Inspection Reports for
Crestview Nursing & Residential Living

The facility failed to ensure designated staff completed Functional Capacity Screens for Residents 1 and 3 when they experienced changes in condition, including a compression fracture and a diagnosis of C-diff, respectively.

The facility was found deficient in revising care plans to address PTSD triggers for a resident, ensuring safe mechanical lift transfers which resulted in a fractured finger for a resident, and failure to offer or document pneumococcal vaccination (PCV20) for eligible residents. Corrections were made for the mechanical lift deficiency prior to the survey.

The facility failed to complete the Functional Capacity Screen (FCS) on or before admission for resident R101, and failed to develop or update Negotiated Service Agreements (NSA) based on the FCS and service needs for residents R101, R102, and R103. Additionally, the NSA did not identify the licensed nurse responsible for health care service implementation and supervision for residents R102 and R103.

The inspection found multiple deficiencies including failure to fully develop negotiated service agreements based on functional capacity screenings for residents, failure to identify licensed nurses responsible for health care service plans, incomplete documentation of medication administration responsibilities, incomplete employee records regarding nurse aide registry verification, lack of quarterly emergency management plan reviews with staff, and failure to ensure food storage temperatures were consistently monitored and documented.

The facility was found deficient in labeling and storing drugs properly, maintaining sanitary food storage and preparation conditions, and adhering to infection prevention and control protocols, including improper handling of resident water and ice passes and failure to disinfect glucometers between uses.

The plan addresses deficiencies related to infection control, including education and competency checks for housekeeping and nursing staff to prevent cross contamination and maintain standard infection control techniques. The facility aims to achieve substantial compliance by October 31, 2017.

The survey found a most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 10/30/2017.

The facility failed to effectively clean and sanitize resident rooms and equipment, including improper handling of reusable glucose testing equipment, failure to use clean barriers during dressing changes, and inadequate cleaning procedures by housekeeping staff, particularly not adhering to disinfectant wet time requirements.

The revisit confirmed that the previously cited deficiency with ID Prefix F0278 related to regulation 483.20(g)-(j) was corrected as of 08/01/2017. No other deficiencies or uncorrected issues were noted.

The facility failed to accurately code intermittent catheterization for resident #7 in multiple MDS assessments, including the 10/26/16 annual MDS and subsequent quarterly assessments. This deficiency involved failure to reflect the resident's use of intermittent catheterization in the bowel and bladder section of the MDS.

The facility acknowledged deficiencies related to the accuracy of Minimum Data Set (MDS) coding and outlined corrective actions including staff education, modification of the resident's MDS, and implementation of monitoring and quality assurance processes to ensure compliance.

The survey found a single isolated 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective August 1, 2017.

The survey found that the facility was not in substantial compliance with participation requirements, constituting past non-compliance to resident health or safety from September 4 through September 8, 2015. Based on these deficiencies and prior non-compliance history, enforcement remedies will be imposed without an opportunity for correction.

The complaint investigation found that resident #20, with severe cognitive impairment and dementia, exited the facility without staff knowledge and was found 12 blocks away. Staff failed to properly respond to door alarms and monitor the resident, resulting in immediate jeopardy to the resident's safety.

The facility failed to provide adequate supervision for a cognitively impaired resident (#20) who eloped from the facility and was found approximately 12 blocks away, placing the resident in immediate jeopardy. The investigation revealed lapses in staff response to door alarms and monitoring of residents at risk for elopement.

The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.

The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected by 02/20/2015.

The visit was complaint-related, triggered by a resident's fall and allegations. The facility found no malice but acknowledged failure to report the incident to the state agency. Staff were inserviced to prevent recurrence. The plan aims to ensure substantial compliance by February 20, 2015.

The facility acknowledged deficiencies related to failure to report a resident's fall allegations to the state agency and has developed a facility-wide system to ensure compliance with reporting requirements and regulations.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The complaint investigation (#83503) was substantiated as the facility failed to report the alleged staff abuse to the state agency in a timely manner and did not properly investigate the incident as required.

The facility failed to investigate and report to the state agency an incident where a resident fell and sustained a fractured hip requiring surgery, and alleged staff abuse. The facility reported the incident to Adult Protective Services but did not notify the state agency as required, and administrative staff only became aware of the abuse allegations approximately 8 days after the incident.

All deficiencies previously cited were corrected as of 09/20/2014, with no uncorrected deficiencies noted at the time of this revisit.

The report confirms that the deficiencies identified in regulations 26-41-202 (a), 26-41-202 (h), and 26-41-205 (d)(3) were corrected as of 09/20/2014.

The plan outlines corrective actions for multiple deficiencies including abuse policy updates, comprehensive assessments, MDS accuracy, neurological checks, pressure sore prevention, elopement safety, care plans for weight loss, pharmacy services, staffing patterns, infection control, and transfer agreements. Each corrective action includes monitoring and compliance measures with a target substantial compliance date of September 20, 2014.

The plan addresses deficiencies related to NSA signing by legal POA and licensed nurses, and documentation of medication administration times, with corrective actions including policy updates, staff inservices, and monitoring by the Quality Assurance team.

The visit included a complaint investigation identified by complaint numbers #KS00077904 and #KS00077712, along with a Health Resurvey and Extended Health Resurvey.

The facility was found deficient in multiple areas including failure to maintain active CNA certification, incomplete comprehensive assessments, inaccurate Minimum Data Set (MDS) assessments, failure to complete neurological checks post-fall, inadequate pressure ulcer care, insufficient supervision to prevent resident elopement, failure to maintain RN coverage for 8 consecutive hours, failure to monitor effectiveness of behavioral medications, improper infection control practices, and lack of a hospital transfer agreement.

The facility failed to ensure the development of written Negotiated Service Agreements (NSA) in collaboration with residents' legal representatives and failed to include licensed nurse signatures on NSAs when health care services were required. Additionally, the facility did not document medication administration times on the medication administration records (MAR) for sampled residents.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety from July 27, 2014 through August 19, 2014. The facility was cited for substandard quality of care and faced enforcement remedies including denial of payment for new admissions and possible termination of provider agreement.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

The report confirms that the previously cited deficiency with regulation 483.25(h) was corrected by 09/30/2013. No other deficiencies or issues are noted.

The Plan of Correction is in response to a complaint survey (Event ID 22GL11) at Crestview Manor.

The facility identified concerns related to resident elopement risks and has developed a comprehensive plan to ensure compliance, including updated policies, staff training, environmental adjustments, and ongoing monitoring.

Complaint investigation #KS68105. The resident was found to have eloped from the facility, was missing for approximately 50 minutes, and was located 1.7 miles away. The resident was cognitively impaired with dementia and Alzheimer's disease and required supervision to prevent elopement. The facility failed to provide adequate supervision and monitoring.

The facility failed to provide adequate supervision to a cognitively impaired resident at risk for elopement, who left the facility unsupervised and traveled 1.7 miles crossing a 4-lane highway and railroad tracks, placing the resident in immediate jeopardy. The facility's policies and care plans were reviewed and corrective actions were implemented to prevent recurrence.

The revisit report shows that the deficiencies identified under regulations 483.25(d) and 483.25(h) were corrected as of 07/01/2013.

The facility has developed and will implement a system to assure continued compliance with regulations, including incontinent care procedures and comprehensive care plans to prevent injury and accidents. Staff education and monitoring processes are scheduled to ensure ongoing compliance.

The facility failed to provide appropriate incontinence care for a severely cognitively impaired resident requiring extensive assistance, and failed to consistently provide supervision and use of safety devices such as body and motion sensor alarms for a resident at high risk for falls.

The report confirms that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 12/01/2012.

This Plan of Correction is in response to a complaint survey identified as Crestview 111912 Complaint Revised.

The facility identified deficiencies related to the use and safety of side rails and has implemented a facility-wide system to ensure compliance, including assessments, care plan updates, removal of side rails, and ongoing monitoring by the Quality Assurance committee.

The visit was complaint-related as indicated by the report title and findings addressing specific resident safety concerns following a fall incident on 11/1/12.

The facility failed to assess the safety of using alternating air mattresses with side rails for cognitively impaired, dependent residents, resulting in a resident found on the floor with neck pressed against side rails causing injury. The facility also failed to conduct side rail assessments and provide staff training on low air loss mattresses, placing residents at risk for falls and injury.

The plan addresses deficiencies related to PTSD care planning and infection control regarding the offering of the PCV20 vaccine to residents. The facility outlines corrective actions including staff education, audits, and ongoing monitoring to ensure compliance.

The plan addresses deficiencies related to medication storage, food preparation and handling, and infection control practices. The facility outlines corrective actions including staff re-education, competency checks, monitoring by designated staff, and equipment improvements to ensure compliance.