Crestpark Stuttgart, LLC

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff performed proper hand hygiene when feeding residents, affecting 4 (Resident #18, #34, #36, #39) of 4 residents observed that required assistance with dining.

Inspectors wroteBased on observations, interview and record review the facility failed to keep heating and air ventilation clean to prevent potential airborne sickness for all 47 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was placed within reach of 3 (Residents #3, #4 and #5) of five sampled residents to enable them to call for assistance when needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident remained free of involuntary seclusion by staff and to ensure all other residents were protected from further involuntary seclusion for 1 of 1 (Resident #34) sampled residents who had been involuntary secluded. The Administrator was informed of the Immediate Jeopardy on 01/09/24 at 3:07 PM The failed practice had the potential to affect all 45 residents currently in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an effective fall prevention program that included adequate supervision and a system for residents who were at risk for falls was developed and consistently implemented, as evidenced by:failure to ensure anti-rollbacks were consistently monitored to ensure they were in working condition to prevent falls to the extent possible and reduce the potential for further injury from falls that did occur for 1 (Resident #148) of 1 (Resident #148) sampled Resident who sustained a fracture; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that meats were stored properly during the thawing process to prevent the potential for food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure expired food items were promptly removed from the stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure dented food cans were promptly removed or discarded to prevent the growth of bacteria, The facility failed to ensure interventions were in place to prevent possible cross contamination during the meal preparation to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 44 residents who received meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident trust account received interest monthly based on the balance in the account. This failed practice affected 2 Residents (Resident #198 and #23) of selected residents for review. This failed practice had the potential to affect all 20 trust accounts in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were reviewed and revised at least quarterly and / or when a resident ' s care needs changed, to include oxygen use for 1 Resident #23 of 4 (R #11, R #23, R #24, and R #28) sampled residents who had order for oxygen, failure to revise the plan of care to address the use of an antidepressant , an antipsychotic and falls to ensure staff were aware of the necessary care, assessments and services required for 1 sampled Resident #18 who had orders for an antidepressant and 1 Resident #20 sampled resident who had orders for an antipsychotic and 3 (Residents #18, #34 and #148) of 5 (Residents #18, #23, #34, #40 and #148) sampled residents who were at risk for falls.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation of the medication pass on 01/10/24 at 12:00 noon and 01/11/24 at 8 AM, record review and interview, the facility failed to ensure the medication error rate was less than 5% to prevent complications. Physician's Orders were not followed for 2 residents (Resident #14, and #148) of 6 residents whose medications were observed with 2 errors in 28 opportunities, resulting in a medication error rate of 7.14 %. The failed practice had the potential to affect all residents who received medications from the Medication Cart.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were not left in resident rooms for 1 of 1 (Resident #7) sampled residents who was observed with medication at the bedside, and failed to ensure the refrigerated narcotic medications in the medication storage room on the South Hall were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were not self-administered without a physician order and the interdisciplinary team (IDT) assessed the resident to determine safe administration for 1 (Resident #44) of 1 (Resident #44) sampled residents who had a box of medication tablets on the bedside table.

Inspectors wroteBased on record review and interview, the facility failed to ensure the requirements of their abuse prohibition policy were followed to protect 1 of 1 (Resident # 34) sampled resident from further abuse. This failure had the potential to affect all 45 residents in the facility. On 12/29/23 at 15:52 a 7734 and a 762 report was sent to DPSQA (Department of Provider Services and Quality Assurance) stating a X-employee had involuntary secluded Resident # 34. The staff member reporting for the facility documented a founded abuse (involuntary seclusion) based off a facility camera video. The Facility documented a founded abuse and immediately terminated the X-employee. The facility failed to notify the Certified Nurse's aide registry of the founded abuse . [...]

Inspectors wroteBased on an interview and record review, the facility failed to thoroughly prevent possible further abuse for 1 Resident (Resident #34) who was involuntarily secluded and possible abuse for all other 44 residents who reside in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure a residents ' s representative was notified in writing of resident's transfer to the hospital and/or discharge and failed to notify the Ombudsman required for 1 (Resident #34) of 7 (Residents #6, #14, #16, #23, #34, #46 and #148) sampled residents who were transferred to the hospital in the last three months.

Inspectors wroteBased on interview and record review, the facility failed to ensure the bed hold policy was provided for a transfer to the hospital for 1 Resident #34. This had the potential to affect 45 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nail care services were regularly provided to promote good personal hygiene and grooming for 1 (Resident #18) of 9 (Residents #6, #12, #18, #23, #30, #34, #35, #40 and #148) sampled residents who required assistance for nail care, as documented on a list provided by the Administrator on 1/12/24 at 12:27 pm.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen tubing was dated to reduce the potential for respiratory complications and failed to ensure Oxygen in Use signage was in place to promote oxygen safety for 1 (Resident #23) of 1 sampled resident that had orders for oxygen therapy. This failed practice had the potential to affect 4 residents that had physician orders for oxygen therapy.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with medication error rates. This failed practice had the potential to affect all 45 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; spices were used in a timely manner to maintain flavor and potency, foods were discarded prior to use by date, 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages, and kitchen ceilings and vents were cleaned to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 60 residents who received meal trays and beverages from the kitchen as documented on the Diet Physician's Orders Report provided by the Dietary Manager (DM) on 01/05/23.

Inspectors wroteBased on record review, and interview, the facility failed to ensure Physician Ordered medication with specific times were administered as ordered for 1 (Resident #13) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure floor tiles were maintained and free from cracks and chips and the glue leaking out from under and around the floor tiles was cleaned in a timely manner to maintain a clean homelike environment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a catheter drainage bag was maintained off the floor and in a privacy bag to prevent the risk for infection and to maintain resident dignity for 1 (Resident #257) of 2 (Residents #256 and #257) sampled residents who had physician orders for an indwelling catheter as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:07 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician ordered pain medications with specific times were administered as ordered for 1 (Resident #19) of 25 (Residents #5, #8, #13, #14, #16, #17, #19, #22, #23, #29, #30, #32, #34, #37, #40, #44, #45, #51, #55, #155, #255, #256, #257, #305 and #307) sampled residents with physician orders for as needed and scheduled pain medications.

Inspectors wroteBased on observation of the 4:00 PM medication pass on 01/05/23 with Licensed Practical Nurse (LPN) #1, record review, and interview, the facility failed to ensure a medication error rate of less than 5% was maintained. The facility had 5 medication errors in 25 opportunities, resulting in a medication error rate of 20%. This failed practice had the potential to affect 34 residents who received their medications from the South Medication Cart as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:33 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident preferences were followed to encourage the amount residents consume for 2 (Residents #30 and #37) of 27 (Resident #5, #8, #11, #13, #14, #16, #17, #19, #22, #23, #28, #29, #30, #32, #34, #37, #38, #40, #44, #45, #46, #52, #54, #255, #256, #257 and #307) sampled residents whose likes and dislikes were listed on their tray cards per the list provided by the Dietary Manager (DM) on 01/06/23, and failed to ensure pureed foods were prepared to maintain nutritive value for 4 (Residents #16, #17, #37 and #255) of 4 sampled residents who received pureed diets per the list provided by the DM on 01/05/23 at 8:20 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food items were blended to a smooth, lump-free, pudding-like consistency to minimize the risk of choking or other complications for residents who required pureed diets. This failed practice had the potential to affect 5 residents who received pureed diets as documented on a list provided by the Dietary Manager (DM) on 01/05/23.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all required members of the QAA (Quality Assessment and Assurance) committee attended required quarterly Quality Assessment and Assurance/Quality Assurance & (and) Performance Improvement (QAA/QAPI) meetings.

Inspectors wroteBased on observation, and interview, the facility failed to ensure all laundry was handled, transported, and processed wearing non-contaminated personal protective equipment (PPE) to help minimize the spread of potential contaminants.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the facility's Antibiotic Stewardship Program was maintained to include protocols to ensure residents who required antibiotics received the correct antibiotic to treat their infection and residents who did not require antibiotics did not receive them to prevent potential development of antibiotic-resistant organisms and facilitate each resident's ability to achieve their highest practicable level of physical well-being and failed to ensure antibiotic use was monitored for appropriateness and signs and/or symptoms of infection and effectiveness or ineffectiveness of antibiotic therapy were evaluated and documented for 3 (September, October, November 2022) of 4 months reviewed. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure staff avoided placing signs that included residents' care information regarding personal care needs, in areas where they could be seen by other residents or visitors, to promote dignity and respect for 1 (Resident #51) sampled resident. This failed practice had the potential to affect 60 residents as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/23/23 at 1:57 PM.

Inspectors wroteBased on observation of the 8:00 AM Medication Pass on 01/05/23, interview, and record review, the facility failed to ensure the Medication Administration Record (MAR) binder was closed when out of the Nurse's line of sight to maintain privacy of resident medical records. This failed practice had the potential to affect 10 residents who received their medications from the [NAME] Hall Medication Cart, as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:37 a.m.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident #45) of 1 sampled resident was free from physical restraints, as evidenced by her wheelchair being physically locked at the dining room table during lunch. This failed practice had to potential to affect 60 residents as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/03/23 at 1:57 PM.

Inspectors wroteBased on observation of the 8:00 AM Medication Pass on 01/05/23, record review, and interview, the facility failed to ensure a Medication Cart was locked to prevent accidents when the cart was out of the nurse's line of sight. This failed practice had the potential to affect 10 residents who received medications from the [NAME] Hall Medication Cart as documented on a list provided by the Director of Nursing (DON) on 01/06/23 at 9:37 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered diets were followed for 1 (Resident #29) of 6 (Residents #11, #23, #29, #32, #38 and #305) sampled residents who received mechanically altered diets per the Physicians Orders Report provided by the Dietary Manager (DM) on 01/05/23 at 8:20 AM.