Viewcrest Health Center

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy to adequately supervise 1 of 3 residents (R1) prior to a successful elopement who was reviewed for accidents. R1 eloped from the facility wearing a WanderGuard system, was found four blocks away and was hospitalized with abrasions.

Inspectors wroteBased on interview and document review, the facility failed to follow manufacturer's recommendation on EZ Way sling usage, facility policy, and transfer care plan for 1 of 3 (R1) residents reviewed for mechanical lift transfers. Additionally, the facility lacked a system to assess and document appropriate resident sling size. R1 fell out of the sling, sustained a laceration to the back of her head and was sent to the Emergency Department (ED). The IJ began on 3/13/25 at 11:00 p.m., when R1 fell from a mechanical lift causing a laceration to her head and the liklihood for potnetial serious harm. The administrator and director of nursing (DON) were informed of the IJ on 3/21/25 at 10:30 a.m. The facility had implemented corrective action on 3/14/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper glove use and hand hygiene was performed during incontinence care and wound care for 2 of 3 residents (R3, R4) reviewed for infection control. In addition, the facility failed to use proper personal protective equipment (PPE) for 1 of 3 (R4) residents reviewed for infection control.

Inspectors wroteBased on interview and document review, the facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, leaving 15 hours between the evening and morning meals. This had the potential to affect 93 out of 94 residents who take in sustenance orally.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure cold beverage items were stored at temperature to prevent foodborne illness. This had the potential to affect 16 out of 94 residents who were served beverages from the dining room beverage cart. Findings Include: On 7/10/24 at 7:28 a.m., dietary aid (AD)-A was preparing five cold beverage carts. Each cart had a bin on the top shelf which contained half gallon containers of assorted milk and juice. One of the five carts also contained milk and juice containers on the second shelf which was not in a bin. Ice was added to all 5 bins containing milk and juice and no ice or other cooling source was applied to the milk or juice on the cart which contained milk and juice on the second shelf. Items on the second shelf included following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nebulized medications were administered safely for 1 of 1 resident (R8) who was observed to self-administer a nebulizer and had not been assessed as safe to do so.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (a requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care (PASSAR)) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident's (R30) reviewed for PASARR.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly care for oxygen and nebulizer equipment for 1 of 2 residents (R8) reviewed for respiratory equipment to help prevent the potential for infection.

Inspectors wroteBased on interview and document review, the facility failed follow medication administration policy for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an immediate jeopardy (IJ) for R1 when LPN-B administered R2's medications to R1, which resulted in severe bradycardia (slower than normal heart rate) for R1 leading to hospitalization and a surgical intervention of a temporary pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 5/7/24, when the facility failed follow medication administration policy when LPN-B administered R2's medications to R1, which resulted in severe bradycardia leading to hospitalization and a surgical intervention of a temporary pacemaker. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the care plan was followed to prevent and/or reduce the risk of burns from hot liquid for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained three 2nd degree burns (damage to outer and second layers of skin) to both thighs. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure use of assistive devices/adaptive equipment when dining.

Inspectors wroteBased on interview and document review the facility failed to ensure the dietary manager was certified and credentialed to oversee food services. This had potential to affect all 69 residents, staff, and visitors who consumed food from the ktichen.

Inspectors wroteBased on observation, interview and document review, the facility failed to utilize proper hand sanitization after topical medication administration for 1 of 5 residents (R226) observed for medication administration; failed to ensure staff completed proper hand hygiene and glove use during distribution of snacks and meals. This had the ability to affect all 69 residents as well as staff and visitors who consumed food in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure residents had reasonable access to their personal funds after hours and on weekends for 2 of 2 residents (R13, R227) reviewed for personal funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure residents with trust accounts received quarterly accounting statements for 2 of 2 residents (R227, R13) reviewed for resident funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the surety bond was equal to or greater than the funds entrusted to the facility. This had the potential to impact all 52 current and 47 discharged residents identified as having a trust fund account at the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R9, R10, R60) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the facility provided a home like environment for 1 of 1 residents (R47) reviewed for home like environment.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the care plan was revised to reflect newly assessed needs and services for 1 of 4 residents (R10) reviewed for changes in activities of daily living (ADL); 1 of 2 residents (R61) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with toileting for 1 of 2 residents (R10) reviewed for activities of daily living and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful activities for 1 of 3 residents (P10) who was dependent on staff for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to recognize positioning needs for 1 of 1 resident (R23) reviewed for positioning; and failed to implement and track a fluid restriction for 1 of 2 residents (R66) reviewed for fluid intake.

Inspectors wroteR23: R23's annual MDS dated [DATE], identified a diagnoses of hemiplegia and hemiparesis of left non-dominant side (weakness and loss of movement on one side of the body) due to a stroke. R23 had moderate cognitive impairment, required extensive assistance to complete transfers and self-cares, and used a wheelchair. R23 was identified to be at risk of skin breakdown with identified treatments of a pressure reducing device for their chair and bed. R23's care plan dated 8/22/22, identified R23 used a Broda wheelchair (wheelchair with increased padding on right and left side that can tilt), a pressure reducing cushion was to be used at all times, their left arm was to be supported on an arm rest when in their wheelchair, and they required assistance with wheelchair mobility. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed ensure an ordered ambulation range of motion (ROM) program was implemented for 1 of 2 residents (R10) reviewed for rehabilitation and restorative nursing.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess for dementia related behaviors and identify the least restictive intervention(s) and provide ongoing reassesment and care planning for 1 of 1 residents (R47) reviewed who had not personal items in their room.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement anticoagulant side-effect monitoring for 1 of 1 resident (R23) reviewed for anticoagulant use.