Crest View Lutheran Home

Based on interview, observation and document review, the facility failed to update the care plan with specific interventions for 1 of 1 resident (R43) reviewed for respiratory care.Findings include:R43's annual MDS (Minimum Data Set) dated 4/14/25, identified R43 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R43's diagnoses included atrial fibrillation (a common type of irregular heartbeat that originates in the heart's upper chambers (atria)), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), hypertension (high blood pressure), cerebrovascular accident (occurs when blood flow to the brain is interrupted, causing brain cells to die due to lack of oxygen and nutrients), depression, attention-deficit hyperactivity disorder (ADHD) (a neurodevelopmental condition that affects brain function and behavior, primarily in the areas of attention, hyperactivity, and impulsivity) and aortic aneurysm and dissection (An aortic aneurysm is a bulge or ballooning of the aortic wall, while an aortic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to provide supervision, cues, and hands on assistance as needed to eat during meals, and with snacks, for 1 of 1 residents (R5) whom required staff direction for eating. Findings include:R5's quarterly Minimum Data Set (MDS) indicated R5 had had impaired cognition and required substantial assistance to complete activities of daily living (ADL's) including eating. R5's medical diagnoses included aphasia (a language disorder which impacts the ability to speak), dementia, and dysphagia (difficulty swallowing).R5's care plan, revised on 5/5/25, identified R5 has potential for alteration in nutrition related to hypertension (high blood pressure), dysphagia, variable intakes and history of refusing meals. The care plan further defined R5 required one-to-one assistance with meals, and cueing/encouragement with foods/snacks/supplements. R5 was identified as having a gradual weight loss and her goal was to maintain current nutritional status as evidenced by stable weight. R5's nutritional care plan directed staff to cue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to consistently meet the identified needs and preferences of 3 of 4 residents (R7, R19, and R76), reviewed for activities.Findings include: R7R7's quarterly Minimum Data Set (MDS) MDS dated [DATE], indicated R7 was alert and oriented. The MDS identified R7's vision was adequate and indicated he was able to see fine detail, including regular print in newspapers/books. The MDS indicated R7 did not require corrective lenses. R7's MDS of 12/1/24, 2/3/24, and 5/4/25 lacked completion of Preferences for Customary Routine and Activities. R7's annual assessment of 11/4/24, identified the following for preferences for Customary Routine and Activities: R7 identified it was very important to listen to music he liked, to complete favorite activities, to go outside to get fresh air when the weather was good, and participate in services or practices; it was somewhat important to keep up the news; it was not very important to do things in groups of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to promote and provide positioning assistance to 1 of 3 (R72), residents reviewed for positioning. Further, the facility failed to implement interventions 1 of 3 residents (R19) reviewed for vision. Findings include: R72's quarterly Minimum Data Set (MDS) dated [DATE], identified R72 had impaired cognition and was dependent of staff for assistance with activities of daily living (ADLs) including mobility and transfer, and was wheelchair bound. R72 had an impairment on one side and was identified as being dependent on staff for assistance with eating. R72's medical diagnoses include dementia, anxiety, psychotic disorder, secondary parkinsonism, and a joint disorder. R72's care plan revised 1/23/25, identified R72 had alteration in mobility related to dementia. The care plan directed staff to turn and reposition, transfer, and boost up in bed with the assist of two staff. R72 used a wheelchair and received assistance of one staff to propel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids/devices were available to maintain hearing/communication needs for 1 of 1 resident (R76) reviewed for hearing. Findings Include: R76's quarterly MDS dated [DATE], identified R76 had severe cognitive impairment and required assistance with all ADL's. R76's diagnoses included non-traumatic brain dysfunction (brain damage that occurs due to internal factors, rather than external trauma), Alzheimer's disease with late onset, diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), anxiety disorder and depression. MDS indicated R76's hearing was moderate difficulty needed hearing aids.R76's care plan, reviewed 6/26/25, identified R76 had an alteration in communication related to hard of hearing and had two hearing aids. The care plan directed staff to ensure glasses and bilateral hearing aides were worn daily, to anticipate needs as needed, allow R76 time to respond,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed for residents who wished to smoke for 1 of 1 resident (R19) reviewed for smoking. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had intact cognition and required assistance with all activities of daily living (ADLs). R19's diagnoses included chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), non-Alzheimer's dementia, anxiety disorder, depression, schizophrenia (a chronic mental disorder that disrupts a person's thinking, behavior, and emotions) and nicotine dependence. The MDS lacked documentation R19 was a current tobacco user.R19's care plan reviewed 6/26/25, indicated R19 had elected to be an active smoker and was an independent smoker, had a goal of remaining free from injury associated with smoking and follow the facility smoking policy. The care plan went on to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to properly assess and obtain orders for 1 of 1 resident (R43) reviewed for use of oxygen therapy.Findings include:R43's annual Minimum Data Set (MDS) dated [DATE], identified R43 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R43's diagnoses included atrial fibrillation (a common type of irregular heartbeat that originates in the heart's upper chambers (atria)), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), hypertension (high blood pressure), cerebrovascular accident (occurs when blood flow to the brain is interrupted, causing brain cells to die due to lack of oxygen and nutrients), depression, attention-deficit hyperactivity disorder (ADHD) (a neurodevelopmental condition that affects brain function and behavior, primarily in the areas of attention, hyperactivity, and impulsivity) and aortic aneurysm and dissection (An aortic aneurysm is a bulge or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R47) resident reviewed who had a history of past traumatic experiences. Findings include:R47's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had intact cognition and required assistance with all activities of daily living (ADLs). R47's diagnoses included alcoholic cirrhosis of liver without ascites (severe, irreversible liver disease caused by long-term, excessive alcohol consumption), hypertension (high blood pressure), renal failure (occurs when the kidneys lose their ability to adequately filter waste and excess fluids from the blood), hepatic encephalopathy (brain dysfunction that can occur in people with severe liver disease), and fibromyalgia (chronic disorder characterized by wide-spread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties).R47's care plan print date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to consistently perform hand hygiene with change of gloves while performing blood glucose monitoring. Additionally, the facility failed to clean the community glucose monitor after use. This had the potential to affect any of the 14 residents on the memory care unit who may require blood glucose checks, either routine or emergent. Further, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms (Evergreen and Willow) and 1 of 1 units (Aspen and [NAME]) reviewed. In addition, the facility failed to properly handle and store clean laundry and linens. This had potential to affect all 78 residents within the care center. Findings include: On 6/24/25 at 3:54 p.m., an observation was completed of medication pass on the memory care unit. During this observation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement the comprehensive care plan for 2 of 3 residents (R1, R2) reviewed for pressure ulcer prevention. Findings include: Pressure Ulcer Definitions: Pressure Ulcer/Injury: is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Unstageable pressure ulcer: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. R1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure individualized activities were provided for 1 of 1 resident (R1) reviewed for activities. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE], understood others and made herself understood., had moderate cognitive impairment, sometimes felt socially isolated, and did not exhibit behaviors. R1's Interview for Activity Preferences identified it was somewhat important to her to do her favorite activities, go outside to get fresh air when the weather was good, participate in religious services or practices, and listen to music she liked. R1's LE [Life Enrichment] Initial and Annual Assessment V2 dated 6/3/24, identified R1 had no preference about interaction (one-to-one, small group, large group, or self) and no preference about setting (own room, day room, off-unit, or outside facility). R2's interests were identified as games/cards/puzzles with note cards, some board games,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for one of one resident (R1) reviewed for physician orders. The facility received an order for a cervical collar to be used by two licensed staff; one to stabilize the resident's cervical spine and one for care of the cervical collar and were observed not following the orders. Findings included: During an observation on 7/24/24 at 11:17 a.m., licensed practical nurse (LPN)-A donned personal protective equipment (PPE) and went into R1's room. Family member (FM)-B was sitting in the room besides R1. LPN-A stated to R1 that she was there to assist R1 in putting his cervical collar on. R1 was seated in his recliner. FM-B stood in front of R1 and grabbed his shoulders while assisting him forward. LPN-A put the foam piece around R1's neck and then placed the hard plastic brace on top of the foam piece. LPN-A tightened the brace by pulling the Velcro straps on each side of his neck. After LPN-A tightened the cervical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow the care plan for 1 of 3 residents (R1) reviewed for abuse, when R1 was transferred and personal cares were provided by one staff when the care plan directed two female staff for all cares and transfers. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated she had diagnoses of anxiety, depression, psychotic disorder, and history of falls. The MDS also indicated R1 had moderate cognitive impairment, and was dependent on staff for transfers. R1's care plan dated 5/21/24 directed two female staff only present during cares and two staff to assist with transfers. The care plan noted a history of past trauma. R1's fall risk assessment dated [DATE] indicated R1 had a high fall risk. Her fall risk assessment indicated she had a balance problem while walking. R1's progress note dated 2/15/24 indicated R1 had a fall on 2/15/24. R1's progress note dated 5/15/24 indicated she alleged a staff member had sexually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to ensure food was labeled, dated, and stored to prevent foodborne illness. The facility failed to maintain clean vents over clean dishes. In addition, the facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all residents and staff who eat from the main kitchen. Findings include: During observation and interview on 4/1/24 at 11:58 a.m., cook and chef supervisor (cook) stated he was cleaning out the refrigerator after the weekend. The refrigerator contained undated items which included a sandwich, Styrofoam container of soup, opened container of a cucumber salad, and bag of lettuce. Director of dining services (CD) confirmed the items were undated and from over the weekend. CD removed other undated items from the refrigerator described as chicken and pork from meals over the weekend. CD stated they keep leftovers for three days, and the lettuce was opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement transmission-based precautions (TBP) for 1 of 1 resident (R17) reviewed who had emesis and loose stools while there was an outbreak of confirmed rotavirus and norovirus cases (contagious viruses which causes vomiting and diarrhea and are spread through feces) in the facility, failed to implement TBP for 1 of 1 residents (R65) who had a history of MRSA (methicillin resistant staphylococcus aureus - a potentially dangerous type of staph bacteria that is resistant to certain antibiotics), and failed to implement enhanced-barrier precautions for 2 of 2 residents (R385, R53) and failed to ensure proper handling of linens observed for infection prevention practices. Findings include: During observation on 4/1/24 at 11:45 a.m., bright pink signs were observed on the front doors to the building which identified the facility had an outbreak of norovirus, rotavirus, and Covid-19. Additional signs were posted on hallway doors throughout…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the resident with a written discharge notice and basis for discharge; and failed notify the Ombudsman Office for Long-Term Care (OOLTC) of transfers and discharges for 1 of 1 resident (R82) reviewed for facility initiated discharge, which has the potential to affect all residents who transfer or discharge. Findings include: R82's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no behaviors or rejection of care and discharge planning was in place to move to another facility. R82 required supervision with bed mobility, transfers and toileting; and was independent with eating after set up. R82's admission Record dated 4/4/24, identified an admission date of 3/1/24, and a discharge date of 3/8/24. R82's diagnoses included chronic kidney disease and urinary tract infection. R82's medical record dated 3/1/24 through 3/8/24, lacked a discharge notice with the basis for discharge, statement of appeal rights, and OOLTC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 (R19) resident observed with medications at bedside. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD). It further indicated R19 received oxygen therapy. R19's physician's orders dated 12/1/23, indicated oxygen 2.5 liters per minute (lpm) per nasal cannula, continuous. It further lacked an order for R19 to self administer medications. R19's SAM assessment dated [DATE], indicated R19 didn't want to administer her own medications and required assistance taking them. R19's care plan dated 2/13/24, indicated R19 received oxygen therapy (per nasal cannula) related to CHF, to keep oxgyen (02) saturations greater than or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a call light was accessible for 1 of 1 resident (R385) reviewed for call light accessibility. Findings include: R385's admission Minimum Data Set (MDS) dated [DATE], included R385 was moderately cognitively impaired, had diagnoses of malnutrition and depression, was dependent on staff to turn in bed, always continent of bowel and occasionally incontinent of urine, was at risk for pressure ulcers, and had a history of falls. R385's care plan dated 3/8/24, included R385 had an alteration in safety related to falls and included interventions of keep call light within reach, remind resident when/how to use it, and remind to ask for assistance. In addition, the care plan directed staff to not wake R385 up at night per their request, and R385 will use their call light if they need any assistance. During observation on 4/1/24 at 5:53 p.m., R385 was lying supine and asleep wearing a gown in their bed with their feet flat against the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to include a physician documented basis for discharge for 1 of 1 resident (R82) reviewed for facility initiated discharge. Findings include: R82's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no behaviors or rejection of care and discharge planning was in place to move to another facility. R82 required supervision with bed mobility, transfers and toileting; and was independent with eating after set up. R82's admission Record dated 4/4/24, identified an admission date of 3/1/24, and a discharge date of 3/8/24. R82's diagnoses included chronic kidney disease and urinary tract infection. R82's Care Plan dated 3/1/24, identified R82 wanted to discharge to an assisted living facility or independent senior living facility with home care services, and the potential for discharge would be reviewed in 30 days. R82's physical (PT) and occupational (OT) therapy notes dated 3/1/24 through 3/8/24, identified the plan was to continue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment to ensure cognitive and mood needs were evaluated and addressed for 1 of 1 resident (R334) reviewed for comprehensive MDS assessment accuracy. Findings include: The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11, dated October 2023, indicated the purpose of the manual was to offer clear guidance about how to use the resident assessment instrument (RAI) correctly and effectively to provide appropriate care. The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. A comprehensive MDS assessment includes completion of both the MDS and the CAA (care area assessment) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure physical devices were assessed and reassessed for continued appropriateness for 1 of 1 resident (R66) who had perimeter mattresses placed on their bed as a fall intervention. Findings include: R66's significant change Minimum Data Set (MDS) dated [DATE], identified she was rarely/never understood, with verbal behaviors toward others one to three days in the lookback period which posed no significant risk or interfered with cares. Diagnoses included Alzheimer's disease and resident was on hospice. Extensive assist of two staff was required with transfers and bed mobility, and no falls occurred since the prior MDS assessment. R66's Care Area assessment dated [DATE], identified she was a fall risk related to weakness, Alzheimer's disease, history of falls and poor safety awareness. R66's Care Plan intervention dated 10/20/23, identified a perimeter mattress was placed due to a potential alteration in safety, falls related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a resident's preferred activities were available for 1 of 1 resident (R36) reviewed for activities. Findings include: R36's annual Minimum Data Set (MDS) dated [DATE], indicated R36 had a memory problem, did not have behaviors, did not reject care, was very important to choose her own bedtime, listen to music R36 liked, very important to participate in religious services or practices, and was very important to do her favorite activities. Additionally, the MDS indicated a diagnoses of Alzheimer's disease, anxiety, and psychotic disorder other than schizophrenia. R36's State Optional quarterly MDS dated [DATE], indicated R36 required extensive assist with bed mobility, transfers, eating, and toileting. R36's care plan dated 1/17/24, indicated R36 had an alteration in bathing, dressing, personal hygiene, grooming due to dementia and immobility and interventions included to offer country music while attempting to complete care or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review the facility failed to ensure the quality assessment and assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in identifying and implementing appropriate action plans to correct quality deficiencies identified during previous surveys related to infection control, respiratory therapy and advanced directives resulting in deficiencies identified during this survey. In addition, the facility failed to review and/or revise policies affecting resident care periodically to ensure the policy/practice was still appropriate. This deficient practice had the potential to affect all 95 residents currently residing in the facility. Findings include: The Certification and Survey Provider Enhanced Reports (CASPER)-3 (assessment data was converted to quality measures (QM) to evaluate nursing home's performance) dated 2/16/23, identified the following prior deficiencies by month and year: -F578-Request/Refuse/Discontinue treatment; Formulate advance directives was cited on prior surveys 10/7/21, 11/19 and 3/18. All were cited at a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure resident ice packs were stored separately from resident food in 2 of 4 nursing unit resident refrigerators. This had the potential to impact 73 residents residing on those units. Furthermore, the facility failed to ensure current standards of practice for glove use and handwashing were being followed for 1 of 1 resident (R31), when staff provided personal care. Findings include: Ice pack storage for resident use An observation on 2/27/23, at 3:03 p.m. the unit-A resident refrigerator sign indicated refrigerator storage was only for items intended for human consumption. Inside the refrigerator's freezer several blue gel ice packs were noted along with smaller white reusable shipping ice packs. An observation on 2/27/23, at 7:02 p.m. unit B and C's resident refrigerator sign indicated refrigerator storage was only for items intended for human consumption. Inside the refrigerator's freezer two blue gel ice packs were noted along with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055) was provided to 2 of 3 residents (R91, R94) who continued to reside in the facility upon termination of Medicare A benefits. Findings include: The Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055) informs resident/beneficiaries of potential liability for payment and related standard claim appeal rights. R91's census report printed 3/2/23, indicated 91's Medicare A benefit ended on 2/23/23. R91's census report further indicated R91 continued to reside in the facility. R91's CMS-10055 was requested however was not provided. R94's census report printed 3/2/23, indicated R94's Medicare A benefit ended on 2/7/23. R94's census report further indicated R94 continued to reside in the facility. R94's CMS-10055 was requested however was not provided. When interviewed on 3/2/23, at 1:23 p.m. the administrator verified a CMS-10055 was not completed for R91 and R94. The administrator further stated the CMS-10055 was not used at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to maintain a walking program for 1 of 1 resident (R25) reviewed for activities of daily living (ADL) decline. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had minimal cognitive impairment and required extensive one-person physical assistance with most ADLs. Walk in room and walk in corridor assessment indicated the activity did not occur. R25 used a wheelchair for mobility. R25's diagnoses included hemiplegia and hemiparesis (weakness or paralysis affecting one side of the body), diabetes, and peripheral vascular disease (condition affecting blood circulation). R25's annual MDS dated [DATE], indicated R25 required one-person physical assist to walk in room and that R25 used a walker and wheelchair for mobility. R25's ADL care plan dated 12/15/22, indicated R25 had an ADL self-care deficit with a goal to maintain current level of function. Interventions included, Ambulate 1 time a day, 7 days a week…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure residents were appropriately assessed post dialysis treatments and resident's health status communicated between dialysis center and facility for 1 of 1 resident (R90) reviewed for dialysis. Findings include: R90's admission Minimum Data Set (MDS) dated [DATE], indicated R90 was cognitively intact, received dialysis treatment, and had diagnoses including end stage renal disease (advanced state with loss of function), diabetes, syncope (feeling lightheaded) and collapse. R90's care plan dated 2/2/23, indicated R90 received dialysis related to renal failure and instructed staff to monitor, document and report signs of infection at the access site, bleeding, changes in level of consciousness and changes in heart and lung sounds. R90's care plan instructed staff to obtain vital signs (VS) and weight per protocol and report significant changes in pulse, respirations, and blood pressure immediately. R90's physician orders indicated R90…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure ongoing assessments for safety and appropriate use of grab bars were completed for 1 of 1 resident (R11) who was observed to have grab bars affixed to their bed. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact and had diagnoses of chronic pain and heart failure. Furthermore, R11's MDS indicated R11 did not use bed rails. R11's medical record lacked indication R11 was assessed for grab bar use since 11/2021. R11's care plan revised 1/20/19, indicated R11 had an alteration in activities of daily living (ADL) related to decreased mobility and utilized two grab bars for independent bed mobility and repositioning. During an observation on 2/27/23, at 12:49 p.m. R11 was laying in bed. R11's bed had bilateral grab bars. When interviewed on 2/27/23, at 12:49 p.m. R11 stated the grab bars helped him with getting out of bed and was not aware of any safety assessment related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and document review, the facility failed to ensure accurate administration of initial COVID-19 vaccination series for 1 of 5 residents (R56) reviewed for COVID-19 vaccinations who received an incorrect initial COVID-19 vaccine. Findings include: R56's immunization record in point click care (PCC) lacked documentation of R56 receiving an initial primary series of COVID-19 vaccinations. R56's medication administration record (MAR) dated December 2022, indicated R56 received the Pfizer bivalent booster vaccine in the right arm with no immediate adverse reactions noted. R56's progress note dated 12/16/22, indicated R56 received Pfizer bivalent booster with no immediate adverse reactions and lacked documentation the physician was notified of the medication error. R56's progress notes were reviewed from 12/16/22, through 3/2/23, and lacked documentation the physician was notified of the medication error and lacked documentation on any follow-up from the medication error. During interview on 3/2/23, at 4:13 p.m. licensed practical nurse (LPN)-B stated R56…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to monitor side effects for 1 of 3 (R43) residents reviewed for anticoagulation (blood thinner) therapy. Findings include: R43's annual Minimum Data Set (MDS) dated [DATE], indicated R43 was cognitively intact and had diagnoses of heart disease and pulmonary embolism (blood clot in lung). Furthermore, R43's MDS indicated R43 received anticoagulation therapy. R43's provider order summary printed 3/2/23, indicated R43 required Rivaroxaban (anticoagulation medication) 20 milligrams(mg) tablet daily to prevent blood clots. R43's weekly skin assessment dated [DATE], indicated no skin concerns. R43's care plan dated 1/27/23, indicated R43 had alterations to skin related to decreased mobility, edema, history of pressure ulcer and aspirin use and directed staff to monitor R43's skin with cares. R3's R43's care plan further indicated R43 had fragile skin on hands however refused Geri sleeve protection. R43's medical record lacked evidence R43 required monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess appropriateness of antibiotic use was completed for 1 of 1 residents (R60) who was prescribed oral antibiotics for a skin infection. Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had moderate cognitive impairment and diagnoses of chronic obstructive pulmonary disease (COPD). R60's provider order dated 2/24/23, indicated R60 required Doxycycline (antibiotic) tablet 100 milligrams(mg) by mouth twice daily for cyst/cellulitis (skin infection) for 10 days. R60's provider order dated 2/27/23, indicated R60 required a 72-hour time out assessment on the evening of 2/27/23. R60's medical record lacked evidence a 72-hour antibiotic time out assessment was completed. When interviewed on 3/1/23, at 10:51 a.m. licensed practical nurse (LPN)-A verified R60 was on Doxycycline for a cyst on his buttock. LPN-A stated when residents were placed on antibiotics, nurses were required to complete a 72-hour assessment to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.