Crossview Care Center

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Freedom of Abuse, Abuse Prevention: Fast Alerts, the facility failed to ensure that one of 18 sample residents (R) (R10) was free from misappropriation of trust account money.

Inspectors wroteBased on record review, staff interviews, and review of the policy titled Freedom of Abuse, Abuse Prevention: Fast Alerts, the facility failed to protect one of 18 sampled residents(R) (R10) from misappropriation of funds by not reporting to the state agency and law enforcement.

Inspectors wroteBased on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure the timely availability of personal resident funds for four of four residents reviewed for access to personal funds out of a total sample of 20 residents (Resident (R) 14, R53, R25, and R29) of 20 sampled residents. Specifically, the facility's banking hours were limited to time when business office staff were in the facility and residents did not have access to their money after office hours, weekends, or holidays. If residents requested money for $99.00 or more the resident had to request it from the facility and then the facility had to request it from Central Office and then the resident would have to wait three working days before resident would get a check. The resident then had to find someone to cash their check. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to enter a Do Not Resuscitate (DNR) status in the electronic medical record (EMR) and failed to obtain a corresponding physician's order for one of two residents (Resident (R) 30) reviewed for Advance Directives (AD) from a sample size of 20 residents. This failure had the potential to have R30's end-of-life wishes not honored.

Inspectors wroteBased on staff interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one resident (Resident (R) 74) out of a total sample of 20 residents. This failure placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on resident and staff interviews and record reviews, the facility failed to ensure that three of nine residents (R) (R1, R2, R3) reviewed for ADL (Activities of Daily Living) received care and services according to their needs and preferences. Specifically, the facility failed to ensure shower/baths were given as scheduled for (R1, R2, and R3).

Inspectors wroteBased on observations, Staff interviews, record review, and review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to report an injury of unknown origin for one of six residents (R) (R6) to the State Agency within the allotted time frame.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to investigate an injury of unknown origin for one of six residents (R) (R6).

Inspectors wroteBased on staff interviews, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for the First Quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 67 residents.

Inspectors wroteBased on observations, staff interviews, and review of a job description titled, Laundry Worker, the facility failed to follow infection control practices by not having a clean and sanitary environment in the laundry department and a heavy buildup of dust, dirt, and grime to prevent cross contamination of dirty and clean laundry. The census was 67 residents. Findings Include: Review of undated job description titled, Laundry Worker revealed, Work Area Maintenance: cleans and sanitizes the work area including machines, worktables, and sorting area. Observation during tour of the laundry department on 4/25/2024 beginning at 9:42 am revealed the following: 1. Spider webs and a buildup of dust noted on walls, ceiling tiles and pipes, and behind the washing machines and dryers. 2. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure four of 20 residents (R) (R3, R10, R22, and R27) did not have unsecured unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a safe/clean/comfortable/homelike environment for one of three hallways (100 Hall), four of 34 bedrooms and two of 17 bathrooms on the100 Hall. Specifically, the hallways had a loose handrail along the interior corridor, the frame on the exit door was jagged with rough edges at the bottom of the door, an old rusty inoperable heater was attached to the wall there were chips and scratches on the floor as residents entered the dining area. Additionally, residents' rooms and bathrooms contained black and sticky substances on the floors, basins uncovered, scraped and jagged closet doors, broken tiles, tiles pulled away from the wall, tiles with stains and dark brown sticky substance covering the floor and peeling paint. The facility census was 67 residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to implement the care plan for one of five residents (R) R17. Specifically, the facility failed to ensure the plan of care was followed for R17 related to oxygen administration.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen, Administration-Delivery Device , the facility failed to ensure oxygen was administered as ordered by the physician for one of five residents (R), R17.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to: maintain a safe, clean, comfortable, homelike environment on two of two Halls (East Hall and [NAME] Hall) free from stained, sagging, and holes in ceiling tiles, dusty, dirty ceiling vents and fans, stained, scratched toilets, missing baseboard, scuffed-up doors, one loose sink that needed caulking, one leaking sink; maintain a comfortable air temperature within range of 71 degrees Fahrenheit (F) to 81 degrees F; maintain a working women's shower free from disrepair, missing floor tiles, musky smell, with equipment stored in it; and ensure the smoking porch was free from dirty ceiling fans and spider webs.

Inspectors wroteBased on observations, interviews, and record review of the policy entitled, Management of the Laundry, the facility failed to provide a separate delivery entrance into the Laundry Room to take soiled or dirty linen/clothes, use appropriate PPE including gloves and an apron when sorting linen, and keep soiled or dirty linen/clothes covered; this affected Residents who used the linen at the facility and had their clothes cleaned in the Laundry Room. The census was 75.

Inspectors wroteBased on observations, record reviews, and staff interviews the facility failed to follow Physician's Order for one of four residents (R) (R#39) who received nutrition via gastric feeding tube.