) resident observed with medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a call light was accessible for 1 of 1 resident (R385) reviewed for call light accessibility.

Inspectors wroteBased on interview and document review, the facility failed to include a physician documented basis for discharge for 1 of 1 resident (R82) reviewed for facility initiated discharge.

Inspectors wroteBased on interview and document review the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment to ensure cognitive and mood needs were evaluated and addressed for 1 of 1 resident (R334) reviewed for comprehensive MDS assessment accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physical devices were assessed and reassessed for continued appropriateness for 1 of 1 resident (R66) who had perimeter mattresses placed on their bed as a fall intervention.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's preferred activities were available for 1 of 1 resident (R36) reviewed for activities.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a do-not-resuscitate (DNR) order was accurately reflected throughout the medical record for 1 of 26 residents (R81) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R81 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when the facility obtained a physician's order for R81 to have a full code status even though the physician order for life sustaining treatment (POLST) indicated do not resuscitate (DNR). The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:15 p.m. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the quality assessment and assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in identifying and implementing appropriate action plans to correct quality deficiencies identified during previous surveys related to infection control, respiratory therapy and advanced directives resulting in deficiencies identified during this survey. In addition, the facility failed to review and/or revise policies affecting resident care periodically to ensure the policy/practice was still appropriate. This deficient practice had the potential to affect all 95 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident ice packs were stored separately from resident food in 2 of 4 nursing unit resident refrigerators. This had the potential to impact 73 residents residing on those units. Furthermore, the facility failed to ensure current standards of practice for glove use and handwashing were being followed for 1 of 1 resident (R31), when staff provided personal care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055) was provided to 2 of 3 residents (R91, R94) who continued to reside in the facility upon termination of Medicare A benefits.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain a walking program for 1 of 1 resident (R25) reviewed for activities of daily living (ADL) decline.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents were appropriately assessed post dialysis treatments and resident's health status communicated between dialysis center and facility for 1 of 1 resident (R90) reviewed for dialysis.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure ongoing assessments for safety and appropriate use of grab bars were completed for 1 of 1 resident (R11) who was observed to have grab bars affixed to their bed.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure accurate administration of initial COVID-19 vaccination series for 1 of 5 residents (R56) reviewed for COVID-19 vaccinations who received an incorrect initial COVID-19 vaccine.

Inspectors wroteBased on interview and document review, the facility failed to monitor side effects for 1 of 3 (R43) residents reviewed for anticoagulation (blood thinner) therapy.

Inspectors wroteBased on interview and document review, the facility failed to assess appropriateness of antibiotic use was completed for 1 of 1 residents (R60) who was prescribed oral antibiotics for a skin infection.