Crestview Healthcare Residence

Inspectors wroteThese failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 1 resident (Resident #1) reviewed for quality of care. Resident #1 had an appointment on or around 4/28/2025, for an MRI (a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body) for his prostate, and the facility failed to schedule the appointment and failed to place the necessary preop instructions needed for the procedure in PCC; subsequently Resident #1 missed his appointment twice. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect and promote the resident's right to a dignified existence and self-determination for 1 of 6 residents (Resident #1) reviewed for resident rights, in that: The facility failed to allow Resident #1 to maintain her smoking privileges. This failure could place residents at risk of feelings of poor self-esteem, anxiety, decreased quality of life and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen and 3 (nourishment room [ROOM NUMBER], 2, and 3) of 3 nourishment rooms reviewed for food safety and sanitation. 1. The facility failed to conduct temperature checks and/or complete the temperature check logs for refrigerators and freezers in the facility's kitchen and nourishment rooms. 2. The facility failed to conduct temperature checks and/or complete the temperature check log form for the 3-compartment sink in the facility's kitchen. 3. The facility failed to ensure the refrigerators and freezers in the facility's nourishment rooms were cleaned, sanitized, and in proper working condition. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 2 medication carts reviewed for pharmaceutical services. The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift. This failure could place residents at risk of drug diversion and could result in diminished health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #19 and Resident #88) reviewed for infection control. 1. The facility failed to ensure hand hygiene was implemented appropriately when CNA-A provided perineal and catheter care for Resident #19. 2. The facility failed to ensure hand hygiene was implemented appropriately when LVN-B provided wound care to Resident #88. These deficient practices could place residents at-risk of the spread of infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the residents' right to be free from neglect for 1 (Resident #3) of 6 residents reviewed for neglect. The facility failed to ensure Resident #3's safety and well-being when RN D and CNA E left her in the Shower Room in soiled undergarments unattended for approximately 30 minutes. This failure could result in residents receiving injuries and possible skin breakdown. Noncompliance existed from 02/13/2025 to 02/18/2025, but the facility corrected the noncompliance through inservicing, one on one inservicing and the QAPI process.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #13) reviewed for accidents hazards and supervision, in that: On 01/23/2025 Resident #13 was transferred by CNA C using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #13 pivoted into the chair, her leg did not pivot well, and the knee twisted and popped which later caused swelling and pain to the left knee. This failure could lead to injury or death to residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services within the facility with reasonable accommodation of the residents' needs and preferences for 4 of 12 residents (Resident #23, Resident # 57, Resident #83, and Resident #45) reviewed, in that: The facility failed to: 1) Ensure a call light was within reach for Resident #23 2) Ensure a call light was within reach for Resident #57 3) Ensure a call light was within reach for Resident #83 4) Ensure a call light was within reach for Resident #45 This deficient practice placed residents at risk for delayed care and a decreased quality of life. Findings Include: 1) Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a Safe/Clean/Comfortable/Homelike Environment for three of six residents (Resident #57, Resident #23, and Resident #66). The facility failed to ensure a safe/clean/comfortable/ homelike environment for Resident #57, Resident #23 and Resident #66. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and placing residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings Include: 1) Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 1 (medication cart #1) of 4 medication carts reviewed for medication storage that. Medication cart # 1 was left unattended and unlocked. An undated, opened and accessed, vial was stored in the medication room [ROOM NUMBER] refrigerator. The medication room [ROOM NUMBER] refrigerator temperature was not monitored daily. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage and sanitation, in that: 1) The facility failed to ensure the kitchen prep area was free of personal items. 2) The facility failed to ensure food and beverages in refrigerator #1 and #2, and the freezer, were covered, labeled, and dated. These deficient practices could cause cross contamination and place residents at risk of foodborne illness.

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 29 of 29 ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) residents by 5 ( DON,ADON,LVN C, CNA D and CNA E) of 5 staff passing lunch trays that were reviewed for infection control and transmission-based precautions policies and practice, in that: The facility failed to ensure DON, ADON, LVN C, CNA D and CNA E did not grab resident's cups by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. This failure could place residents at risk for infection through cross contaminations of pathogens.

Inspectors wroteBased on record review and interview, the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #300 and Resident #301), reviewed for changes made to charges or other items and services. The facility failed to ensure that Resident #300 and Resident #301 were provided a SNF ABN (SNF ABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that: 1. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 2. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 3. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not discarded by use by/expiration date. 4. [...]

Inspectors wroteFACILITY Medication Storage and Labeling Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #37) reviewed for PASARR Level 1 screenings. The facility did not send the correct PASARR Level 1 screening to the local authority for Residents #37. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview, observation, and record review the facility failed to assure that menus were developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines for 4 of 8 residents reviewed for specialty diets. - [NAME] A was not following menu and recipes for specialty diets. This failure could prevent 70 residents from receiving their recommended daily nutritional intake.