Crestview Health & Rehabilitation

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to maintain accurate advance directive information throughout the medical record (Resident #50) and failed to have a signed Medical Orders for Scope of Treatment (MOST) form (Resident #13, Resident #74, Resident #84). This deficient practice affected 4 of 8 residents reviewed for advance directives (Resident #50, Resident #13, Resident #74, Resident #84).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to post cautionary signage outside of resident rooms that indicated the use of oxygen for 4 of 5 residents reviewed for respiratory care (Resident #2, Resident #55, Resident #87, and Resident #88).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired milk from 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator. This failure had the potential to affect all resident who eat food items prepared with milk and all residents who may ingest milk as fluid.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to assess a resident for the use of side rails prior to installation of bed rails on the resident's bed for 1 of 1 resident reviewed for side rails (Resident #4).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policy for Enhanced Barrier Precautions (EPB) when the Wound Nurse did not don (put on) a gown when performing wound care for Resident #44. The Wound Nurse also failed to perform change gloves and perform hand hygiene between wound sites. This occurred for 1 of 3 staff members observed for infection control practices (Wound Nurse).

Inspectors wroteBased on record review, resident, family, staff interviews and physician interviews, the facility failed to provide care in a safe manner when Resident #1 fell out of her bed during incontinent care. Resident #1 fell from an elevated bed position hitting her head and reported immediate pain in her right lower extremity upon falling. Resident #1 was subsequently transported to the Emergency Department via ambulance and was diagnosed with a right leg bone fracture. The facility also failed to provide a transfer in a safe manner when Resident #3's left eyebrow area was grazed with the mechanical lift during a transfer causing a skin tear. The deficient practice occurred for 2 of 3 residents reviewed for supervision to prevent accidents (Resident #1 and Resident #3).

Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to provide notification of an accident that resulted in Resident #3 being hit in the eye area with the mechanical lift handle causing a skin tear with a small amount of bleeding that required a wound covering to the resident's family member or resident representative for 1 of 4 residents reviewed for notification of change (Resident #3). Resident #3 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type II diabetes mellitus, atherosclerotic heart disease, and hypertension. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact. Review of Resident #3's electronic health record revealed Family Member #1 as his resident representative. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to implement care planned interventions by not placing a fall mat at the bedside of a resident with a history of falls. This occurred for 1 of 3 residents reviewed for care plan implementation (Resident #2). Findings Included: Resident #2 was admitted to the facility on [DATE] with Parkinson’s disease, epilepsy and dementia. A care plan revised on 5/7/25 indicated Resident #2 was at risk of falls related to cognitive impairment and impulsively attempting to get up without assistance at times. An intervention noted was to have a fall mat at the right side of the Resident’s bed. Review of the Quarterly MDS assessment dated [DATE] revealed Resident was cognitively intact. [...]

Inspectors wroteBased on record reviews, staff and Resident interviews the facility failed to protect a resident's (Resident #1) right to be free from abuse for 1 of 2 residents reviewed for abuse. Resident #2 was observed to cover Resident #1's mouth with his hand and pinch her nose using his thumb and index finger preventing her from breathing and causing her face to turn bright red and causing her to cry. Resident #1 stated she was afraid of Resident #2.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating. When there was an allegation of abuse, an initial report was not submitted to the State Agency, a 5 day investigation was not submitted to the State Agency, law enforcement and Adult Protective Services (APS) were not notified for 1 of 2 residents reviewed for abuse (Resident # 1).

Inspectors wroteBased on record review, staff, and Medical Director interviews the facility failed to ensure that Nurse Aides (NA) #3 and NA #4 knew how to respond to a medical emergency, and what role to assume during a medical emergency, and were certified in cardiopulmonary resuscitation (CPR) before participating in an emergency situation that resulted in performing CPR on Resident #70. On [DATE] Resident #70 went into sudden cardiac arrest and NA #3, NA #4, and NA #5 began CPR without the use of backboard which creates a hard surface for effective chest compressions that allows for adequate recoil (allow the chest to fully expand after compressions which pushes blood to vital organs). NA #3 and NA #4 were not certified in CPR for Healthcare Providers. [...]

Inspectors wroteBased on record reviews, resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect by failing to comprehensively assess a resident prior to moving the resident off of the floor following a fall with injury, seek immediate medical treatment or hospitalization to provide the necessary care and services to the resident, and provide effective pain management. On 5/27/24 Resident #40 sustained a fall with injury and a comprehensive assessment was not completed prior to transferring the resident to bed. The resident's left leg was observed internally rotated and shorter than the right leg. [...]

Inspectors wroteBased on observations, record review, staff, and Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. [...]

Inspectors wroteBased on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. [...]

Inspectors wroteBased on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. [...]

Inspectors wroteBased on record review, and staff and Resident Responsible Party (RP) interviews the facility failed to permit a resident (Resident #346) who required skill nursing services to return to the facility after being sent to the Emergency Department (ED) for evaluation on 07/08/2023 after he cut himself with a soda can. On 7/11/2023, Hospital Social Worker #1 contacted the Admissions Coordinator at the facility and informed her that Resident #346 had been cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued involuntary commitment (IVC) paperwork had been reversed. The facility did not accept Resident #346 for readmission. The hospital sent Resident #346's skilled nursing referrals to 50 other skilled nursing facilities and was unable to place Resident #346. [...]

Inspectors wroteBased on record review, staff, and Medical Director (MD) interviews the facility failed to ensure the MD was aware of resident care policies related to Cardiopulmonary Resuscitation (CPR) and Emergency Response. This deficient practice had the potential to affect all current residents in the facility.

Inspectors wroteBased on medical record review, staff interviews, and review of the facility's Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a resident's code status election was evident and accurately documented in the medical record for 6 of 6 (Resident #81, #83, #86, #68, #32, and #72) residents reviewed for advance directive.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to ensure a resident was administered oxygen per physician order, failed to clean oxygen concentrators, and failed to post cautionary and safety signs that indicated oxygen was in use for 3 of 3 residents reviewed for respiratory care (Residents #34, #40 and #45).

Inspectors wroteBased on observations, record reviews and staff interviews the facility failed to remove open and expired medications from 2 of 2 medication rooms (front and back medication rooms), failed to remove open and undated medication from 1 of 4 medication carts (300 hall medication cart), failed to secure medications in 1 of 4 medication carts (500/700 hall medication cart) and failed to secure a controlled substance medication under double lock (back medication room) in 1 of 2 medication rooms (back medication room) for review of medication storage.

Inspectors wroteBased on observations, record review, and staff and Pest Control Technician interviews the facility failed to maintain an effective pest control program as evidenced by the presence of flies on 1 of 7 hallways that affected resident rooms [ROOM NUMBERS].

Inspectors wroteBased on observations, record reviews, staff and Resident interviews, the facility failed to assess Resident #99 for the ability to self-administer medications for 1 of 1 Resident reviewed for self-administering medications.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating. When there was an allegation of abuse, an initial report was not submitted to the State Agency, a 5 day investigation was not submitted to the State Agency, law enforcement and Adult Protective Services (APS) were not notified for 1 of 2 residents reviewed for abuse (Resident # 1).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) for anticoagulants (blood thinners) and Pre-admission Screening and Resident Review (PASRR) information for 3 of 3 residents reviewed for accuracy of assessments (Residents #68, #196, and #346).

Inspectors wroteBased on record review and staff interviews the facility failed to develop and implement a person-centered care plan for a resident (Resident #346) with a history of suicidal ideation for 1 of 2 residents reviewed for development and implementation of a comprehensive care plan.

Inspectors wroteBased on record reviews and staff and Resident interviews the facility failed to update a care plan in the area of smoking for 1 of 1 resident reviewed for safe smoking (Resident #62).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide nail care for a dependent resident (Resident #40) and failed to provide a haircut for a dependent resident (Resident #78) for 2 of 10 dependent residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on record reviews and staff and Resident interviews, the facility failed to ensure physical therapy had established a safe means for nursing to transfer a resident prior to a resident (Resident #346) falling. The facility also failed to complete quarterly safe smoking assessments on a resident (Resident #62) for 2 of 7 reviewed for accidents.

Inspectors wroteBased on observations, record review, resident, and staff interview the facility failed to secure an indwelling catheter to prevent displacement and/or tension for 1 of 1 resident reviewed with a catheter (Resident #39).

Inspectors wroteBased on record reviews, Resident, staff, Physician Assistant, Medical Director and Consultant Pharmacist interviews the facility failed to limit the use of a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration for the PRN order to be extended beyond 14 days. The facility also failed to identify the lack of monitoring for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #32).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by having 3 medication errors out of 27 opportunities, resulting in a medication error rate of 11.11%. This affected 2 of 7 residents reviewed for medication pass (Resident #99 and Resident #51).

Inspectors wroteBased on record review, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to ensure accurate medical records when a resident's labs were incorrectly documented as collected for 1 of 1 resident (Resident #196) reviewed for medical record accuracy.

Inspectors wroteBased on record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to notify the provider that the ordered laboratory testing was not obtained for 1 of 2 residents (Resident #196) reviewed for notification of change.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to submit a 5-Day Investigation Report within the required timeframe to the State Agency for 1 of 1 resident reviewed for misappropriation of property (Resident # 247).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving and did not serve resident mechanically altered diets as ordered. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 9 of 9 residents (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26) for 3 of 3 meals. The staff also prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving for 91 of 91 residents. [...]

Inspectors wroteBased on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Immediate Jeopardy (IJ) began on 1/22/23 when residents with orders for a puree diet were not served 3 of 3 meals pureed to a smooth consistency. [...]

Inspectors wroteBased on record review, resident, staff interviews, the facility Administration failed to provide effective leadership and oversight to ensure effective systems were in place to have trained dietary staff available to prepare meals for residents. On 1/22/23 dietary staff did not arrive to work and the Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without serving 9 of 9 residents mechanically altered meals as ordered (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). This led to the high likelihood of aspiration or choking. The Immediate Jeopardy (IJ) began on 1/22/23 when systems were not in place to ensure trained dietary staff were available to prepare resident meals. [...]

Inspectors wroteBased on observations, record review, staff interviews and manufacturer's recommendations, the facility failed to follow manufacturer's recommendations for the sanitary operation of a high temperature dish machine. The facility also failed to have testing equipment to measure the chemical concentration of the dish machine and test the chemical concentration of the 3-in 1 sink prior to use. The facility also failed to remove expired food items stored for use and date leftover foods stored for use in 1 of 1 reach-in refrigerator, 1 of 1 walk-in refrigerator and 1 of 1 freezer. These practices had the potential to affect all residents.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure the area around the dumpster was free of debris and trash was contained in an enclosed receptacle for 2 of 2 dumpsters reviewed.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 06/25/21, the complaint investigation survey conducted on 06/15/22 and the focused infection control and complaint investigation surveys conducted on 04/29/22 and 12/07/20. [...]

Inspectors wroteBased on observations, record reviews, staff and resident interviews, the facility failed to provide dependent residents with showers (Resident #74, #183, #184 and #186) and failed to provide nail care (Resident #53) and failed to provide shaves (Resident#75) to 6 of 8 residents reviewed for activities of daily living.

Inspectors wrote3. Resident #22 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder with behavioral disturbances, depression, and Alzheimer's disease. A review of Resident #22's medical record revealed the last valproic acid (Depakote) level was obtained in June 2022 at a level of 3 which was low. A review of Resident #22's physician orders for 12/27/22 revealed orders for *Bupropion SR (antidepressant) 100 milligrams (mg) by mouth every day. *Valproic Acid (Depakote) (mood stabilizer) 250 mg/5 milliliters (ml) give 2.5 ml by mouth twice a day. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment and received 7 days of an antianxiety and antidepressant medication. A review of Resident #22's Psychiatry progress notes dated 12/27/22 revealed the reason for review was for Medical Management. [...]

Inspectors wroteBased on observations, record review, test tray, resident, and staff interview's the facility failed to provide palatable food that was appetizing in temperature and texture for 5 of 5 residents reviewed with food concerns (Resident #9, Resident #12, Resident #27, Resident #30, and Resident #35).

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide snacks when requested for 5 of 5 residents reviewed for resident council (Resident #9, Resident #12, Resident #27, Resident #30, and Resident #35).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to repair exposed damaged dry wall on 1 of 7 units (100 hall) and affected 5 of 12 occupied rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), the facility also failed to label personal care items located in shared bathrooms on 1 of 7 units (400 hall) and affected 3 of 6 shared bathrooms (Rooms #400/402, Rooms #401/403, and Rooms #405/407).

Inspectors wroteBased on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) in the areas of antipsychotic medications and indwelling catheters (Resident #43, Resident #22 and Resident #51) for 3 of 6 sampled residents.

Inspectors wroteBased on observations, record review, resident, and staff interview's the facility failed to implement a comprehensive care plan for a resident that wandered daily (Resident #43) and for a resident that verbalized a desire to lose weight (Resident #54) for 2 of 4 residents reviewed.

Inspectors wroteBased on observations, record review, resident, and staff interview's the facility failed to offer or apply a hand splint and palm guard as ordered for 1 of 3 residents reviewed for range of motion (Resident #48).

Inspectors wroteBased on observations, record review and Registered Dietician (RD), Medical Director (MD) and staff interviews the facility failed to provide a nutritional supplement as recommended by the Registered Dietician for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition (Resident 22).

Inspectors wroteBased on observations, record review, and staff interview's the facility failed to administer oxygen at the prescribed rate and failed to clean the oxygen concentrator filter for 1 of 3 residents reviewed for respiratory care (Resident #11).

Inspectors wroteBased on record reviews and staff, Psychiatric Nurse Practitioner, Nurse Practitioner and Medical Director interviews the facility failed to implement Psychiatry recommendations for psychotropic medication changes for 1 of 5 residents reviewed for unnecessary medications (Resident #22).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure there was an active order to initiate hospice services for 1 of 1 resident reviewed for hospice. (Resident #65)