Inspection Reports for
Crestview Home
1313 SOUTH 25TH ST, BETHANY, MO, 64424-2634
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
264% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
43% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 40
Deficiencies: 22
Date: Mar 4, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, facility environment, staffing, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure lawful advance directives, maintain a safe and homelike environment, develop complete care plans, provide necessary assistance with activities of daily living, offer meaningful activities, timely blood transfusions, pressure ulcer care, range of motion services, adequate nutrition, safe respiratory care, proper use of bed rails, adequate staffing, staff education, posting of nurse staffing information, dietary management, food preparation, kitchen sanitation, infection prevention and control, and antibiotic stewardship.
Deficiencies (22)
Failed to ensure lawful advance directives for residents when Power of Attorney signed Do Not Resuscitate forms prior to residents being declared incapacitated.
Failed to maintain walls, hallways, ceilings, floors, furnishings, and dining room temperature in a clean, safe, and homelike environment.
Failed to develop and implement complete, accurate, and individualized care plans for residents addressing specific needs including elopement risk, pressure ulcers, wounds, and weight loss.
Failed to provide necessary assistance with activities of daily living including timely repositioning and perineal care for a resident dependent on mechanical lift.
Failed to provide meaningful activities and have an assigned activity director, resulting in residents being lonely and bored.
Failed to provide timely blood transfusion as ordered by physician, resulting in a 14-day delay.
Failed to provide appropriate pressure ulcer care including timely physician notification, wound assessments, documentation, and adherence to prevention protocols.
Failed to provide range of motion services or devices to prevent further loss of function for a resident with contracture.
Failed to provide ordered nutritional supplements (Magic Cup) daily, contributing to significant weight loss.
Failed to store nebulizer masks in bags when not in use for two residents.
Failed to document assessment, obtain consent, and conduct ongoing assessments for use of Halo side rails for one resident.
Failed to provide adequate staffing to meet resident needs including repositioning, incontinence care, showers, and meal assistance.
Failed to provide a Registered Nurse on duty for eight consecutive hours per day seven days a week.
Failed to ensure nurse aides had yearly performance reviews and individually based education plans.
Failed to post required nurse staffing information daily including census and actual hours worked.
Dietary Manager lacked required certification and training to manage food and nutrition services.
Failed to prepare and serve food in a form consistent with resident needs; pureed foods were thick with chunks or watery, mechanical soft foods were dry and hard to chew.
Failed to maintain kitchen and dish room in a sanitary manner including dirty sinks, floors, food storage on floor, unclean equipment, and missing dishwasher sanitizer logs.
Failed to follow infection control guidelines including administering eye drops without gloves and lack of water management plan to reduce Legionella risk.
Failed to establish an antibiotic stewardship program including protocols, monitoring, education, and designated staff.
Failed to designate a qualified Infection Preventionist responsible for infection prevention and control program.
Failed to ensure nurse aides had minimum 12 hours yearly in-service education including abuse, neglect, and dementia care.
Report Facts
Resident census: 40
Sampled residents: 12
Weight loss: 26.2
Weight loss percentage: 10.5
Blood transfusion delay: 14
Missing RN days: 38
Infections January 2025: 10
Infections February 2025: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in multiple interviews related to care findings and assessments |
| CNA C | Certified Nurse Aide | Named in interviews related to resident care and repositioning |
| Administrator | Facility Administrator | Named in interviews regarding staffing, policies, and expectations |
| Quality Assurance Nurse | Quality Assurance Nurse | Named in interviews regarding care expectations and deficiencies |
| Dietary Manager | Dietary Manager | Named in interviews regarding dietary services and food preparation |
| Registered Dietitian | Registered Dietitian | Named in interviews regarding dietary services and food preparation |
| Medical Director | Medical Director | Named in interview regarding staffing and resident care |
| Physician | Physician | Named in interview regarding blood transfusion orders and delays |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in wound care and resident assessments |
| Certified Medication Technician B | Certified Medication Technician | Named in interview regarding infection control and glove use |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Feb 19, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and comfortable environment, including issues with heating, maintenance, and cleanliness, as well as failure to provide timely physician-ordered care for a resident's blood transfusion.
Complaint Details
The complaint investigation was triggered by concerns about the facility's failure to maintain a safe and comfortable environment and failure to provide timely physician-ordered blood transfusion for Resident #7. The blood transfusion was delayed by 14 days after the order was placed, with communication and scheduling breakdowns identified.
Findings
The facility failed to maintain the physical environment in a safe and homelike condition, including inadequate heating in the dining room, poor maintenance of furnishings and building infrastructure, and cleanliness issues. Additionally, the facility failed to provide timely blood transfusion treatment for a resident, delaying the transfusion by fourteen days after the physician's order.
Deficiencies (3)
Facility failed to maintain walls, hallways, ceilings, floors, furnishings, and dining room temperature at a comfortable level.
Facility lacked maintenance supervisor for over a month, resulting in unresolved maintenance issues including cracked floor tiles, dust and debris in vents and light fixtures, damaged fire doors, gouged sheetrock, loose and missing handrail end caps, stained carpets, mold in shower room, and unclean surfaces.
Failure to provide timely blood transfusion for Resident #7, with a 14-day delay from physician order to transfusion.
Report Facts
Facility census: 40
Facility census: 43
Days delay: 14
Units of PRBC ordered: 2
Units of PRBC received: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reported facility had no maintenance supervisor for over a month and described maintenance and heating issues. | |
| Housekeeping/Laundry Aide A | Described cleaning responsibilities and lack of deep cleaning assignments. | |
| Quality Assurance Nurse | Reported maintenance struggles and lack of maintenance staff. | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Provided information on lab result handling and uncertainty about blood transfusion delay. |
| Physician's Registered Nurse (RN) A | Registered Nurse | Described physician orders for blood transfusion and communication with facility. |
| Business Office Manager (BOM) | Responsible for scheduling appointments and arranging transportation; acknowledged paperwork sometimes missed. | |
| Family Representative A | Reported resident fatigue and delay in blood transfusion. | |
| Family Representative B | Reported disagreement with facility over transportation for second blood transfusion. | |
| Physician | Expected blood transfusion to be carried out within 5-7 days of order. | |
| Director of Nursing | Expected physician orders to be carried out as soon as possible. |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 2
Date: Jun 24, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident care and skin integrity.
Findings
The facility failed to prevent compromised skin integrity for two of four sampled residents, specifically related to pressure ulcers and inadequate repositioning and treatment. Staff did not report or properly treat residents' pressure ulcers, leading to open areas and skin breakdown.
Deficiencies (2)
F686 Skin Integrity: The facility failed to prevent pressure ulcers for two residents by not ensuring timely repositioning and treatment, and staff did not report open areas to the charge nurse.
A4075 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, as referenced by F686.
Report Facts
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Fletcherhall | Administrator | Signed the report and plan of correction |
| Unnamed Director of Nursing | Director of Nursing | Interviewed regarding expectations for CNA reporting and resident care |
| CNA A | Certified Nurse Aide | Observed providing care and interviewed about resident care |
| CNA B | Certified Nurse Aide | Observed providing care and interviewed about resident care |
| LPN A | Licensed Practical Nurse | Interviewed regarding CNA reporting and resident care |
Inspection Report
Routine
Census: 39
Deficiencies: 3
Date: Jun 24, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure ulcer care and prevention protocols, focusing on the care provided to residents at risk for pressure ulcers.
Findings
The facility failed to prevent compromised skin integrity for two sampled residents by not ensuring timely reporting of open and red skin areas to the charge nurse and not repositioning residents properly after care. Staff did not apply moisture barrier cream or offload pressure as required, resulting in minimal harm or potential for actual harm.
Deficiencies (3)
Failure to report open areas and red skin to the charge nurse immediately for Resident #1 and Resident #2.
Failure to reposition residents properly after care, leaving them on compromised skin areas.
Failure to apply moisture barrier cream to residents' red skin areas as per protocol.
Report Facts
Residents affected: 2
Census: 39
Open areas size: 0.5
Open areas size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Expected CNAs to report red and open areas immediately and reposition residents. |
| Director of Nursing | Director of Nursing | Expected CNAs to report red bottoms and open areas immediately and reposition residents to avoid pressure on compromised skin. |
| Administrator | Administrator | Expected staff to reposition residents every two hours and report red areas immediately. |
Inspection Report
Life Safety
Deficiencies: 7
Date: May 27, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 standards.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included failure to conduct required emergency preparedness exercises, inadequate testing and documentation of emergency lighting, fire suppression systems, sprinkler systems, fire extinguishers, fire doors, and electrical systems.
Deficiencies (7)
E039 Emergency Preparedness Testing Requirements: The facility failed to conduct and maintain documentation of at least two exercises annually to test the emergency plan. A tabletop emergency preparedness drill was last completed on June 21, 2024, with missing documentation for other required exercises.
K291 Emergency Lighting: The facility failed to ensure monthly testing of 38 battery backup emergency exit lights as required by NFPA 101. Documentation showed incomplete inspections and testing.
K324 Cooking Facilities: The facility failed to ensure one kitchen extinguishing system was inspected and maintained according to NFPA 96 standards. The last hydrostatic test was in 2011, with no recent documentation.
K353 Sprinkler System - Maintenance and Testing: The facility failed to document sprinkler system inspections in accordance with NFPA 25. Gauges were not inspected weekly, and inspections were missed for multiple quarters.
K355 Portable Fire Extinguishers: The facility failed to perform and document monthly visual examinations of 43 fire extinguishers as required by NFPA 10 standards.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to inspect 11 fire-rated doors annually as required by NFPA 101 and NFPA 80. Documentation of annual inspections was missing.
K918 Electrical Systems - Essential Electric Systems: The facility failed to inspect the essential emergency power generator and associated equipment as required by NFPA 110. Weekly and monthly inspections and testing were incomplete or undocumented.
Report Facts
Battery backup emergency exit lights: 38
Fire extinguishers: 43
Fire-rated doors: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements regarding emergency preparedness exercises and life safety code compliance | |
| Maintenance Supervisor | Provided statements regarding emergency lighting testing and fire extinguisher inspections | |
| Director of Nursing | Responsible for emergency preparedness exercises as stated by Administrator |
Inspection Report
Routine
Deficiencies: 13
Date: May 23, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, safety, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of medication holds, inadequate maintenance of resident rooms, incomplete care plans for psychotropic medication use, failure to provide scheduled showers, failure to respond appropriately to hypertensive crisis, unsecured medications, incomplete fall investigations and interventions, failure to monitor fluid intake for a resident on fluid restriction, poor communication with dialysis provider, failure to provide pneumococcal vaccination, unsafe kitchen equipment, and inadequate water management program to prevent Legionella.
Deficiencies (13)
Failed to notify physician when blood pressure medication was held for Resident #41.
Closet doors missing in Resident #13 and Resident #17's rooms, exposing clothing.
Failed to develop care plan addressing use of psychotropic medications for Resident #34.
Failed to provide showers as scheduled/preferred for Residents #34 and #37.
Failed to provide appropriate treatment for hypertensive crisis for Resident #32.
Failed to keep medication secure and failed to assess Resident #30 for self-administration safety.
Failed to thoroughly investigate fall and implement fall interventions for Resident #28.
Failed to monitor and record fluid intake for Resident #28 on fluid restriction.
Failed to communicate effectively with dialysis provider for Resident #28.
Failed to provide pneumococcal vaccine to Resident #8 despite consent.
Failed to maintain essential kitchen equipment in safe operating condition including walk-in freezer with ice buildup, broken oven door, and non-working steamer.
Failed to maintain a water management program to minimize Legionella risk in facility water supply.
Failed to specify target behaviors, monitor for adverse drug reactions, and complete behavior tracking for residents on antipsychotic medications (Residents #34 and #41).
Report Facts
Freezer storage bags: 50
Blood pressure readings: 189
Blood pressure readings: 113
Fluid restriction: 1500
Fall risk assessment: 1
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Interviewed regarding notification of medication holds and fall investigations. |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding fall interventions, fluid restriction monitoring, and dialysis communication. |
| CNA #7 | Certified Nurse Aide | Interviewed regarding medication security and shower provision. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication notification, behavior monitoring, dialysis communication, and vaccination. |
| Administrator | Facility Administrator | Interviewed regarding facility policies, maintenance, vaccination program, and overall compliance. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding facility maintenance and water management. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding kitchen equipment and food storage. |
| Medical Director | Medical Director | Interviewed regarding appropriateness of antipsychotic medication use. |
Inspection Report
Routine
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards, specifically focusing on the provision of showers as scheduled for residents and the sanitary storage of food.
Findings
The facility failed to provide showers as scheduled or preferred for two sampled residents, Resident #34 and Resident #37, with documentation and staffing issues contributing to the problem. Additionally, the facility failed to ensure leftover food was properly labeled, dated, and discarded, posing a risk to all residents receiving nourishment from the kitchen.
Deficiencies (2)
Failed to provide showers as scheduled/preferred for 2 of 5 sampled residents (Resident #34 and Resident #37).
Failed to ensure staff stored leftover food in a sanitary manner, including failure to label, date, and discard leftover food.
Report Facts
Residents affected: 2
Residents affected: 43
Number of freezer storage bags: 50
Dated freezer storage bags: 42
Undated freezer storage bags: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Interviewed regarding shower schedule and documentation for Resident #37. |
| CNA #1 | Certified Nurse Aide | Interviewed about staffing and shower provision. |
| CNA #2 | Certified Nurse Aide | Interviewed about shower schedules and resident care. |
| Nursing Assistant #12 | Nursing Assistant | Interviewed about Resident #37's refusal of care. |
| CNA #17 | Certified Nurse Aide | Interviewed about shower schedules and interactions with Resident #37 and Resident #34. |
| LPN #6 | Licensed Practical Nurse | Interviewed about shower refusal documentation and staff reporting. |
| RN #4 | Registered Nurse | Interviewed about Resident #37's shower refusals and whirlpool bath preferences. |
| HR staff member | Interviewed about shower sheet documentation and follow-up procedures. | |
| DON | Director of Nursing | Interviewed about shower scheduling and documentation. |
| Administrator | Administrator | Interviewed about shower refusal procedures and staff responsibilities. |
| Dietary Supervisor | Dietary Supervisor | Interviewed about leftover food storage and labeling. |
| Dietary Aide #15 | Dietary Aide | Interviewed about leftover food labeling and discard policies. |
| Dietary Manager Assistant | Dietary Manager Assistant | Interviewed about leftover food labeling and discard responsibilities. |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 11
Date: May 10, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Crestview Home, a healthcare facility.
Findings
The facility was found deficient in maintaining safe operating conditions for essential equipment, call system functionality, and providing a safe, functional, sanitary, and comfortable environment. Multiple maintenance issues were identified including broken bed locks, non-functioning exhaust fans, call lights not working, HVAC problems, mold presence, and plumbing issues.
Deficiencies (11)
F908 Essential Equipment, Safe Operating Condition: The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, including bed locks and kitchen exhaust fans. Maintenance requests were not properly documented or completed.
F919 Resident Call System: The call light system was not functioning properly, affecting all residents on the 400 and 500 halls. Maintenance requests showed multiple call lights were not working and the facility lacked a policy regarding call lights.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a safe and sanitary environment, with issues including mold, water damage, missing ceiling tiles, rusted pipes, and poor maintenance of HVAC and plumbing systems.
A3001 Substantially Constructed/Maintained: The building was not maintained in good repair, with physical plant deficiencies noted in F908 and F921.
A3026 Call System Requirements: The facility's call system did not meet regulatory requirements for audible signals in staff areas and resident rooms, as referenced in F919.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards, as referenced in F921.
A3038 Furniture/Equip, Provide Comfort & Safety: Furniture and equipment were not maintained in good condition, impacting resident comfort and safety, as referenced in F908, F919, and F921.
A3040 Bed Requirements: Beds were not maintained in good repair, with issues noted in F921.
A6001 Fac Property Free of Litter: The facility property was not kept free of litter, as referenced in F921.
A6012 Floor Surfaces: Floors were not maintained in good repair and cleanliness, as referenced in F921.
A6041 Toilet Room Requirements: Toilet rooms were not properly maintained or accessible, as referenced in F921.
Report Facts
Facility census: 50
Deficiencies cited: 11
Inspection Report
Life Safety
Census: 50
Capacity: 92
Deficiencies: 9
Date: May 10, 2023
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and building safety regulations at Crestview Home.
Findings
The facility was found deficient in multiple life safety areas including means of egress obstructions, vertical openings enclosure, fire alarm system maintenance, sprinkler system inspections, portable fire extinguisher maintenance, fire drills, electrical system safety, and fire alarm activation and records. The facility had a capacity of 92 with a census of 50 at the time of the survey.
Deficiencies (9)
K211 Means of Egress - General: The facility failed to keep aisles, exit discharges, and means of egress free of obstructions including towels on floors, trash barrels, and plastic barriers blocking exits.
K311 Vertical Openings - Enclosure: The facility did not maintain one-hour fire rating between floors and allowed penetrations in ceilings and walls without proper firestopping.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain and test the fire alarm system and lacked documentation of required inspections and testing.
K353 Sprinkler System - Maintenance and Testing: The facility failed to conduct required inspections and maintain documentation for the sprinkler system.
K355 Portable Fire Extinguishers: The facility staff failed to ensure all fire extinguishers were inspected, maintained, and present in all areas of the facility.
K712 Fire Drills: The facility failed to conduct monthly fire drills to ensure staff, visitors, and residents knew how to respond during a fire emergency.
K911 Electrical Systems - Other: The facility failed to ensure ground fault circuit interrupters (GFCI) were installed and maintained in hazardous areas and had exposed wiring near residents.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain documentation and perform required maintenance on the emergency power generator.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure extension cords and three-way adapters were not used in the boiler room, creating a fire hazard.
Report Facts
Facility capacity: 92
Resident census: 50
Inspection date: May 10, 2023
Inspection Report
Follow-Up
Census: 50
Deficiencies: 3
Date: May 10, 2023
Visit Reason
The inspection was a follow-up to verify correction of previously identified deficiencies related to maintenance and safety issues in the facility, including equipment repairs, call light system functionality, and environmental safety concerns.
Findings
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, including resident beds, lifts, and kitchen exhaust fans. The call light system was not functioning properly, leading to resident falls. The environment was unsafe and unsanitary with issues such as water damage, mold, broken plumbing, and deteriorated infrastructure. The facility lacked adequate maintenance staff and documentation of inspections.
Deficiencies (3)
Failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, including resident beds, lifts, and kitchen exhaust fans.
Call light system did not function properly, affecting residents on the 400 and 500 halls and contributing to falls.
Facility failed to provide a safe, functional, sanitary, and comfortable environment; issues included poor repair, malfunctioning HVAC, water leaks, mold, and deteriorated pipes.
Report Facts
Facility census: 50
Maintenance requests: 10
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide E | Certified Nurse Aide | Attempted to lock Resident #5's bed and reported lift issues |
| Dietary Manager | Dietary Manager | Reported kitchen exhaust fan not working |
| Administrator | Administrator | Interviewed multiple times regarding maintenance issues, call light system, and environmental concerns |
| Licensed Practical Nurse A | Licensed Practical Nurse | Reported call light system issues and environmental observations |
| Certified Nurse Aide C | Certified Nurse Aide | Reported call light system issues and maintenance delays |
| Certified Nurse Aide D | Certified Nurse Aide | Reported resident falls due to call light system failure |
| Marmic representative | Fire Alarm Vendor Representative | Explained call light system failure due to short circuit from a resident room |
| Business Office Manager | Business Office Manager | Reported sprinkler pipe break and roof leaks |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 3
Date: Feb 1, 2023
Visit Reason
The inspection was conducted following allegations of abuse involving a Registered Nurse (RN A) who was reported to have slapped a resident. The visit included investigation of abuse, neglect, and exploitation concerns.
Complaint Details
The investigation was complaint-related, triggered by allegations that Registered Nurse (RN A) slapped Resident #1. The complaint was substantiated as the facility confirmed the abuse and took corrective actions including suspension and termination of RN A.
Findings
The facility failed to protect a resident from abuse by a Registered Nurse who slapped the resident. The facility also failed to prevent further potential abuse during an ongoing investigation and did not adequately educate staff on abuse prevention and recognizing signs of burnout.
Deficiencies (3)
F600: The facility failed to protect a resident from abuse when a Registered Nurse slapped the resident. The facility did not adequately protect residents from continuing abuse and failed to suspend alleged offenders immediately.
F610: The facility failed to thoroughly investigate alleged abuse and prevent further potential abuse while the investigation was in progress. The facility also failed to educate staff on abuse prevention and recognizing signs of burnout.
A8023: The facility did not develop and implement policies requiring reports of abuse or neglect to the department and mental health authorities as required by regulation.
Report Facts
Facility census: 54
Hours worked: 24
Completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in abuse finding for slapping Resident #1 and working unauthorized shifts |
| CNA G | Certified Nursing Assistant | Witnessed abuse and reported observations related to Resident #1 |
| Administrator | Facility Administrator | Involved in suspension and investigation of RN A |
| DON | Director of Nursing | Acting Director of Nursing during the incident and investigation |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Jan 13, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or misappropriation of residents' narcotic medications at Crestview Home.
Complaint Details
The investigation was triggered by allegations of misappropriation of residents' narcotic medications. The complaint was substantiated as the facility failed to conduct a thorough and timely investigation and did not interview all relevant staff and residents.
Findings
The facility failed to thoroughly investigate allegations of misappropriation of residents' narcotic medications in a timely manner and did not interview all staff with access to the controlled drugs. The investigation lacked completeness and did not include interviews with certain residents and staff.
Deficiencies (2)
F610: The facility failed to thoroughly investigate allegations of misappropriation of residents' narcotic medications, did not interview all staff with access to controlled drugs, and did not follow policy for timely investigation and reporting.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, including required reporting procedures.
Report Facts
Facility census: 53
Missing narcotic pills: 26
Narcotic pills on sheets: 15
Narcotic pills on sheets: 19
Staff with access to narcotics: 5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 12, 2022
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from 12/8/22 through 12/12/22 to assess compliance with CMS and CDC recommended practices and related federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Census: 57
Deficiencies: 18
Date: Aug 5, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, dietary services, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to maintain residents' dignity during meal service, improper management of resident funds, incomplete advance directive documentation, unsafe and unclean environment, incomplete and inaccurate care plans, medication administration errors, inadequate infection control practices, insufficient dietary management and staffing, poor kitchen sanitation, and lack of a functional quality assurance program.
Deficiencies (18)
Residents were served meals on Styrofoam plates, bowls, cups and plastic silverware, failing to maintain dignity.
Facility failed to provide receipts for Resident Trust Fund transactions and maintain signed authorizations.
Facility failed to ensure Out of Hospital Do Not Resuscitate forms were present and code status matched physician orders for sampled residents.
Facility environment was unclean with discolored floors, stains, holes in walls, and insufficient maintenance.
Care plans for sampled residents lacked comprehensive, measurable objectives and did not address all medical, nursing, and psychosocial needs.
Facility failed to follow procedures for medication administration and resident pass medication management, resulting in missed doses and medication errors.
Dependent residents did not consistently receive assistance with activities of daily living such as bathing and grooming.
Facility failed to assist a resident with obtaining prescription eyeglasses and maintain related records.
Staff failed to use proper lift sling and wheelchair brakes during resident transfer and failed to set low air loss mattress to correct weight setting.
Facility failed to ensure correct installation, use, and maintenance of bed rails and halos, including assessments, consents, and physician orders.
Facility failed to post accurate and current nurse staffing information daily.
Facility failed to employ a qualified dietary manager with accredited education in food service management.
Facility failed to ensure sufficient dietary staffing to serve meals timely and maintain kitchen cleanliness.
Facility failed to prepare pureed foods according to recipes and served pureed food more than 90 minutes before meal service.
Facility failed to follow physician's order for renal diet and served a regular diet to a resident requiring renal diet.
Facility failed to discard expired medications and biologicals, failed to ensure no food in medication refrigerators, failed to date opened medications and food, failed to record refrigerator temperatures, and failed to ensure no loose pills in medication cart.
Facility failed to follow infection control practices including staff not performing two-step TB testing for residents and employees, staff handling medications with bare hands, and improper hand hygiene during medication pass and blood glucose monitoring.
Facility failed to maintain an ongoing antibiotic stewardship program with monitoring and improvement plans.
Report Facts
Medication errors: 5
Facility census: 57
Temperature log entries: 14
Temperature log entries: 14
Pureed food temperature: 132.5
Pureed food temperature: 143.4
Pureed food temperature: 114.2
Pureed food temperature: 97.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication error and infection control findings related to medication handling and blood glucose monitoring. |
| Dietary Aide A | Dietary Aide | Named in findings related to dietary staffing, kitchen cleanliness, and pureed food preparation. |
| Interim Director of Nursing | Interim Director of Nursing | Named in multiple findings including infection control, medication administration, dietary services, and quality assurance. |
| Administrator | Administrator | Named in findings related to dietary management, kitchen cleanliness, quality assurance, and staffing. |
| Certified Medication Technician A | Certified Medication Technician | Named in medication administration and infection control findings. |
| Certified Medication Technician B | Certified Medication Technician | Named in medication pass and low air loss mattress findings. |
| Certified Nurse Aide B | Certified Nurse Aide | Named in grooming assistance findings. |
| Registered Dietician | Registered Dietician | Named in dietary and pureed food preparation findings. |
| Social Services Designee | Social Services Designee | Named in vision care and advance directive findings. |
| Transition Program Director | Transition Program Director | Named in medication pass and vision care findings. |
Inspection Report
Abbreviated Survey
Census: 60
Deficiencies: 2
Date: Aug 18, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess the facility's compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility was found to be non-compliant with infection prevention and control requirements, specifically failing to prevent the potential spread of infection due to incomplete staff screening for illness prior to entry. Several staff members did not complete required COVID-19 screenings on multiple dates.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to prevent the potential spread of infection for COVID-19 due to incomplete staff illness screenings prior to entry on multiple dates in August 2021.
A4085 Infection Control/Communicable Disease: The facility did not meet infection control regulations requiring reporting of communicable diseases to the state within seven days.
Report Facts
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Hitchcock | Administrator | Signed the report and plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from June 17, 2021 through June 24, 2021.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Mar 23, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident rights, visitation policies, and quality of care at Crestview Home.
Complaint Details
The complaint investigation was substantiated as the facility failed to allow residents on the observation unit to smoke, did not have a proper visitation policy during the COVID-19 public health emergency, and had deficiencies in quality of care and dignity/privacy.
Findings
The facility failed to ensure residents could exercise their rights, including smoking privileges on the observation hall, and failed to develop a written visitation policy consistent with COVID-19 public health emergency guidelines. Additionally, deficiencies were found in quality of care related to medication administration and food temperature monitoring.
Deficiencies (9)
F550 Resident Rights: The facility failed to allow residents on the 14-day observation unit to smoke as per facility policy and did not ensure residents could exercise their rights without interference.
F563 Right to Receive/Deny Visitors: The facility failed to develop a written visitation policy consistent with Public Health Emergency guidelines, affecting seven sampled residents.
F684 Quality of Care: The facility failed to ensure timely reordering of Resident #4's oxycontin medication, resulting in missed doses and inadequate documentation.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to document food temperatures for room trays and dining room meals, affecting multiple residents.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A5005 Hot Food Hot, Cold Food Cold: The facility failed to assure hot food was served hot and cold food was served cold.
A8030 Dignity/Privacy: The facility failed to ensure residents were treated with respect, dignity, and privacy during care and visits.
A8032 Resident Communicate With Persons of Choice: The facility failed to permit residents to communicate privately with persons of their choice without unreasonable limitations.
A8033 Private Meeting Areas Available: The facility failed to provide private areas for residents to meet alone with persons of their choice.
Report Facts
Facility census: 53
Number of sampled residents affected: 7
Number of opioid doses missed: 3
Food temperature documentation failures: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Fletcher | Administrator | Named in relation to smoking policy and visitation guideline findings |
| Certified Medication Technician (CMT) A | Reported staff not allowing residents to smoke on observation hall | |
| Director of Nursing (DON) | Reported residents on observation unit not allowed to smoke since January | |
| Licensed Practical Nurse (LPN) B | Reported previous DON allowed smoking on observation unit; new DON stopped it | |
| Dietary Manager (DM) | Reported food temperature logs were not properly filled out | |
| Assistant Director of Nursing (ADON) | Reported residents complained about cold food |
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 5
Date: Dec 4, 2020
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction following a COVID-19 Focused Emergency Preparedness survey conducted from 11/10/20 to 12/4/20 at Crestview Home.
Findings
The facility was found in compliance with COVID-19 emergency preparedness regulations but failed to meet professional standards for wound care for one resident. The facility also failed to maintain an effective infection prevention and control program, including failure to follow COVID-19 PPE policies for residents with suspected COVID-19.
Deficiencies (5)
F658: The facility failed to provide wound care according to physician orders for one resident, with incomplete documentation and declining wound healing status.
F880: The facility failed to maintain an infection prevention and control program, including failure to ensure staff wore appropriate PPE when caring for residents with suspected COVID-19.
A4053: No medication, treatment, or diet shall be given without a written order from a person lawfully authorized; this regulation was not met.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice; this regulation was not met.
A4085: Residents shall be cared for using acceptable infection control procedures to prevent spread of infection; this regulation was not met.
Report Facts
Facility census: 60
COVID-19 positive residents: 5
COVID-19 positive residents: 25
Inspection Report
Routine
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from July 27 to July 29, 2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from June 9 to June 11, 2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Jan 21, 2020
Visit Reason
The inspection was conducted to investigate deficiencies related to the handling and storage of controlled substances at Crestview Home, triggered by concerns about medication management and compliance with state and federal laws.
Complaint Details
The visit was complaint-related, focusing on medication handling and storage deficiencies. The report does not explicitly state substantiation status.
Findings
The facility failed to ensure proper handling and storage of controlled substances, including improper taping of pills inside bubbles, damaged medication packaging, and failure to count medications every shift. The facility also lacked an accurate system for reconciling controlled substance records.
Deficiencies (2)
F 761: The facility failed to properly store and label drugs and biologics, including controlled substances, with issues such as torn and taped medication bubbles and improper handling of controlled substances.
A4070: The facility did not establish an adequate system for recording receipt and disposition of controlled drugs to enable accurate reconciliation.
Report Facts
Resident census: 76
Controlled substances sampled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roxann Fletchall | Administrator | Signed the report and plan of correction |
| Director of Nursing | Interviewed regarding medication handling policies and practices |
Inspection Report
Re-Inspection
Census: 82
Capacity: 82
Deficiencies: 8
Date: Sep 4, 2019
Visit Reason
This re-inspection was conducted to follow up on previously cited deficiencies related to resident care, medication administration, infection control, and staff training at Crestview Home.
Findings
The facility was found to have ongoing issues with resident care preferences, medication administration, infection control, and staff training. Several deficiencies remained uncorrected, including failure to provide showers according to resident preferences, incomplete medication documentation, inadequate infection control practices, and insufficient staff training.
Deficiencies (8)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure residents received services with reasonable accommodations of their needs and preferences, including honoring shower preferences for five residents.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to conduct a thorough investigation and take corrective action regarding an injury of unknown origin to a resident.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders and assure medication availability for four sampled residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary services to maintain good hygiene and personal care for dependent residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide proper catheter care and maintain continence for residents with indwelling catheters.
F725 Sufficient Nursing Staff: The facility failed to have sufficient nursing staff with appropriate competencies to assure resident safety and well-being.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to serve food at safe and acceptable temperatures and ensure palatability.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program.
Report Facts
Facility census: 82
Facility total capacity: 82
Residents affected: 5
Residents affected: 4
Residents affected: 7
Residents affected: 3
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darren Hotchhall | Administrator | Named in relation to plan of correction and facility oversight |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 8
Date: May 23, 2019
Visit Reason
Annual inspection survey conducted on 05/23/2019 to assess compliance with federal regulations for Crestview Home nursing facility.
Findings
The facility was found noncompliant with several federal regulations including resident rights, comprehensive care plans, professional standards of care, skin integrity, accident prevention, nutrition/hydration, and infection control. Deficiencies were noted in privacy during care, care plan updates, pressure ulcer prevention and treatment, accident supervision, and infection prevention practices.
Deficiencies (8)
F550 Resident Rights: Facility failed to ensure staff treated residents with dignity and respect, including failure to provide privacy during personal care and treatment procedures.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop, implement, and update care plans consistent with residents' specific conditions and needs, including wound care and fall risk.
F658 Services Provided Meet Professional Standards: Facility failed to provide care and treatment in accordance with professional standards for two residents, including failure to follow physician orders.
F686 Skin Integrity: Facility failed to follow policy and conduct weekly skin assessments to identify and treat pressure ulcers, resulting in untreated wounds and inadequate documentation.
F689 Free of Accident Hazards: Facility failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and assistive devices to prevent falls.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide appropriate care and assessment for residents with urinary catheters and bowel/bladder incontinence, including infection prevention.
F692 Nutrition/Hydration Status Maintenance: Facility failed to maintain acceptable nutritional status for residents, including failure to monitor and document weights and notify physician of weight loss.
F880 Infection Prevention & Control: Facility failed to establish and maintain an infection prevention program, including failure to follow hand hygiene and wound care protocols.
Report Facts
Facility census: 70
Sampled residents: 16
Facility census: 63
Facility census: 60
Inspection Report
Life Safety
Census: 70
Capacity: 92
Deficiencies: 10
Date: May 23, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Crestview Home.
Findings
The facility failed to maintain proper delayed-egress locking systems, exit signage, corridor door resistance to smoke passage, fire drill compliance, and smoking material maintenance. These deficiencies had the potential to affect residents, staff, and visitors' safety during emergencies.
Deficiencies (10)
K222 Delayed-egress locking arrangements were not maintained, causing obstruction to exit access egress and failure to release doors within 15 seconds. The front entrance and Transition lobby doors were affected.
K293 Exit signage was inadequate as the facility failed to post NO EXIT signs on four interior courtyard doors, risking confusion during emergencies.
K363 Corridor doors failed to resist smoke passage due to gaps and improper sealing, affecting five of fourteen smoke compartments.
K712 Fire drills were not conducted on every shift each quarter as required, with no drills documented for August through November 2018.
K741 Smoking regulations were not met as designated smoking areas lacked required ashtrays for safe disposal of cigarette butts.
A2058 The facility failed to obtain required annual consultation from the local fire department regarding emergency evacuation plans, affecting safety preparedness.
A2037 Exit requirements were not met as the facility lacked two unobstructed remote exits on each floor, violating fire safety codes.
A2057 Smoking areas did not have proper ashtrays of noncombustible material, violating safe disposal requirements.
A2061 Fire drill requirements were not met; a minimum of twelve fire drills annually with at least one every three months per shift were not conducted.
A3001 The building was not substantially constructed and maintained in good repair as required by regulations.
Report Facts
Bed capacity: 92
Resident census: 70
Fire drills missing: 4
Number of smoke compartments affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding door repairs, fire drills, and smoking area maintenance | |
| Administrator | In-serviced Maintenance Supervisor on fire drill and smoking regulations |
Inspection Report
Census: 57
Deficiencies: 2
Date: Dec 27, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident self-determination rights and food safety standards at Crestview Home.
Findings
The facility failed to ensure residents received baths/showers according to their preferences and did not maintain proper food temperatures during meal service. These deficiencies affected multiple residents and were supported by observations, interviews, and record reviews.
Deficiencies (2)
F561 Self-determination: The facility failed to maintain residents' rights to make choices about significant aspects of their lives, including bathing preferences, as staff did not provide baths/showers according to resident preferences. This affected two of five sampled residents.
F804 Food and drink: The facility failed to ensure food was served at safe and appetizing temperatures, with at least one resident receiving meals that were cold or lukewarm. Observations and interviews confirmed food temperatures were not maintained properly.
Report Facts
Facility census: 57
Number of sampled residents affected: 2
Number of residents affected by food temperature deficiency: 1
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 8
Date: May 3, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies related to medication administration, resident care plans, infection control, fall prevention, and staff training. Several residents' care needs were not met according to professional standards and regulatory requirements.
Deficiencies (8)
F658 Services Provided Meet Professional Standards: The facility failed to ensure medications were administered and documented properly for residents #7 and #40.
F677 Dependent Residents: The facility failed to provide adequate personal care and hygiene for residents, including perineal care and showering.
F689 Accidents: The facility failed to ensure residents were free from accident hazards and did not follow proper procedures for mechanical lifts and transfers.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide adequate care to prevent urinary tract infections and maintain catheter care.
F761 Labeling of Drugs and Biologicals: The facility failed to ensure medications were properly labeled and stored with expiration dates.
F809 Bedtime Snacks: The facility failed to provide bedtime snacks to all residents as required by policy.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection control program, including hand hygiene and use of gloves.
F580 Notify of Changes (Injury/Decline/Room, etc.): The facility failed to notify the responsible party promptly of a resident's fall and injury.
Report Facts
Facility census: 58
Deficiencies cited: 8
Inspection Report
Life Safety
Census: 58
Capacity: 122
Deficiencies: 8
Date: May 3, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements at Crestview Home.
Findings
The facility failed to maintain a comprehensive emergency preparedness plan and did not meet several life safety code requirements including smoke barrier maintenance, smoke damper functionality, and fire drill procedures. Deficiencies affected all residents and posed potential safety risks.
Deficiencies (8)
E001: The facility failed to have a complete comprehensive emergency preparedness plan covering sheltering, evacuation, staffing, and communication procedures. The plan lacked provisions for at-risk residents and call light outages.
K161: The facility failed to maintain smoke barrier walls when attic doors were left open, affecting 4 of 10 smoke compartments. This violated NFPA 101 Life Safety Code requirements.
K372: The facility failed to ensure all four smoke dampers closed upon fire alarm activation; one damper over the 200 hall did not close properly.
K712: The facility failed to conduct fire drills in accordance with NFPA 101, 2012 edition, at unexpected times under varying conditions to familiarize occupants with routine response.
A2054: The facility did not meet the requirement for one-hour fire-rated smoke section walls and doors with self-closing or automatic closing features.
A2059: The facility failed to meet fire drill and emergency preparedness plan requirements including phased evacuation and staff instructions.
A2061: The facility did not conduct the minimum required twelve fire drills annually with unannounced drills including simulated resident evacuation.
A3001: The building was not substantially constructed and maintained in good repair per NFPA 101 standards.
Report Facts
Facility capacity: 122
Resident census: 58
Fire drills: 12
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