Inspection Reports for
Crestview Nursing & Residential Living

The facility failed to ensure designated staff completed Functional Capacity Screens for Residents 1 and 3 upon changes in their conditions. Staff documented over prior FCS forms instead of completing new assessments as required.

The facility was found deficient in revising individualized care plans for residents with PTSD, ensuring safe mechanical lift transfers to prevent accidents, and offering or documenting pneumococcal vaccinations for eligible residents. These deficiencies placed residents at risk for impaired care, injury, and increased risk of pneumonia complications.

The facility failed to revise a resident's care plan to address PTSD triggers, resulting in risk of impaired care. The facility also failed to prevent a resident's injury during a mechanical lift transfer, resulting in a fractured finger. Additionally, the facility did not offer or document pneumococcal vaccination (PCV20) for three residents, increasing their risk for pneumonia complications.

The facility failed to complete the Functional Capacity Screen (FCS) on or before admission for resident R101. The negotiated service agreements (NSA) for residents R101, R102, and R103 were either not developed based on completed FCS or did not fully address service needs and preferences. Additionally, the NSA did not identify the current licensed nurse responsible for implementation and supervision of health care services for residents R102 and R103.

The inspection identified multiple deficiencies including incomplete negotiated service agreements for residents, failure to identify licensed nurses responsible for health care service plans, incomplete medication administration documentation, missing timely verification of nurse aide registry checks for new employees, lack of quarterly emergency management plan reviews with staff, and unsafe food storage practices with missing temperature logs.

The facility failed to label and date opened insulin pens, store and serve food under sanitary conditions, and properly disinfect glucometers and maintain infection control during resident water and ice pass, placing residents at risk for ineffective medication, foodborne illnesses, and communicable diseases.

The facility failed to label and date opened insulin pens, store and serve food under sanitary conditions, maintain infection control during water and ice pass, and properly disinfect glucometers, placing residents at risk for ineffective medication, foodborne illnesses, and communicable diseases.

The investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The facility plans to implement a facility-wide system to ensure continued compliance with regulations, focusing on infection control through staff education and competency checks for housekeeping and nursing staff.

The survey found a widespread 'F' level deficiency 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 reviewed and accepted, resulting in a finding of 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 report confirms that the previously cited deficiency under regulation 483.20(g)-(j) was corrected as of 08/01/2017. No other deficiencies or uncorrected issues are noted.

The facility acknowledged deficiencies related to MDS coding accuracy and outlined corrective actions including staff education, double-checking MDS codes, and ongoing monitoring through self-audits and QA team chart reviews.

The survey found a most serious deficiency at a 'D' level, isolated, 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 based on the credible allegation of compliance and evidence of correction.

The facility failed to accurately code intermittent catheterization for one resident (#7) in multiple MDS assessments, including the annual and quarterly assessments, despite clinical evidence and physician orders indicating the need for intermittent catheterization.

The complaint investigation substantiated that resident #20, identified as an elopement risk, left 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.

The facility failed to provide adequate supervision for a cognitively impaired resident who eloped approximately 12 blocks from the facility without staff knowledge, placing the resident in immediate jeopardy. The investigation revealed door alarm and staff response failures.

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

The revisit confirmed that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 02/20/2015. No other deficiencies were noted.

The facility acknowledged failure to report a resident's fall investigation to the state agency despite no malice found. The facility has reviewed and updated its policies and trained staff to ensure proper reporting and compliance.

The survey identified a 'D' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.

The complaint investigation #83503 was substantiated as the facility did not report the resident's allegation of staff abuse to the state agency within the required timeframe, only reporting to Adult Protective Services.

The facility failed to investigate and report to the state agency an incident where a resident fell resulting in a fractured hip and alleged staff abuse. The facility reported the incident to Adult Protective Services but did not notify the state agency as required.

The facility addressed 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 deficiency includes a corrective action plan with monitoring and education to ensure continued compliance.

The report confirms that all previously cited deficiencies identified by regulation numbers 26-41-202 (a), 26-41-202 (h), and 26-41-205 (d)(3) were corrected as of the revisit date.

The facility has developed and will implement a system to assure continued compliance with regulations, including updating policies related to NSA signing and medication documentation. Monitoring and compliance measurement will be conducted by the Quality Assurance team and the Operator.

The facility was found not in substantial compliance and was cited for immediate jeopardy to resident health or safety from July 27, 2014 through August 19, 2014 related to F323"K" CFR 01-483.25(h). The facility was also cited for substandard quality of care and noncompliance with pressure ulcer prevention requirements.

The inspection was triggered by complaint investigations #KS00077904 and #KS00077712 and included an 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, failure to follow pressure ulcer care plans, inadequate supervision of residents at risk for elopement, failure to monitor supplement intake, failure to monitor effectiveness of behavioral medications, insufficient RN coverage, failure to report irregularities in drug regimen, improper infection control practices, and lack of a hospital transfer agreement.

The facility failed to ensure the development of written Negotiated Service Agreements (NSA) that included collaboration with residents' legal representatives and licensed nurses for residents requiring health care services. Additionally, the facility failed to document medication administration times on the medication administration records (MAR) for sampled residents.

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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the previously identified deficiencies, including one under regulation 483.25(h), were corrected by the date specified. No uncorrected deficiencies remain.

This Plan of Correction addresses deficiencies cited in a complaint investigation at Crestview Manor.

The facility identified concerns related to resident elopement risk and has developed a comprehensive plan to ensure compliance with regulations, including updated policies, staff training, and monitoring procedures.

The complaint investigation #KS68105 found that the facility failed to supervise a cognitively impaired resident who eloped from the facility, traveling 1.7 miles and crossing a highway and railroad tracks. The resident was found and returned by a family member. The facility's policies and procedures were reviewed and found deficient in preventing elopement.

The facility failed to provide supervision to prevent a cognitively impaired resident from leaving the facility unsupervised, resulting in the resident traveling 1.7 miles, crossing a highway and railroad tracks. This placed the resident in immediate jeopardy. The facility implemented corrective actions to address the issue.

The report shows that deficiencies previously reported under regulations 483.25(d) and 483.25(h) were corrected as of the revisit date.

The facility identified deficiencies related to incontinent care procedures and comprehensive care to prevent injuries and accidents. The plan includes staff education, care plan updates, monitoring compliance, and ongoing training to ensure substantial compliance by July 1, 2013.

The facility failed to provide appropriate incontinence care for a severely cognitively impaired resident and failed to consistently use body and motion sensor alarms for a resident at high risk for falls, resulting in safety concerns.

The report shows that the previously cited deficiency under regulation 483.25(h) was corrected as of 12/01/2012. No other deficiencies or issues are noted.

This Plan of Correction is in response to a complaint survey, indicating deficiencies were identified during a complaint investigation.

The facility identified deficiencies related to the use and safety of side rails. The Plan of Correction outlines actions to ensure resident safety, including assessments, care plan updates, removal of side rails, and ongoing monitoring by the Quality Assurance committee.

The inspection was triggered by a complaint investigation regarding resident safety related to side rails and alternating air mattresses.

The facility failed to assess the safety of using side rails in conjunction with alternating air mattresses 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 provide staff training on low air loss mattresses and did not conduct side rail assessments for residents. Immediate jeopardy was identified and later abated with corrective actions including assessments, policy development, staff training, and quality assurance monitoring.

The facility identified deficiencies related to medication storage, food preparation and handling, and infection control. The Plan of Correction outlines staff education, competency checks, monitoring, and quality assurance measures to ensure compliance.

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