Inspection Reports for
North Crest Living Center
34 Northcrest Drive, Council Bluffs, IA, 515031695
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
255% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
92% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
A complaint investigation for complaint #2637597-C and facility reported incident #2647838-I was conducted from October 21, 2025 to October 23, 2025.
Complaint Details
Complaint investigation for complaint #2637597-C and facility reported incident #2647838-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 30, 2025
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective September 24, 2025.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Report Facts
Certification effective date: Sep 24, 2025
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status following a prior inspection or complaint.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective August 23, 2025.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Aug 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the primary care physician of lab results and failure to provide appropriate catheter care and infection prevention practices for residents with indwelling catheters.
Complaint Details
The complaint investigation substantiated failures in physician notification of lab results and catheter care, resulting in Resident #1's hospitalization for sepsis secondary to urinary tract infection.
Findings
The facility failed to notify the physician of abnormal urine analysis and culture results for Resident #1, leading to hospitalization for sepsis secondary to urinary tract infection. The facility also failed to provide appropriate catheter flush interventions and infection prevention practices, including gown use and hand hygiene, for residents with indwelling catheters.
Deficiencies (3)
F 0580: The facility failed to notify the primary care physician of abnormal urine analysis and bacteria culture results for Resident #1, resulting in delayed treatment and hospitalization.
F 0690: The facility failed to provide appropriate catheter care interventions, including flushing the catheter as needed for Resident #1, despite physician orders and documented low urine output.
F 0880: The facility failed to implement proper infection prevention practices, including gown use and hand hygiene, during catheter and peri care for Resident #3 on Enhanced Barrier Precautions.
Report Facts
Residents reported in census: 57
Urine analysis red blood cells: 51
Urine analysis bacteria: 4
Urine output measurements: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) / Charge Nurse | Acknowledged responsibility for lab results processing and notification on 8/7/25 |
| Staff B | Medical Doctor (MD) / Primary Care Physician | Notified of Resident #1's hospitalization and commented on lab result notification |
| Staff C | Medical Records Staff | Acknowledged role in lab results processing and fail safe |
| Director of Nursing (DON) | Director of Nursing | Acknowledged missed physician notification and updated nurses on lab result handling |
| Staff D | Physician's Assistant (PA) | Provided expert opinion on catheter flush expectations for Resident #1 |
| Staff E | Registered Nurse (RN) | Described catheter flush indications for Resident #1 |
| Staff F | Licensed Practical Nurse (LPN) | Acknowledged catheter flush use and documentation for Resident #1 |
| Staff G | Licensed Practical Nurse (LPN) | Explained catheter flush use for Resident #1 |
| Staff H | Certified Nursing Assistant (CNA) | Observed providing catheter care without gown use for Resident #3 |
| Staff I | Certified Nursing Assistant (CNA) | Observed providing catheter care without gown use for Resident #3 |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Aug 26, 2025
Visit Reason
The inspection was conducted as a result of investigations of complaints #2579967-C, #2571024-C, and #2593508-C between August 21 and August 26, 2025.
Complaint Details
The visit was triggered by complaints #2579967-C, #2571024-C, and #2593508-C. Complaints #2571024-C and #2593508-C resulted in deficiencies.
Findings
The facility failed to notify the primary care physician timely of lab results related to a urine analysis for Resident #1, resulting in a hospitalization due to respiratory failure from aspiration. The facility also failed to provide appropriate interventions to prevent urinary tract infections and did not consistently follow infection prevention and control practices, including enhanced barrier precautions for residents with catheters.
Deficiencies (3)
Failure to notify the primary care physician of lab results related to a urine analysis for Resident #1.
Failure to provide appropriate interventions and services to prevent urinary tract infections for residents with catheters.
Failure to follow appropriate infection prevention and control practices, including enhanced barrier precautions for residents with catheters.
Report Facts
Census: 57
Deficiencies cited: 3
Inspection Report
Routine
Census: 61
Deficiencies: 14
Date: Jul 24, 2025
Visit Reason
Routine inspection of North Crest Living Center to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to inform residents about Medicare coverage options, inadequate care plans for residents with catheters and psychotropic medications, failure to follow physician orders for insulin and catheter use, inadequate respiratory care documentation, failure to maintain food at safe temperatures, insufficient dementia care planning, incomplete infection prevention practices, and lack of proper consent and education documentation for influenza and COVID-19 vaccinations.
Deficiencies (14)
F0582: Facility failed to inform residents of Medicaid/Medicare coverage options and potential liability for non-covered services for 3 residents.
F0584: Facility failed to provide a safe, clean, comfortable, and homelike environment; beds were unmade and linen was not timely applied for 3 residents.
F0605: Facility failed to identify non-pharmacological interventions and targeted behaviors on care plans related to high risk psychotropic medications for 3 residents.
F0628: Facility failed to provide bed hold notice to resident or responsible person when resident transferred to hospital for 1 resident.
F0656: Facility failed to develop and implement comprehensive care plans with measurable goals and interventions for residents with catheters, depression, and anxiety for 6 residents.
F0658: Facility failed to obtain and follow physician orders for insulin administration and catheter use for 2 residents.
F0695: Facility failed to provide safe and appropriate respiratory care; lacked orders and documentation for oxygen tubing changes for 1 resident.
F0744: Facility failed to provide appropriate treatment and services for a resident with dementia; care plan lacked individualized goals and interventions.
F0804: Facility failed to provide food at safe and appetizing temperatures for 4 residents; food temperatures were below expected levels.
F0865: Facility failed to demonstrate effective quality assurance and performance improvement (QAPI) with incomplete correction of repeat deficiencies related to catheter care plans and orders.
F0880: Facility failed to implement infection prevention and control program; laundry staff did not use proper PPE and infection preventionist duties were not consistently performed.
F0881: Facility failed to implement an effective antibiotic stewardship program; lacked monitoring and tools to track antibiotic use.
F0883: Facility failed to obtain signed consents and provide education prior to influenza vaccination for multiple residents.
F0887: Facility failed to obtain signed consents and provide education prior to COVID-19 vaccination for multiple residents.
Report Facts
Residents on antibiotics: 6
Residents census: 61
Food temperature: 105
Food temperature: 124.5
Food temperature: 109.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Named in insulin administration finding for Resident #36. |
| Staff B | Licensed Practical Nurse | Named in insulin administration finding for Resident #36 and dementia care observation. |
| Staff D | Certified Nurse Assistant | Named in dementia care observation for Resident #37. |
| Staff J | Certified Dietary Manager | Named in food temperature observation. |
| Staff K | Registered Dietitian | Named in food temperature observation. |
| Staff L | Environmental Aide | Named in infection control observation for failure to wear PPE in laundry. |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection control, antibiotic stewardship, and immunization consent. |
| Administrator | Administrator | Named in multiple findings including food temperature, immunization consent, and quality assurance. |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 13
Date: Jul 24, 2025
Visit Reason
The inspection visit was the facility's annual recertification survey conducted from July 21, 2025 to July 24, 2025.
Findings
The facility was found to have multiple deficiencies including failure to inform residents of Medicaid/Medicare coverage changes, failure to maintain a safe, clean, and homelike environment, failure to identify non-pharmacological interventions for high-risk medications, failure to ensure bed hold notices, incomplete comprehensive care plans, failure to follow physician orders for insulin and catheter care, failure to provide food at appetizing temperatures, failure to demonstrate good faith efforts to correct deficiencies, failure to follow infection control standards, failure to follow antibiotic stewardship practices, and failure to obtain and document consents and education for influenza and COVID-19 immunizations.
Deficiencies (13)
Facility failed to inform residents of their options and costs when services were no longer covered by Medicare Part A for 3 of 3 residents reviewed.
Facility failed to provide residents with a safe, clean, comfortable, and homelike environment; beds not made timely; debris on floors for multiple residents.
Facility failed to identify non-pharmacological interventions and targeted behaviors on care plans related to high risk medications for 3 of 5 sampled residents.
Facility failed to ensure bed hold notice was sent to resident or responsible person when resident transferred out for 1 of 1 residents reviewed.
Facility failed to provide a comprehensive care plan including goals or interventions for residents with catheter, depression, and anxiety for 6 of 10 residents reviewed.
Facility failed to obtain and follow physician orders for insulin administration and indwelling urinary catheter for 2 of 21 residents reviewed.
Facility failed to provide respiratory care and services in accordance with professional standards for 1 of 1 residents reviewed.
Facility failed to provide food at an appetizing temperature to 4 of 24 residents reviewed.
Facility failed to demonstrate good faith attempts to correct quality deficiencies based on repeat deficiencies and incomplete corrective action plan.
Facility failed to follow infection control standards; laundry staff failed to wear PPE while sorting laundry; inconsistent implementation of infection preventionist responsibilities.
Facility failed to ensure antibiotic stewardship practices were followed.
Facility failed to ensure staff obtained signed consents and provided education on influenza immunization before administration.
Facility failed to ensure staff obtained signed consents and provided education on COVID-19 immunization before administration.
Report Facts
Census: 61
Deficiencies cited: 13
Linen purchase amount: 1559.46
Linen purchase amount: 1234.1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
A complaint investigation was conducted for complaints #124177-C and #125415-C from December 30, 2024 to December 31, 2024.
Complaint Details
Complaint investigation for complaints #124177-C and #125415-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2024
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction for regulatory compliance certification.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted, resulting in certification effective October 19, 2024.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify the physician immediately after a resident's sudden change in condition and transfer to the emergency department, failure to obtain bed hold notifications for hospitalized residents, and failure to provide professional standards of care by obtaining daily weights as ordered.
Complaint Details
The complaint investigation substantiated failures in timely physician notification after emergency transfer, bed hold notification documentation, and adherence to physician orders for daily weights.
Findings
The facility failed to notify the primary care physician immediately after a resident was transferred to the emergency department with chest pain and shortness of breath. The facility also failed to obtain bed hold notifications for two residents hospitalized during the review period. Additionally, the facility did not obtain daily weights as ordered for one resident at risk for weight variations.
Deficiencies (3)
F 0580: The facility failed to notify the physician immediately after a resident's sudden change in condition and transfer to the emergency department with chest pain and shortness of breath.
F 0625: The facility failed to notify the resident or representative in writing how long the nursing home will hold the resident's bed during hospital or therapeutic leave for 2 of 3 residents reviewed.
F 0658: The facility failed to provide professional standards of care by not obtaining daily weights per physician orders for 1 of 16 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Census: 56
Dates weights not obtained: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported on failure to notify PCP immediately after resident transfer and daily weights not obtained | |
| Primary Care Physician | Reported not being notified immediately after resident transfer to ED | |
| Administrator | Acknowledged failure to obtain bed hold notifications and discussed facility policy |
Inspection Report
Routine
Census: 56
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
Routine state inspection of North Crest Living Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to obtain physician orders for DNR, failure to notify physicians immediately after resident condition changes, missing bed hold notifications, inaccurate Minimum Data Set (MDS) submissions, incomplete care plans for high risk medications, failure to obtain daily weights as ordered, inadequate nursing staff on weekends, and failure to follow infection prevention and control protocols including lack of a facility-wide infection control policy.
Deficiencies (10)
F 0578: The facility failed to obtain a signed physician order for DNR status for 1 of 14 residents reviewed.
F 0580: The facility failed to notify the physician immediately after a resident's sudden change in condition and transfer to the emergency department for 1 of 16 residents reviewed.
F 0582: The facility failed to notify a resident 48 hours in advance when Medicare Part A stay or Part B therapies were ending for 1 of 3 residents reviewed.
F 0625: The facility failed to obtain bed hold notifications for 2 of 3 residents reviewed after hospitalizations.
F 0640: The facility failed to submit a comprehensive Minimum Data Set (MDS) within the required timeframe for 1 of 16 residents reviewed.
F 0641: The facility failed to accurately record medication use on MDS for 2 of 5 residents reviewed.
F 0656: The facility failed to provide a comprehensive care plan related to high risk medications for 2 of 5 residents reviewed.
F 0658: The facility failed to obtain daily weights per physician orders for 1 of 16 residents reviewed.
F 0725: The facility failed to provide adequate nursing staff to assure residents' safety and well-being, with lower staffing on weekends.
F 0880: The facility failed to follow standard and enhanced barrier precautions, lacked a facility-wide infection prevention and control policy, and staff did not consistently wear gowns and gloves when required.
Report Facts
Residents census: 56
Deficiencies cited: 10
Scheduled nursing hours per patient day (PPD): 3
Scheduled nursing hours per patient day (PPD): 2.44
Scheduled nursing hours per patient day (PPD): 3.53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Confirmed Resident #32 had DNR status without physician order |
| Staff B | MDS Coordinator | Acknowledged incomplete MDS submissions and inaccurate medication recording |
| Staff C | Certified Nursing Assistant (CNA) | Reported staffing shortages affecting call light response |
| Staff D | Scheduler | Confirmed staffing data accuracy |
| Staff E | Laundry Staff | Observed not wearing gloves and gowns when separating laundry |
| Staff F | Certified Nurse Aide (CNA) | Reported training on enhanced barrier precautions (EBP) |
| Staff G | Certified Nurse Aide (CNA) | Reported wearing EBP for Covid-19 residents |
| Staff H | Certified Nurse Aide (CNA) | Did not wear gown when providing catheter care and unaware of EBP requirements |
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficiencies in daily weights, infection control policy, and staffing |
| Administrator | Facility Administrator | Acknowledged deficiencies and expectations for correction |
| Primary Care Physician | Reported not being notified immediately after resident transfer to ED | |
| Infection Preventionist | Infection Preventionist (IP) | Outlined expectations for EBP and staff training |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of a substantiated complaint #122776-C.
Complaint Details
Complaint #122776-C was substantiated. The complaint investigation was part of the annual recertification survey.
Findings
The facility was found deficient in multiple areas including failure to obtain a physician order for DNR, failure to notify physicians immediately of resident condition changes or transfers to the emergency department, failure to notify residents timely about Medicare coverage changes, failure to provide bed hold notifications, failure to submit timely and accurate Minimum Data Set (MDS) assessments, inaccurate MDS medication recording, incomplete care plans related to high-risk medications, failure to obtain daily weights as ordered, insufficient nursing staff on weekends, and failure to follow infection prevention and control protocols including enhanced barrier precautions.
Deficiencies (10)
Failed to obtain a physician order for DNR for 1 of 14 residents (Resident #32).
Failed to notify the physician immediately after a sudden change in resident condition and after transferring a resident to the emergency department (Resident #28).
Failed to notify a resident 48 hours in advance when Medicare Part A stay ended or Part B therapies ended (Resident #146).
Failed to obtain bed hold notifications for 2 of 3 residents reviewed (Residents #1, #60).
Failed to submit comprehensive Minimum Data Set (MDS) assessments within required timeframes for 3 of 16 residents (Residents #32, #55, #216).
Failed to accurately record medication use on MDS for 2 of 5 residents (Residents #7, #31).
Failed to provide comprehensive care plans related to high-risk medications for 2 of 5 residents (Residents #17, #31).
Failed to obtain daily weights as ordered for 1 of 16 residents (Resident #56).
Failed to provide sufficient nursing staff to assure resident safety and well-being, especially on weekends.
Failed to follow infection prevention and control protocols including standard precautions during laundry handling and enhanced barrier precautions for residents with indwelling devices or wounds.
Report Facts
Residents reviewed: 16
Residents reviewed: 14
Residents reviewed: 3
Residents reviewed: 3
Residents reviewed: 16
Residents reviewed: 5
Residents reviewed: 5
Residents reviewed: 16
Facility census: 56
Staffing PPD weekday average: 3.29
Staffing PPD weekend average: 2.69
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2024
Visit Reason
The document serves as a plan of correction following a previous deficiency statement, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective September 2, 2024, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Aug 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to ensure resident safety from accident hazards, inadequate nursing staff response to call lights, and failure to maintain infection control practices.
Complaint Details
The investigation was complaint-driven based on reports of falls, delayed call light responses, and infection control concerns. The complaints were substantiated as deficiencies were found in resident safety, staffing responsiveness, and infection prevention.
Findings
The facility failed to follow implemented interventions to reduce hazards and protect residents, did not respond timely to call lights for some residents, and failed to maintain proper hand hygiene during personal care for one resident. The facility reported a census of 54 residents.
Deficiencies (3)
F 0689: The facility failed to ensure implemented interventions to reduce hazards and protect residents were followed for 3 residents, resulting in falls and injuries including a femur fracture.
F 0725: The facility failed to provide enough nursing staff to meet resident needs by not responding to call lights in a timely manner for 2 residents.
F 0880: The facility failed to maintain infection control practices by not performing hand hygiene between glove changes during personal care for 1 resident.
Report Facts
Resident census: 54
Call light response delays: 41
Call light response delays: 18
BIMS score: 9
BIMS score: 12
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Involved in transfer and fall incident of Resident #1 |
| Staff E | Certified Nursing Assistant | Assisted Resident #2 without gait belt contrary to care plan |
| Staff B | Certified Nursing Assistant | Observed failing to perform hand hygiene between glove changes during personal care of Resident #3 |
| Staff C | Certified Nursing Assistant | Observed failing to perform hand hygiene between glove changes during personal care of Resident #3 |
| Staff A | Certified Nursing Assistant | Provided statements regarding Resident #2's need for assistance and call light response expectations |
| Director of Nursing | Director of Nursing (DON) | Provided statements on fall review process, call light response expectations, and infection control standards |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Aug 2, 2024
Visit Reason
The inspection was conducted as a result of complaint #122474-C and a facility reported incident #122491-I, both substantiated, to investigate concerns related to resident safety, call light response times, and infection control practices.
Complaint Details
Complaint #122474-C was substantiated. Facility reported incident #122491-I was substantiated.
Findings
The facility failed to ensure implemented interventions to reduce hazards and protect residents were followed for 3 residents reviewed, failed to respond to call lights in a timely manner for 2 residents, and failed to maintain infection control practices by not performing hand hygiene during personal care for 1 resident.
Deficiencies (3)
Failed to ensure implemented interventions to reduce hazards and protect residents were followed for 3 residents (#1, #2, #3).
Failed to provide sufficient nursing staff to meet resident needs by not responding to call lights in a timely manner for 2 residents (#1 and #2).
Failed to maintain infection control practices by failing to wash hands during personal care for 1 resident (#3).
Report Facts
Census: 54
Call light response delays: 41
Call light response delays: 18
BIMS score: 9
BIMS score: 12
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Involved in transfer and fall incident of Resident #1 |
| Staff E | Certified Nursing Assistant | Assisted Resident #2 without gait belt |
| Staff A | Certified Nursing Assistant | Provided statements about Resident #2 and call light response expectations |
| Staff B | Certified Nursing Assistant | Observed failing to perform hand hygiene during personal care for Resident #3 |
| Staff C | Certified Nursing Assistant | Observed failing to perform hand hygiene during personal care for Resident #3 |
| Director of Nursing | Director of Nursing | Provided statements on fall reviews, call light expectations, and hand hygiene standards |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and will be certified in compliance effective April 22, 2024.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Mar 28, 2024
Visit Reason
The inspection was conducted following complaints regarding failure to notify families of resident falls and failure to complete assessments prior to hospitalization and upon return for certain residents.
Complaint Details
The investigation was triggered by complaints that the facility did not notify families of falls for Resident #1 and Resident #2. Family members confirmed lack of notification. The facility also failed to document assessments for Resident #5 before and after hospitalization.
Findings
The facility failed to notify family members of falls sustained by two residents and failed to complete assessments prior to hospitalization and upon return for one resident. The facility reported a census of 53 residents during the inspection.
Deficiencies (2)
F 0580: The facility failed to notify family members of falls sustained by Resident #1 and Resident #2. Incident reports documented notification to primary care providers but not to families.
F 0684: The facility failed to complete an assessment prior to hospitalization and upon return from the hospital for Resident #5. Progress notes lacked documentation of these assessments.
Report Facts
Residents present: 53
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Stated nurse responsibility for notifying family of falls | |
| Director of Nursing (DON) | Provided information about family notification process and assessments |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Mar 28, 2024
Visit Reason
The inspection was conducted as a result of complaints #114863-C and #118094-C alleging failure to notify families of residents sustaining falls and failure to complete assessments prior to hospitalization and upon return.
Complaint Details
Complaints #114863-C and #118094-C were substantiated. The facility failed to notify families of falls for Resident #1 and Resident #2 and failed to complete required assessments for Resident #5 prior to and after hospitalization.
Findings
The facility was found to have failed to notify families of two residents who sustained falls and failed to complete assessments prior to hospitalization and upon return for one resident. The facility reported a census of 53 residents during the inspection.
Deficiencies (2)
Failure to notify family of Resident #1 and Resident #2 when they sustained a fall.
Failure to complete an assessment prior to hospitalization and upon return from the hospital for Resident #5.
Report Facts
Resident census: 53
Number of residents with fall notification failure: 2
Number of residents with assessment failure: 1
Audit frequency for fall notification: 5
Audit frequency for assessment completion: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective June 28, 2023.
Inspection Report
Routine
Census: 57
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on hand hygiene and medication administration practices.
Findings
The facility failed to complete routine hand hygiene and failed to use sanitized oral syringes for medication administration for several residents. Observations showed staff did not perform hand hygiene before and after medication administration and failed to sanitize medication bottles after use.
Deficiencies (1)
F 0880: The facility failed to complete routine hand hygiene and failed to use a sanitized oral syringe for medication administration for 1 out of 1 residents reviewed. The facility also failed to complete hand hygiene after administration of eye drops for 5 of 5 residents reviewed.
Report Facts
Residents affected: 6
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medical Assistant (Staff B) | Named in multiple hand hygiene and medication administration deficiencies | |
| Director of Nursing (DON) | Interviewed regarding hand hygiene expectations |
Inspection Report
Routine
Census: 57
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including comprehensive resident assessments and infection prevention and control practices.
Findings
The facility failed to complete a comprehensive assessment related to a significant change for one resident and failed to perform proper hand hygiene and use sanitized oral syringes during medication administration for multiple residents.
Deficiencies (2)
F 0637: The facility failed to complete and submit a comprehensive assessment related to a significant change for 1 of 5 residents reviewed (Resident #29).
F 0880: The facility failed to complete routine hand hygiene and failed to use a sanitized oral syringe for medication administration for 1 of 1 residents reviewed (Resident #9) and failed hand hygiene after eye drop administration for 5 of 5 residents reviewed.
Report Facts
Residents census: 57
Medication dose: 0.5
Residents reviewed for assessment: 5
Residents reviewed for hand hygiene: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medical Assistant (Staff B) | Named in multiple hand hygiene and medication administration findings | |
| Director of Nursing (DON) | Provided statements regarding assessment requirements and hand hygiene expectations | |
| MDS Coordinator | Acknowledged failure to complete significant change MDS assessment |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaints #111236-C and #111499-C.
Complaint Details
Complaints #111236-C and #111499-C were investigated and found not substantiated.
Findings
The facility failed to complete and submit a comprehensive assessment related to a significant change for one resident (Resident #29). Additionally, the facility failed to follow proper infection prevention and control procedures, including hand hygiene and use of sanitized medication administration equipment for multiple residents.
Deficiencies (2)
Failure to complete and submit a comprehensive assessment related to a significant change for Resident #29.
Failure to complete routine hand hygiene and use a sanitized oral syringe for medication administration for Resident #9 and failure to perform hand hygiene after administration of eye drops for Residents #14, #41, #22, and #17.
Report Facts
Resident census: 57
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medical Assistant (CMA) | Named in infection prevention and control deficiencies related to improper hand hygiene and medication administration |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding assessment requirements and infection control expectations |
| MDS Coordinator | Acknowledged failure to complete significant change MDS and updated it during the survey |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The inspection was conducted to investigate complaints numbered 107060-C, 107883-C, 108348-C, and 108350-C.
Complaint Details
Complaints 107060-C, 107883-C, 108348-C, and 108350-C were investigated and found not substantiated.
Findings
The complaints investigated during the visit from November 15-18, 2022, were not substantiated.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Aug 5, 2022
Visit Reason
Investigation of complaint #106254-C and facility reported incident #106383 conducted from July 27 to August 3, 2022, regarding a resident burn injury caused by hot chocolate served at an unsafe temperature.
Complaint Details
The investigation was triggered by complaint #106254-C and facility incident #106383. Both were substantiated. Resident #1 suffered burns from hot chocolate served at a temperature that was too high, causing hospitalization and pain control treatment.
Findings
The facility failed to ensure the resident environment was free of accident hazards, resulting in Resident #1 suffering severe oral burns from hot chocolate served at approximately 140 degrees Fahrenheit. The resident required hospitalization for burns and respiratory complications. The facility implemented a new policy to ensure hot liquids are served at or below 135 degrees Fahrenheit.
Deficiencies (1)
Failure to ensure the resident environment remains free of accident hazards, resulting in a resident being burned by hot chocolate served at an unsafe temperature.
Report Facts
Resident census: 46
Hot water temperature before mixing: 160
Hot chocolate temperature after mixing: 140
Safe hot liquid serving temperature: 135
Resident initial temperature: 104.1
Resident temperature peak: 105
Resident oxygen saturation: 77
Resident oxygen saturation after adjustment: 92
Resident oxygen saturation in ER: 76
Resident oxygen saturation after titration: 91
Resident oxygen saturation after oxygen turned off: 81
Resident temperature lowest recorded by nurse: 103.7
Hot water temperature tested with thermometer: 104
Hot water temperature retested: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Dietary Aide | Served hot chocolate to Resident #1; stated water was heated on stove and served without temperature check |
| Staff G | Dietary Aide | Reported Resident #1 did not come out for dinner on 7/21/22 and usually asks for hot chocolate |
| Staff C | Certified Nursing Assistant (CNA) | Resident #1's CNA on 7/21/22 overnight shift; noted resident was confused and had blisters on 7/22/22 |
| Staff B | Licensed Practical Nurse (LPN) | Assessed Resident #1 on 7/22/22 with fever and lethargy; sent resident to ER |
| Staff D | Dietary Aide | Reported boiling water on stove for hot chocolate and not checking temperature prior to incident |
| Staff E | Cook | Reported no temperature checks before incident; now required to ensure hot beverage temperature is at or below 135°F |
| Staff A | Dietary Aide | Reported boiling water on stove and no temperature checks before incident; now cooks check temperature |
| Administrator | Tested hot water temperature; implemented new hot liquid temperature policy; educated dietary staff | |
| DON | Director of Nursing | Visited Resident #1 in hospital; communicated with PCP and hospitalist; involved in investigation |
| Hospitalist | Physician | Provided hospital care to Resident #1; documented thermal burns from hot liquid retained by dentures |
| PCP | Primary Care Provider | Spoke with hospitalist and facility DON; confirmed burns were thermal, not thrush |
| Dietary Manager | Monitors hot liquid temperature logs and enforces new policy |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 22, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility was certified in compliance effective 4/22/22 based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 2
Date: Mar 24, 2022
Visit Reason
The inspection was conducted as an annual recertification survey of North Crest Living Center from March 21-24, 2022.
Findings
The facility was found deficient in providing adequate bathing assistance to dependent residents and in infection prevention and control practices, including hand hygiene and laundry handling. Specific residents were identified with care deficits and the facility failed to ensure proper staff compliance with hygiene protocols.
Deficiencies (2)
Failure to provide adequate bathing assistance to dependent residents, specifically Resident #40.
Failure to establish and maintain an infection prevention and control program, including failure to perform hand hygiene during perineal care and failure to cover laundry carts properly.
Report Facts
Census: 48
Bath frequency: 3
Rooms with hand hygiene failures: 9
Residents reviewed for bathing assistance: 4
Residents reviewed for hand hygiene: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported on bath schedules and staff expectations for hand hygiene |
| Staff D | Certified Nursing Assistant (CNA) | Reported that at times residents did not have their baths due to only one aide scheduled |
| Staff A | Certified Nurse's Aide (CNA) | Observed failing to perform hand hygiene approximately 5 times during perineal care |
| Staff B | Certified Nurse's Aide (CNA) | Observed washing hands and donning gloves during perineal care |
| Staff C | Laundry Staff | Observed failing to perform hand hygiene while delivering residents' personal clothes |
| Director of Housekeeping | Director of Housekeeping | Reported on laundry cart coverage and staff hand hygiene expectations |
| Infection Preventionist | Infection Preventionist | Responsible for ensuring completion of hand hygiene and peri care audits |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2022
Visit Reason
The inspection was conducted as an investigation of complaint #94487-C and mandatory self-report #100221-M from February 8 to February 15, 2022.
Complaint Details
Complaint #94487-C was investigated and found not substantiated. The findings relate to mandatory self-report #100221-M.
Findings
The complaint #94487-C was not substantiated. Deficiencies were found related to pharmacy services, specifically regarding narcotic medication counts and documentation for morphine sulfate for Resident #3. The facility implemented new procedures and education to address these issues.
Deficiencies (1)
Failure to properly document morphine administration and narcotic counts for Resident #3, including missing morphine documentation in the Medication Administration Record and issues with narcotic seal integrity.
Report Facts
Medication count: 30
Medication dosage: 20
Medication dosage: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic count and seal issues on 2/10/22. |
| Staff B | Registered Nurse (RN) | Interviewed regarding narcotic count and seal issues on 2/10/22. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic seal and morphine usage on 2/10/22 and 2/14/22. |
| Director of Nursing | Director of Nursing (DON) | Commented on narcotic system changes and education during interview on 2/10/22 and 2/14/22. |
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 50
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as part of the facility's annual recertification and licensure survey to assess compliance with federal regulations.
Findings
The facility failed to label and date food items properly, increasing the risk of contamination and food-borne illness. A corrective action plan included re-education of dietary staff on food safety, storage, and labeling, with ongoing audits and monitoring.
Deficiencies (1)
Failure to label and date food items in order to reduce the risk of contamination and food-borne illness.
Report Facts
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Verified facility expectations for labeling, covering, and dating opened food items; responsible for audits and documentation of food safety compliance. | |
| Staff A | Participated in observation of kitchen refrigerator and freezer during inspection. |
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