Crestmont North Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to ensure resident that care plan meetings were held quarterly as required. This affected three (Residents #23, #48, and #66) of three residents reviewed for care plan meetings. The facility census was 62.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that a resident with severe cognitive impairment was not permitted to sign financial documents. This affected one resident (Resident #66) out of three residents reviewed for protection and management of personal funds. The facility census was 62.

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on Self-Reported Incident Review (SRI), facility timeline, and facility policy review, medical record review and interview, the facility failed to ensure resident narcotic and anti-anxiety medications were not misappropriated. This finding affected three (Residents #26, #56 and #67) of four residents reviewed for misappropriation. The facility census was 62.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure Resident #66's skin was assessed per the physician's orders. This finding affected one (Resident #66) of three residents reviewed for wound care. The facility census was 62.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to ensure medications for Resident #4 were administered as ordered. A total of 27 medications were administered with two medications omitted, for a total of 29 medication opportunities. Three medication errors were identified, resulting in a medication error rate of 10.34%. This deficiency affected one resident (Resident #4) of four residents reviewed for medication administration. The facility census was 62.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure the residents were provided routine and timely notices when their resident's funds exceeded the Supplement Security Income (SSI) resource limit for one person. This affected four (Resident #17, #29, #31 and #47) of seven residents reviewed for personal funds. The facility census was 68. Findings Include: 1. Review of the Authorization to Manage Resident Funds dated 01/20/21 revealed Resident #47 authorized the facility to manage her money. Review of the spend-down notice dated 04/05/25 revealed Resident #47 had $9,060.24 in her account that needed to be spent down some of the money, so she did not exceed the limit, or it would have to be submitted to Medicaid. The spend down notice was signed by Resident #47 on 04/05/25. [...]

Inspectors wrote3. Review of the medical record for Resident #1 revealed an admission dated [DATE]. Diagnoses included schizoaffective disorder, dementia and severe morbid obesity. Review of the physician orders dated [DATE] revealed Resident #1's advance directive was Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) (would receive standard medical care until experiencing a cardiac or respiratory arrest). The comprehensive care plan for Resident #1 dated [DATE] did not address Resident #1's advance directives. Review of the DNR Identification Form for Resident #1 revealed the top portion was filled out with Resident #1's name, address, birthday and signature of legal guardian. [...]

Inspectors wroteBased on record review, policy review, and staff and resident interview, the facility failed to ensure care plans were completed accurately to include fall interventions and behaviors exhibited by the resident. This affected two (Residents #9 and #58) of 21 residents reviewed for care plans. The facility census was 68.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure falls were investigated thoroughly. This affected one (Resident #9) of three residents reviewed for falls. The facility census was 68.

Inspectors wrote2. Review of medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat) and hypotension. Review of undated care plan revealed Resident #23 was at risk for impaired gas exchange related to malignant neoplasm of the oropharynx requiring a tracheostomy. Intervention included ensure trach ties were always secured, give humidified oxygen as prescribed, observe for changes in level of consciousness, observe respiratory rate, depth, and quality, and suction as needed. The undated care plan revealed Resident #23 had alteration in cardiac status. Interventions included administer oxygen as ordered and monitor vitals as indicated. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had impaired cognition. He had a tracheostomy and had oxygen. [...]

Inspectors wrote3. Record review of Resident #26 revealed she was admitted to the facility 03/21/25. Diagnoses included PTSD. Her care plan identified potential for behaviors related to PTSD including accusatory behaviors, but did not clarify what caused the PTSD or potential triggers or situations to avoid. Review of her progress notes, care plan, assessments, and psychiatry service notes revealed no documentation of the cause, triggers, or ongoing effects of the PTSD. Interview with the Director of Nursing (DON) on 05/29/25 at 9:35 A.M. confirmed Resident #26's medical record did not contain an assessment for trauma informed care related to the resident's of PTSD and did not address the needs of the trauma survivor by minimizing triggers and/or re-traumatization. [...]

Inspectors wroteBased observation, staff interview, record review, and review of facility policy, the facility failed to ensure Resident #23 was free of significant medication errors. This affected one (#23) of five residents observed for medication administration. The facility census was 68.

Inspectors wroteBased on observation, staff interview, record review, facility policy review, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to initiate and use enhanced barrier precautions (EBP) for residents with indwelling medical devices during high contact resident care activities. The facility also failed to ensure staff followed infection control procedures during catheter care. This affected two (#12 and #23) of two residents reviewed for EBP and one (#12) of one resident reviewed for catheter care. The facility identified nine residents on EBP and two residents with catheters. The facility census was 68.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure comprehensive care plans were initiated for all resident care needs. This affected four residents (Resident #7, Resident #11, Resident #25, and Resident #48's) out of five residents reviewed for comprehensive care plans. The facility census was 56.

Inspectors wroteBased on record review and interviews, the facility failed to ensure comprehensive care plans were revised to reflect new fall interventions. This affected three residents (Resident #7, Resident #25, and Resident #48) out of five residents reviewed for comprehensive care plans.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were timely assessed for risk of falls to ensure appropriate interventions were in place to prevent falls. This affected three residents (Resident #11, Resident #21, and Resident #48) out of five residents reviewed for accident hazards.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were administered medication per physician orders. This affected two residents (#7 and #48) out of three residents reviewed for medication administration.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to maintain the kitchen area in a clean and sanitary condition. This had the potential to affect 57 of 58 residents who resided in the facility. The facility identified one resident (#30) who did not receive food from the kitchen.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment for residents, employees and visitors. This affected all 58 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 18 residents (Residents #18, #51, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220 and #221.) The census was 58.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to develop individualized care plans for Residents #14, #35, #37, #42 and #48 related to smoking, wounds, and pain. This affected five of 24 resident care plans reviewed.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure the designated smoking area was maintained in a safe manner affecting all 23 residents (Residents #1, #2, #3, #8, #10, #11, #12, #14, #16, #20, #21, #23, #27, #31, #35, #37, #44, #45, #48, #51, #54, #156, #207) that smoked at the facility. The facility also failed to ensure Resident #31 was properly supervised and smoking materials were maintained by nursing as identified in her care plan and/or smoking assessment affecting one resident (Resident #31) out of three residents (Residents #31, #35, and #37) reviewed for smoking. The facility census was 58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon discharge from the facility. This affected one resident (#221) of two residents reviewed for conveyance of funds. The facility census was 58.

Inspectors wroteBased on interview and record review the facility failed to ensure reasonable care was taken for the protection of resident property from loss or theft. This affected two residents (Resident#14, and #34) out of three residents (Resident #14, #32, and #34) reviewed for misappropriation of personal property. The facility census was 58.

Inspectors wroteBased on interview and record review the facility failed to ensure a Patient Assessment and Resident Review (PASRR) was completed as required for two residents (Resident #34 and Resident #37) out of two residents (Resident #34 and #37) reviewed for PASRR. The facility census was 58.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician acted upon the recommendations by the pharmacist for Resident #42. This affected one of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure a bottle of Dakin's (diluted bleach solution) was secured in Resident #30 and Resident #48's room located on the secured unit. This affected two (Residents #30 and #48) out of seven Residents (#8, #15, #28, #29, #30, #48, and #256) reviewed for unsecured medications and/ or treatment supplies in their rooms. This had the potential to affect 18 residents (Resident #11, #12, #13, #16, #20, #24, #25, #27, #30, #32, #40, #48, #49, #50, #51, #52, #54, #156, #256) on the secured unit that were independent with ambulation and/or locomotion or unsecured medication was located in their room.

Inspectors wroteBased on review of Medicare Beneficiary Notices and interview, the facility failed to provide complete Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) forms for two residents (#35 and #45) and provided the Medicare Notice of Non-Coverage and the SNFABN to Resident #56 when these forms were not appropriate for a voluntary end of coverage. This affected three of three residents reviewed for SNFABN.

Inspectors wroteBased on observation of trayline, review of a test tray, interview, record review and policy review the facility failed to ensure meals were served at palatable temperatures. This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure clean and sanitary nourishment areas. This affected all 49 residents receiving food from the kitchen. The facility census was 49.

Inspectors wroteBased on interview and review of beneficiary notices, the facility failed to ensure Residents #38 and #53 were provided skilled nursing facility advanced beneficiary notices upon being cut from skilled services and remaining in the facility and failed to provide 48 hours notice of the end of skilled services to Resident #53 to initiate an appeal if desired. This affected two of three beneficiary notices reviewed (#3). The facility census was 49 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive appropriate and assessed restorative services. This affected three residents (#9, #27 and #43) of four residents (#9, #27, #31 and #43) reviewed for range of motion out of 45 residents #2, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53 and #204) identified as receiving one or more restorative services. The facility census was 49 residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the humidifier had enough water to bubble and failed to ensure oxygen equipment was kept clean. The affected six residents (#6, #35, #38, #41, #43 and #55) of eight residents (#6, #18, #35, #38, #41, #43, #49, and #55) whose oxygen concentrators were not maintained. The facility census was 49.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with written notice of transfer. This affected one resident (Resident #41) of one resident reviewed for hospitalization. The facility census was 49 residents.

Inspectors wroteBased on record review and interview, the facility failed to submit a resident discharge assessment for a resident who was discharged to the hospital and did not return to the facility. This affected one resident (Resident #1) of one residents reviewed for resident discharge assessments. The facility census was 49.

Inspectors wroteBased on record review and interview, the facility failed to coordinate care regarding resident pre-admission screen and resident review (PASRR). This affected one resident (Resident #19) of three residents reviewed who had a level two mental illness or intellectual disability. The facility census was 49.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care plans were revised as needed. This affected one (Resident #51) of 23 residents reviewed for care plans. The facility census was 49 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #48 received treatment and care in accordance with the comprehensive person-centered care plan. This affected one, Resident #48, of three residents (#21, #35 and #48) reviewed for non-pressure skin impairment. The facility census was 49 residents.

Inspectors wroteBased on record review and staff interview the facility failed to ensure daily posted nursing staff information was updated timely. This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observations and interviews the facility failed to ensure smoking areas were maintained in a clean manner, and cigarette butts were disposed of in approved containers. This had the potential to affect the 12 Residents who smoke. The facility census was 49.