Crestview Nursing and Rehabilitation

Inspectors wroteBased on observations, clinical record review, staff interview and policy review, the facility failed to treat residents (Resident #6 and Resident #18) with dignity during meal service. The facility reported a census of 58 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident had diagnoses of other orthopedic conditions, cirrhosis, renal insufficiency and non-Alzheimer's dementia. The MDS documented the resident required substantial/maximal assistance with eating. The Care Plan for Resident #6, with a revision date of 10/7/24, included a focus area the resident will need help to complete Activities of Daily Living (ADL's) daily due to weakness. The Interventions instructed staff Resident #6 could eat independently after setting up. [...]

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to submit a Level 1 and a Level II Preadmission Screening and Resident Review (PASRR) evaluation to the appropriate state-designated authority prior to the expiration date for 2 of 2 residents reviewed for PASRR (Resident #4 and Resident #38). The facility reported a census of 58 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 2 of 16 residents (Resident #4 and Resident #38) sampled for Care Plan review. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, clinical chart review and staff interview the facility failed to check placement for jejunostomy tube (j-tube or a small tube inserted through the stomach to provide nutrients and potential medication) for 1 of 1 resident (Resident #1). The facility reported a census of 58 residents.

Inspectors wroteBased on observation, record review, document review and staff interviews the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions (EBP) for 1 out of 1 resident reviewed (Resident #1). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews, family interview, clinical record review, hospital clinical record review, facility images, hospital images and policy review, the facility staff failed to ensure residents who required assistance to move around couldn't come into direct contact with the electric baseboard heater for 1 of 3 residents (Resident #1) reviewed. Resident #1 required the staff to utilize a mechanical lift to transfer in or out of the bed, needing significant assistance from the staff for all mobility. A staff member found Resident #1 with their legs laying on top of the electric baseboard heater on 12/8/24 at 12:44 AM. Staff interviews revealed Resident #1 potentially laid on the electric baseboard heater for approximately an hour before staff discovered him. When the staff moved Resident #1, they discovered he suffered burns to both legs. [...]

Inspectors wroteBased on clinical record review, hospital clinical record review, hospital images, staff interviews and policy review, the facility failed to identify a resident with pressure ulcers/wounds and assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of ulcers/wounds for 1 of 2 resident reviewed (Resident #1). The facility reported a census of 60 residents.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to have a Physician or a Non-Physician Practitioner (NPP) provide a face to face visit which includes a comprehensive assessment once every 60 days for 1 of 6 residents (Residents #3) reviewed for Physician Services. The facility reported a census of 60 residents.

Inspectors wroteBased on staff interviews, observations and insulin pen manufacturer directive the facility failed to follow professional standards for 3 of 7 residents observed during medication administration (Residents #27, and #17). The facility reported a census of 59.

Inspectors wroteBased on resident interview, staff interviews, record review, and manufacturer guide booklet the facility failed to ensure a resident's safety for 1 of 3 residents reviewed for accidents (Resident #27). As the staff helped Resident #27 prepare to take a bath, they failed to secure him in the chair with the seat belt. As they lifted the shower chair, Resident #27 fell from the shower chair to the floor. The facility reported a census of 59 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to serve the correct diets to 2 out of 59 residents (Resident #2 and Resident #28). During an observation of lunch service, Staff F, Cook, dished up a general diet for both Resident #2 and Resident #28. Resident #2 and Resident #28 were to receive mechanical soft diets (A type of texture-modified diet for people who have difficulty chewing and swallowing.) During the lunch service it was noted that another 6 residents were not on the Diet Type Report. Of these 6 residents, 4 of them did not have a Doctor's order for a diet (Resident's #20, #46, #64 and #65). These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 58. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed for a Level 2 PASRR evaluation (Resident #37). The facility reported a census of 58 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to document the administration of a prescribed medication for 1 of 1 residents reviewed for Respiratory Care (Resident #50). The facility reported a census of 58.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to ensure the medication cart was locked on 4 occasions when the Certified Medication Aide (CMA) responsible for the cart was not in site. The facility reported a census of 58 residents.

Inspectors wroteBased on staff interviews and facility job description review, the facility failed to employ a qualified Director of food and nutrition services. The facility reported a census of 58 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident received the 3 ounces of meatloaf per the menu approved by the facility's dietitian. An observation of the lunch meal service revealed that different size portions of meatloaf was dished up for residents on a general diet. The pieces were not measured to ensure the 3 ounces of meatloaf was provided for these residents. The facility reported a census of 58.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain physician diet orders upon admission for 4 out of 6 residents reviewed (Resident's #20, #46, #64, and #65). During an observation of a lunch service it was noted that 6 residents were not on the Diet Type Report. Further record review of the 6 residents not on the report revealed that 4 of them did not have a Doctor's diet order. The facility reported a census of 58 residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure open items of food were dated, covered, and labeled. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly handle medications and an inhaler spacer using acceptable infection control practices for 2 of 10 residents reviewed (Resident #5 and Resident #59). The facility reported a census of 58 residents.