Crestview Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 40. The facility did not provide the requested job description for the Dietary Manager. Review of the DM's personnel file showed: -Date of hire 10/04/2023; -No certification for food service management or dietary manager was found. During an interview on 02/24/25 at 11:32 A.M., the DM said: -He had been the DM for six months; -He has worked as a dietary aide, but does not have any managerial experience; -The facility was getting ready to start on his DM training; -He has not completed his/her DM's course. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She would expect the DM to know all regulations related to the kitchen; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and to maintain the kitchen in a sanitary manner. The food facility census was 40. Review of the facility's policy, General Dish Room Sanitation, dated, May 2015, showed: -Dish rooms must be maintained in a clean and sanitary condition; -Items must be stored inverted (upside down) to prevent contamination. Review of the facility's policy, Cleaning Floors, dated, May 2015, showed: -Floors will be cleaned after every meal; -The dietary department must keep the floors of the kitchen free from soil and clutter. Review of the facility's policy, Refrigerators and Freezers, dated, May 2015, showed: -The floors of walk in refrigerators and freezers should be swept and mopped weekly; -Food should be stored at least 6 inches above the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) which had the potential to affect all residents who resided at the facility. Furthermore, the facility failed to follow infection control guidelines when one staff administered eye drops for one resident (Resident #23) without the use of gloves. The facility census was 40. The facility did not provide a Legionella policy. 1. Review of the facility's records showed they did not have an implemented water management plan. During an interview on 2/25/25 at 3:50 P.M. the Administrator said: - The facility had not had a maintenance employee for over a month; - The maintenance employee would assess the building water systems; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 40. The facility did not provide an Antibiotic Stewardship policy. The facility did not provide Antibiotic Stewardship Program documentation that should include: - Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic; - Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; [...]

Inspectors wroteBased on interview and record review, the facility failed to hire an Infection Preventionist (IP). The facility census was 40. The facility did not provide and Infection Preventionist policy. Review of the Infection Control binder showed it did not include an IP training or certification. During an interview on 2/25/25 at 3:00 P.M. the Administrator said; - The Director of Nursing (DON) said he/she completed the IP course, but had not produced certification indicating the DON had completed the task; - The facility did not have a current IP; - She knew the facility was suppose to have an IP.

Inspectors wroteBased on interview and record review, the facility failed to ensure three Certified Nursing Assistants (CNAs), of 7 sampled staff had a minimum of 12 hours of documented yearly in-service education (which should have included abuse, neglect, and dementia cares). This had the potential to affect all of the residents. The facility census was 40 residents. The facility did not provide a policy for education or and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No other education/in-service records; -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No other education/in-service records; -CNA F, Date of Hire 9/17/01, Annual Education Quiz completed 6/6/24. No other education/in-service records; -Nurse Aide A, Date of Hire 10/3/24, no education/in-service records. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that Advance Directives for three Residents (Resident #3, #19, and #32) were lawful when a Designated Power of Attorney signed an out of hospital Do Not Resuscitate (OHDNR) form prior to two residents (Residents #3 and #19) being declared incapacitated to sign. Additionally, the facility failed to ensure that one resident (Resident #32) had 2 physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. There were 12 total sampled residents. The facility census was 40. The facility did not provide the requested policy on Advance Directives. 1. Review of Resident #3's Quarterly minimum data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/07/25, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the walls, hallways, ceilings and floors in a clean and homelike environment. Furthermore the facility failed to ensure furnishings were in good repair and temperatures in the dining room remained at a comfortable level. This had the potential to effect all residents. The facility census was 40. The facility did not provide a policy for cleaning, maintenance of the facility and care of furnishings, or temperatures. 1. Observations on 2/19/25 at 10:30 A.M., showed: -Main dining room thermostat read 61 degrees Fahrenheit; -All doors to the main dining room were closed; -Window blinds in the dining room and attached hallways were drawn; -White blankets were rolled up and placed at the threshold of the doors leading to the courtyard. Observation on 2/19/25 at 11:22 A.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 12 sampled residents (Residents #28, #92, #11, #15, and #36). The facility census is 40. Review of the facility provided, undated, policy Care Planning showed the facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the facility provided, undated policy Care Area Assessments showed Care Area Assessments (CAAs) will be used to develop individualized care plans. 1. Review of Resident #28 Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 1/3/25, showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities to meet the needs for three of 12 sampled residents (Resident #6, #28, and #92). The facility did not have an employee responsible for the activity program and did not have a system to inform all residents in advance of available activities, including location and time, which had the potential to impact all residents in the facility. The facility census was 40. The facility did not provide a policy regarding Activities. Review of the facility provided Resident Right policy, dated April 2006, showed: -The resident has the right to a dignified existence and self determination. A Facility must protect and promote the rights of each resident. --Right to participate in activities. --Resident Rights are to be fully respected and adhered to. The facility did not provide an activity calendar. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development and/or deterioration of pressure ulcers (PU) for four of 12 sampled residents (Resident #28, #92, #11, and #15). Facility staff failed to ensure the physician was notified of the PU and treatment obtained timely for one resident (Resident #92). The facility failed to ensure PU precautions were adhered to for one resident, resulting in the resident developing a PU (Resident #15), and failed to thoroughly assess and document assessments and measurements, and update the physician to obtain treatment orders for a new pressure ulcer for (Resident #92) and when a PU deteriorated for (Resident #11). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate staffing to reposition and provide incontinence care for three residents who were at risk for pressure ulcers (Residents #28, #92, and #15), failed to answer the call light in a timely manner resulting in incontinence for one resident (Resident #92), and failed to provide two showers per week to one resident (Resident #28) as a standard of care. Additionally, the facility failed to ensure enough staff were in the dining room to assist residents who required assistance during meals, resulting in one staff member going between two tables to assist eight residents who needed nutritional assistance. The facility census was 40. The facility did not supply a policy on staffing. Review of staff schedules showed: -January 14th: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The census was 70. The facility did not provide a policy on staffing. Observation and interview on 02/23/25 at 9:44 A.M., showed: -Licensed Practical Nurse (LPN) B was the Charge Nurse; -He/She was the only nurse at the facility; -He/She was the only nurse the previous day; -There was no RN in the facility. Review of the daily staffing sheets showed no RN on: July 2024: 6th, 7th, 20th, and 21st; August 2024: 3rd, 4th, 17th, and 18th; September 2024: 1st, 14th, 15th, and 24th; No staffing sheets provided for October; November 2024: 16th, 17th, 23rd, 28th, 29th, and 30th; December 2024: 1st, 6th, 7th, 8th, 14th, 15th, 21st, 22nd, 24th, 26th, 27th, 28th, 29th, 30th, and 31st; January 2025: 4th, 5th, 11th, 12th, 15th, 18th, 19th, 25th, and 26th; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides had a yearly performance review, with resulting individually based education plans, for three nurse aides employed longer than 12 months. The facility census was 40. The facility did not provide a policy for education, and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide (CNA) D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No competency assessment and training plan. -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. -CNA F, Date of Hire DOH 9/17/01, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. During an interview on 02/27/25 at 12:28 PM, the Quality Assurance Registered Nurse said trainings and tracking were completed by nurse leadership. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff prepared foods in a way to meet the needs of individual residents, when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency and failed to ensure the mechanical soft diet contained meat that was ground and easy to chew. This affected two residents who had orders for a pureed diet (Residents #6, and #15) and one resident (Resident #3) who had an order for a mechanical soft diet. The facility census was 40. Review of the facility's policy titled, Types of Diets, dated, May 2015, showed: -Mechanical soft diet is a regular diet modified using chopped or ground meat; -Puree diet foods are blended to mashed potato consistency or altered to meet the needs of the residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident #15) received necessary assistance with activities of daily living (ADL). Resident #15 was dependent on a mechanical lift and two staff for transfers and required assistance with all his/her ADL's. Facility staff failed to reposition the resident every two hours and to provide timely perineal care. The facility census was 40. The facility did not provide a policy for timing and repositioning and perineal care for a resident's. 1. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of three sampled residents (Resident #7) when staff failed to obtain a physician ordered blood transfusion in January 2025 for an anemic resident in a timely manner. The blood transfusion was not carried out until fourteen days after it was ordered. The facility census was 43. Review of facility policy titled Physician Orders, undated, showed physician's orders must be signed by the physician and dated when such order was signed. Review of facility policy titled Lab Reporting Guidelines, undated, showed: -Guidelines will be followed to ensure that lab recommendations are completed timely; -Nurse will received the lab for a lab draw; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure a resident (Resident #15) with limited range of motion (ROM) to his/her left hand received treatment to prevent further ROM loss. The facility census was 40. Review of the facility's undated policy titled, Range of Motion, showed: - ROM was suppose to be provided to prevent contractures from becoming worse; To maintain normal ROM; - The facility staff can provide passive range of motion (PROM) for residents that cannot complete it themselves; To simulate circulation. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant weight loss for one of 12 sampled resident's (Resident #15), when the facility did not provide the resident with his/her physician ordered Magic Cup (a nutritional supplement that contains additional calories and protein for persons experiencing involuntary weight loss) daily at lunch. The facility census was 40. The facility did not provide a significant weight loss policy. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture) and dysphagia (difficulty swallowing); [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to store nebulizer machine masks in a bag when not in use for two residents (Resident # 15 and #38) of 12 sampled residents. The facility census was 40. The facility did not provide a policy for nebulizer masks. 1. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), bronchitis, and weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of Halo side rails (a circular bed rail used for repositioning and bed mobility); failed to document assessing risk versus benefits of Halo side rail use; failed to obtain informed consent for the use of Halo side rails prior to installation; and failed to complete ongoing assessments to ensure the side rails were appropriate for use for one resident, and do not pose an entrapment risk (Resident #6), in a sample of 12 residents. The facility census was 40. Review of the facility provided, undated, Bed Rails policy showed: -Once a bed rail observation is completed the facility will review the associated risks and benefits with the resident and/or resident representative. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the resident census, and actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 40. Observations on 02/24/25 at 2:50 P.M., 02/25/25 at 9:51 A.M., and 02/26/25 at 1:31 P.M., showed posted staffing dated as February 10, 2025. During an interview on 02/27/25 at 12:28 PM, Quality Assurance Registered Nurse (QA RN) said: -He/She was the Interim Director of Nursing (DON) December 20, 2024 through February 3, 2025. -Daily staffing numbers are posted by the night nurse, if it is not done, the DON should pick it up and try to catch it up to the correct day; -He/She expected the DON ,or the person the DON assigned, to make sure it is done. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to prevent compromised skin integrity for two of 4 sampled residents, (Resident #1 and Resident #2) when the staff did not alert the charge nurse when Resident #1 had open areas to the back of his/her upper right thigh and did not ensure the resident was turned to his/her side after cares. The staff did not ensure Resident #2 was turned to his/her side when the resident was found to have dark red buttocks after cares were provided. The facility census was 39. Review of the undated pressure ulcer care and prevention policy showed: - The purpose of the policy was to prevent and treat further breakdown of pressure ulcers; - Observe the resident's skin. Areas that remain reddened after pressure has been relieved is at risk for developing into a pressure ulcer; - Use pressure relieving devices; [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure staff stored food for residents in a sanitary manner. Specifically, the facility failed to label, date, and discard left over food. This had the potential to affect 43 of 43 residents who received nourishment from the facility kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to maintain a water management program to minimize the risk of Legionella in the facility's water supply. This had the potential to affect all 43 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition. The deficiency affected 2 of 3 ovens, 1 of 2 freezers, and 1 of 1 food steamers in the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician when blood pressure medication was held for 1 (Resident #41) of sampled 3 residents reviewed for notification of change. Specifically, the facility held Resident #41's blood pressure medication on three occasions when the resident's blood pressure (BP) was outside the physician-ordered parameters, with no notification made to the physician.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure residents' rooms were maintained in a homelike manner for 2 (Resident #13 and Resident #17) of 43 total residents who resided in the facility at the time of survey. Specifically, Resident #13 and Resident #17's closet doors were missing.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of a psychotropic medication for 1 (Resident #34) of 6 sampled residents reviewed for unnecessary medications. Specifically, the facility failed to develop a care plan addressing Resident #34's use of antipsychotic, antidepressant, and antianxiety medications, including information regarding target behaviors and monitoring for potential side effects of the medications.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide showers as scheduled/preferred for 2 (Resident #34 and Resident #37) of 5 sampled residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on interview, record review, review of an American Heart Association (AHA) blood pressure publication, and facility policy review, the facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for 1 (Resident #32) of 5 sampled residents whose medication regimen was reviewed. Specifically, on 04/06/2024 when Resident #32's blood pressure (BP) met the criteria for hypertensive crisis as defined by the AHA, nursing staff did not re-evaluate the resident or consult with the resident's physician.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to keep medication secure for 1 (Resident #30) of 1 sampled resident reviewed for accident hazards and failed to thoroughly investigate a fall and failed to implement fall interventions to prevent falls for 1 (Resident #28) of 1 sampled resident reviewed for falls.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to monitor and record fluid intake for 1 (Resident #28) of 3 sampled residents reviewed for nutrition, who had a physician's order for a fluid restriction.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to communicate with a dialysis provider for 1 (Resident #28) of 1 sampled resident reviewed for dialysis services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents' medication regimen was free of unnecessary medications for 2 (Resident #34 and Resident #41) of 6 residents reviewed for unnecessary medications. Specifically, the facility failed to specify the target behaviors for which antipsychotic medications were prescribed, failed to monitor for potential adverse drug reactions, and failed to complete behavior tracking for Resident #34 and Resident #41 to ensure continued use of an antipsychotic was indicated.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccine to 1 (Residents #8) of 5 residents reviewed for vaccinations.

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing an antibiotic stewardship program that promotes the appropriate use and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The facility census was 57. The facility did not provide a policy and procedure regarding an antibiotic stewardship program. During an observation and interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - She had completed the online training for an Infection Preventionist but was not able to locate it; - She had been in the DON position for about 6 months. - She did not know where the previous DON had placed the Antibiotic Stewardship book; - She looked through several different binders and finally found the Antibiotic Stewardship book but it did not have anything in it; - She said it should be updated and current. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' dignity when they served the residents their meals on Styrofoam plates, bowls, cups and plastic silverware which affected all residents who participated in meal service. (Resident #17, #19, #45, #49) and all residents who ate in the facility and failed to ensure residents' personal information was kept confidential The facility census was 57. Review of the facility's policy for meal service sequencing, dated May 2015, showed, in part: - Meal service sequencing is used in a facility to assure that all residents at a table are served at the same time; - The policy did not specify what type of dinnerware should be used. 1. Observation on 8/2/22 at 12:00 P.M., showed: - The staff were passing out packages of plastic silverware with a napkin and a package of salt and pepper in it; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide residents receipts for each transaction from the Resident Trust Fund (RTF) and failed to maintain signed authorization from residents/representatives to manage resident funds. This affected three of 15 sampled residents (Residents #13, #38, and #40). The facility census was 57. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, revised 8/4/22, did not show information regarding providing a receipt to the resident for each transaction. 1. Review of Resident #38's ledger showed the following: - Withdrawal of $20 on 7/11/22; - There was an initial from the resident showing he/she received the funds but there was no copy that a receipt had been provided. 2. Review of Resident #40's RTF records included the following: - Withdrawal of $10.00 on 1/19/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had an Out of Hospital Do Not Resuscitate form (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, (CPR), if the resident's breathing stopped or if the resident's heart stopped beating) for two of 15 sampled residents (Resident #49 and #42) and failed to ensure the code status matched the physician's order sheet (POS) and the resident's face sheet for two of 15 sampled residents, (Resident #43 and #21). The facility census was 57. Review of the facility's undated policy for advance directives, showed, in part: - The facility will respect advance directives in accordance with state law; [...]

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for residents. The facility census was 57. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on [DATE] at 10:52 A.M. the resident said: - His/her floor was embarrassing. Staff do come in and mop it but it was beyond mopping. He/she had even been on his/her hands and knees trying to scrub it; - He/she did not walk around bare foot on his/her own floor because it was dirty. Observation of the resident's room showed: - 1 inch () by 4 inch hole in the wall behind the door; - Large brown discoloration on the floor under the resident's bed and around the toilet and brown around the base of the toilet. 2. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop and implement comprehensive person-centered care plans consistent with resident rights that include measurable objectives and timeframes to meet the resident's medical, nursing and psychosocial need for five of 15 sampled residents (Residents #37, #40, #20, #42, and #51). The facility census was 57. Review of the facility's undated Comprehensive Care Plan policy, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. - A well developed care plan will be oriented to: Preventing avoidable declines in functioning or functional levels. Managing risk factors to the extent possible or indicating the limits of such interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the professional standards of following doctors orders regarding medications. This affected one of fifteen sampled residents (Resident #1). The facility also failed to ensure they followed their procedures for sending medications with one sampled resident (Resident #40) when he/she left the faciity on pass causing him/her to miss multiple doses of evening medications and failed to follow physicians' orders regarding monitoring and recording percentage of meals eaten which affected one sampled resident (Resident #4). Facility census was 57. Facility failed to provide a policy addressing following physicians' orders. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for two of 15 sampled residents, Resident #13 and Resident #21. The facility census was 57. Review of the facility's undated policy for baths or showers showed included: - The purpose was to maintain skin integrity, comfort and cleanliness. 1. Review of Resident #13's care plan, revised 6/1/22 showed: - The resident required assistance with ADLs; - The resident needed assistance of one staff in the shower. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/22, showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff used proper transfer techniques to reduce the possibility of accidents or injuries when transferring one of fifteen sampled residents (Resident #46) when they failed to use the proper lift sling during a transfer with the mechanical lift and when staff failed to ensure the low air loss mattress was set on the correct setting for Resident #37. The facility census was 57. Review of the facility's policy for Hydraulic Lift (Hoyer Lift) undated, showed, in part: Guidelines 1. Open lift to widest point and set the brakes. 2. Roll resident on his/her side away from you. Avoid unnecessary exposure. 3. Place widest seat part under the residents' buttocks and thighs so that the lower edge of the seat is under knees. 4. Place narrow part of the seat just above the small of the residents back. 5. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to discard expired medications and biological's stored within the medication cart and medication rooms, failed to ensure staff did not place food in the medication refrigerator in the [NAME] medication room, failed to ensure staff dated opened medications and food containers and disposed of expired food, failed to record refrigerator temperatures in the [NAME] medication room, failed to ensure there were no loose pills in the medication cart. This affected three of 15 sampled residents (Resident #43, #45, #46) and had the potential to affect all residents within the facility. The facility census was 57. Review of the facility's undated policy for storage of medications, showed, in part: - All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. [...]

Inspectors wroteBased on interviews, observation and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 57. 1. Record review of the facility's dietary staffing scheduled showed the facility did not currently employ a qualified dietary manager. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -There is not currently a dietary manager. -He/she is doing their best to manage the kitchen and cook meals. -If he/she needs direction or has a question, he/she goes to the administrator. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -The facility does not currently have a dietary manager and has been without one for quite some time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals in a timely manner and maintain the cleanliness of the kitchen. This has the potential to affect all residents of the facility. The facility census was 57. During the entrance interview on 8/02/22 at 9:42 AM, the administrator said: -Meal times are as follows: -Breakfast at 7:15 A.M. - Lunch at 12:00 P.M. - Dinner at 5:15 P.M Observation of the facility on 8/2/222 at 9:45 A.M., showed: -No meal times are posted in the facility. Observations of meal service in the facility showed: -8/2/22 The first resident was served lunch at 12:35 P.M. -8/3/22 The first resident was served breakfast at 7:28 A.M. -8/4/22 The first resident was served lunch at 12.41 P.M. During an interview on 8/2/22 at 11:23 A.M., Resident #25 said: -He/she never knows when meals are going to be served. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to assure they prepared foods in the appropriate manner when staff did not follow a recipe for pureed foods and prepared pureed food more than 90 minutes before the scheduled meal services. The facility census was 57. The facility did not provide a policy regarding pureed foods. Observation of a pureed test tray on 8/3/2022 at 12:22 P.M. showed: -Pureed Chicken: 132.5 degrees Fahrenheit. The texture is smooth but has little flavor. -Potatoes: 143.4 degrees Fahrenheit. The consistency is very thick, a spoon stood up. They are very sticky in the mouth and difficult to swallow, with a bitter flavor. -Green Beans 114.2 degrees Fahrenheit. They are lukewarm with a thick gel-like texture, with little flavor. -Bread Stick: 97.7 degrees Fahrenheit. It felt cold in the mouth, with a very sticky consistency. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 57. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed: -The Dietary Department will store dry food and supplies according to facility guidelines and state regulations. -The storeroom must be neat and orderly. Shelving is kept clean and free of rust and chipped paint. -Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing open products. -Open boxes are to be effectively re-sealed. Bulk crackers, cereal, cookies, pasta, etc., are to be stored and properly labeled in sealed containers. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) plan and implement appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 57. 1. When the QAPI plan was requested, the Administrator provided a copy of a Template that had not been completed to be individualized to the facility. When the Administrator provided the plan she acknowledged it was a template. 2. Review of the facility's morning meeting notes dated 4/18/22 included the following: - The QAPI items included: o Meal intake not being done; o Meal intake sheets re-done for each side; o Certified Medication Technician (CMT) will record on paper log including room trays; o CMT/designee will chart. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 57. The facility did not provide a policy regarding the QAA committee. 1. Review of the facility's QAA committee records showed the medical director had not attended a QAA committee meeting since January 2022. During an interview on 8/5/22 at 3:43 P.M. the Administrator said: - QAA meetings were held monthly and the Medical Director came quarterly except when he/she had COVID-19; - The Medical Director did not attend in April due to having COVID-19, he/she did not attend in May because it conflicted with his/her schedule and did not attend in June, he/she did not respond to a text. The facility did not have a meeting in July.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure staff followed their policy to provide a Two-Step Purified Protein Derivative (PPD) Tuberculosis (TB, a highly contagious lung disease) skin test for three sampled residents (Resident #13, #45, #49) and failed to follow their policy that all staff would receive a Two-Step PPD TB skin test upon hire. This effected 6 of 10 staff members sampled. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain records and assist one of 15 sampled residents (Resident #40) with obtaining prescription eyeglasses. The facility census was 57. The facility did not provide a policy regarding vision/eye glasses. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/24/22, included the following: - Date admitted [DATE]; - Cognitively intact; - Indicated corrective lenses (contacts, glasses, or magnifying glass) for vision. Review of the resident's care plan dated 7/5/22 showed staff did not include any information regarding the resident's vision or need to wear corrective lenses. During an interview on 8/3/22 at 8:18 A.M. the resident said: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure correct installation, use, and maintenance of bed rails, assess the residents for entrapment, review risks and benefits with the resident and/or resident representative and obtain informed consent prior to installation, and obtain physician orders for. This affected four of 15 sampled residents (Resident #1, #5, #15, and #46). The facility census was 57. Facility did not provide requested copies of policy regarding halo and half rail entrapment assessments, informed consents, and orders for side rails or halos. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to post accurate and current nurse staffing information, per shift, on a daily basis. The facility census was 57. The facility did not provide a policy for posting nurse staffing information. 1. Observation on 8/2/22 at 10:35 A.M., and at various times from 8/3/22 to 8/5/22, showed three different sheets with the nurse staffing posted on a clipboard on the wall across from the South Nurses' station, showed: - The first sheet was dated 12/2/22. Census was 64. Licensed staff: Registered Nurse (RN): days- one for eight hours; Licensed staff: Licensed Practical Nurse (LPN): 6:00 A.M. to 6:00 P.M.- two for 24 hours; 6:00 P.M. to 6:00 A.M. - two for 24 hours; Non licensed staff: Certified Medication Technician (CMTs), Certified Nurse Aides (CNAs) and nurse aides (NAs):days: 6:00 A.M. to 2:00 P.M.- three for 24 hours; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 30 opportunities for error which resulted in a medication error rate of 16.66%, which affected four of 15 sampled residents, (Resident #19, #46 and #6). The facility census was 57. Review of the facility's undated medication administration guidelines, showed, in part: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - The person administering the drugs must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data; [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to follow the physician's order for a renal diet when staff served the resident a regular diet which affected one of 15 sampled residents, (Resident #3). The facility census was 57. Review of the facility's policy for diet orders, dated May 2015, showed, in part: - Diet orders prescribed by the attending physician shall be reviewed monthly by Dietary Service Manager (DSM) to assure that the diet orders in the resident's chart and the dietary meal cards are accurate; - Nursing will be responsible for written notification to the dietary department of changes and additions in diets or eating habits. Review of the facility's policy for monthly diet audits, dated May 2015, showed, in part: - Monthly audits will be conducted by the DSM; [...]