Crestview Manor Healthcare

Inspectors wroteBased on observation and interviews, the facility failed to ensure meals were served at a palatable temperature at time of delivery. This failed practice had the potential to affect more than a minimal number of residents residing in the long term care facility. Census:

Inspectors wroteBased on record review, resident interview, and staff interviews, the facility failed to review Resident #40's care plan related to activities. This failed practice was found to be true for one (1) of 16 resident care plans reviewed during the long-term care survey process. Resident identifier: #40. Facility census: 69.

Inspectors wroteBased on resident interview, staff interviews, and record review, the facility failed to ensure activity programming was based on Resident #40's person centered care plan and personal interests. The facility had no documentation to reflect Resident #40 received activities of interests. This failed practice was found true for one (1) of two (2) residents reviewed for the care area of activities during the long-term care survey process. Resident identifier: #40 Facility census: 69.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure foods and equipment were stored under sanitary conditions. This failed practice had the potential to contaminate food-contact surfaces and cause foodborne illness. It also had the potential to affect more than a minimal number of residents who receive nutrition through the kitchen. These were random opportunities of discovery during the follow up kitchen tour. Census: 69.a) ObservationDuring a kitchen tour on 02/10/26, there was buildup noted in the bottom of the walk-in refrigerator. This was verified by corporate dietary #104 at 9:03 AM.There was a storage bin full of lids that had a brown sticky substance along the bottom of the bin. [...]

Inspectors wroteBased on record review, and resident, family, and staff interviews, the facility failed to provide the necessary supervision required to keep the environment for Resident #273 as free from accidents as possible, causing Resident #273 to have multiple falls in which she sustained multiple injuries. This was true for one (1) of three (3) residents reviewed for falls during the survey process. Resident Identifier: #273. Facility census: 69. Additionally, based on observation and resident and staff interview, the facility failed to keep the resident environment, over which it had control, was as free of accident hazards as possible, by leaving a potentially toxic substance on Resident #66's bedside table, making it accessible to other residents in the facility. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. [...]

Inspectors wroteBased on resident interview, staff interview and observation, the facility failed to ensure hot food were served at a temperature of at least 120 degrees Fahrenheit (F). This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #21, #50, #66, and #51. Facility Census 69.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to adequately resolve a grievance. This was true for one (1) of two (2) residents reviewed for personal property. Resident identifier: #27. Facility census 59.

Inspectors wroteBased on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASSAR) for Resident #3, after being diagnosed with major depressive disorder. Resident #51's PASSAR was not updated after being diagnosed with Post Traumatic Stress Disorder (PTSD) and Unspecified Psychosis. This was true for two (2) of two (2) residents reviewed for PASSAR's during the survey process. Resident identifiers: #3, #51. Facility census: 69.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately develop care plans related to capacity and one on one supervision. This failed practice was found true for (2) two of 17 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: #50 and #273. Facility census: 69. Findings Included: a) Resident #50 A record review on 06/25/24 at 11:06 AM, of Resident #50's care plan revealed the following: Intervention revised on 03/06/24: The resident has a communication problem r/t vision deficit/lacks capacity to make medical decisions. Further record review revealed a capacity form completed on 01/05/24 that is marked as Resident #50 demonstrates capacity to make decisions. During an interview on 06/26/24 at 12:15 PM, The Director of Social Services (DSS) confirmed that Resident #50 does have capacity and the care plan was wrong. [...]

Inspectors wroteBased on record review and staff interview the facility failed to complete a discharge summary of Resident #72. This failed practice was found true for (1) one of (1) residents reviewed for unplanned discharge during the Long-Term Care Survey Process. Resident identifier #72. Facility census 69. Findings Include a) Resident #72 A record review on 06/26/24 at 12:54 PM, revealed that Resident #72 had an unplanned discharge from the facility. Further record review revealed that a discharge summary was not completed in its entirety. During an interview on 06/26/24 at 12:57 PM, the Director of Nursing (DON) stated, Her discharge was so confusing. It was planned in the fact that she was going home, but unplanned because we did not know when her son was coming to get her. The DON further stated, We do have a problem with our discharge process and we are working on it

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multidose medication vial was not dated when opened. This was a random opportunity for discovery made during the medication storage task. Facility census: 69.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the Infection Prevention and Control Program (IPCP) policy and procedures were reviewed annually in accordance with the federal guidance and the facility assessment. This had a potential to affect all residents residing in the facility. Facility Census:

Inspectors wroteBased on observation, facility policy, record review and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. During the observation of the kitchen, unsanitary and unclean areas were discovered. This had the potential to affect all residents receiving nourishment from the kitchen. Facility Census: 63.

Inspectors wroteBased on observation and staff interview the facility failed to maintain sanitary condition of the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect all the residents that reside in the facility.

Inspectors wroteBased on observation,record review and staff interview the facility failed to ensure an environment for residents that was free of rodents. The practice had the potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 63 Findings Included: a) Kitchen During an initial tour of the kitchen with the Culinary Director (CD) beginning on 09/06/23 at 8:49 AM revealed the following pest control traps. On the floor under the steam table/serving table were the following pest control traps A round ant bait trap A white carbon bait box with large of amount of bugs inside, including roaches A white flat adhesive bait pad with large amount of bugs attached including 4 roaches During an immediate interview the Culinary Director (CD) and [NAME] #18 acknowledged the bugs inside and on the bait. [...]

Inspectors wroteBased on observations during the kitchen tour and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. It was discovered during the kitchen tour that food items were not stored properly after opening and the walk-in cooler was very dirty. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 63.

Inspectors wroteBased on medical record review and staff interview the facility failed to develop a comprehensive care plan in the area of dialysis services. This was discovered for one (1) of one (1) residents reviewed for dialysis services. Resident #11's care plan interventions did not include the specified days hemodialysis services were being provided. Resident identifier: #11 Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for the care area of risk for falls. This is true for one (1) of two (2) residents reviewed for the care area of accidents during the long-term survey. Resident #7. Facility Census: 63. Findings Included: a) Resident #7 On 09/13/22 at 2:00 PM, the care plan with the focus area of risk for falls was reviewed. An intervention of hourly rounds at night was found. A review of the record found no evidence of the hourly rounds at night being completed. An interview on 09/13/22 at 2:38 PM with Assistant Director of Nursing (ADON) #32 was held. The ADON #32 stated, the intervention of hourly rounds at night was discontinued in June. The ADON #32 confirmed the care plan had not been revised to discontinue the intervention. No further information was provided during the survey process.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the residents physician when a change of condition occurred. This was a random opportunity for discovery. Resident identifier: 163. Facility census: 63.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to provide care and services to promote healing of a known pressure ulcer and to prevent further pressure ulcers from developing. The facility failed to accurately assess and/or correctly document the location of the coccyx/buttocks wound care site (incorrect measurements and staging were conducted on 04/28/22, 05/10/22 and 05/17/22. Resident identifier: #163. Facility census: 63.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide a dialysis order to include the designated days of treatment. This was discovered for one (1) of one (1) residents reviewed for the care area of dialysis services. The dialysis order for Resident #11 did not indicate what days dialysis services were being received. Resident identifier: #11. Facility census: 63.