Crest Nursing Home

Based on interview and record review, the facility failed to ensure a Director of Nursing (DON) worked full-time (defined by CMS as 40 hours or more per week) as the Director of Nursing. This failure increased the risk of negative outcomes for all residents. Findings include:During an interview on 5/4/26 at 12:30 p.m., staff member A stated the facility employed a full-time Director of Nursing and did not have any nurse staffing waivers in place.During an interview on 5/7/26 at 10:20 a.m., staff member B stated she is the infection preventionist and also the DON. Staff member B stated she dedicated 20 hours per week to infection control and the rest of her time to director of nursing responsibilities. During an interview on 5/7/26 at 11:40 a.m., staff member A stated staff member B could complete all her DON duties and infection control duties within a 40-hour work week due to the size of the facility and the low census. Staff member A stated staff member B never went into overtime. Staff member A stated they had always combined DON and infection control duties. Review of a letter…

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 record review, the facility failed to protect a vulnerable resident from non-consensual sexual contact by a resident #22, who had a with a history of sexually inappropriate behaviors, for 1 (#1); and failed to monitor physical and psychosocial harm for 1 (#18) after an incident of abuse by resident #43, of 5 residents sampled for abuse by another resident. This failure resulted in resident #1 having her breast groped and bruising to resident #18's head and neck. Findings include:1. Review of a facility-reported event submitted to the State Survey Agency on 7/22/25, showed resident #22 was observed with one hand holding up resident #1's shirt while holding her breast with his other hand. During an observation and interview on 5/5/26 at 1:22 p.m., resident #22 was standing alone in the sitting room staring at the TV. Resident #22 stated he . touched someone's breast, and I am not allowed to do that. I have been good now. During a telephone interview on 5/5/26 at 1:40 p.m., NF1 stated he observed resident #22 lift resident #1's shirt with one hand while holding…

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 record review, the facility failed to revise a care plan to include interventions that were effective in monitoring the bed rails for a resident's ongoing use of the rails, for 1 (#43) of 15 sampled residents. This failure caused the staff to provide inconsistent reasoning for the use of the bed rails. Findings include:During an observation on 5/6/26 at 10:03 a.m., resident #43 was observed in bed with upper and lower bed rails in place. Both upper and lower bed rails had open areas for potential entrapment of arms, and there was space between the upper and lower bed rails which could have the potential for entrapment of a limb.During an interview on 5/6/26 at 10:17 a.m., staff member F stated all four rails were to be up while resident #43 was in bed. Staff member F stated the bed rails help with repositioning. Staff member F stated there was always someone in the resident's room during repositioning. During an interview on 5/6/26 at 1:36 p.m., staff member C stated bed rails were part of the MDS assessment, and interventions should be on 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.

Based on observation, interview, and record review, the facility failed to ensure bed rails were assessed for entrapment, assessed for other alternatives, failed to ensure the bed rails had a documented medical rationale for the use of the bed rails, and failed to have a physician-signed order for the bed rails for 1 (#43) of 15 sampled residents. The failure placed the resident at risk for entrapment or injury from the use of bed rails. Findings include:During an observation on 5/5/26 at 4:30 p.m., resident #43 was lying in bed with full upper and lower bed rails on both sides of the bed.During an observation on 5/6/26 at 10:03 a.m., resident #43 was observed in bed. He was sleeping with his head tilted to the right with the head of the bed elevated. There were open areas on the upper and lower rails potentially creating a risk for entrapment. There was space between the upper and lower rails, potentially creating a risk for entrapment.During an interview on 5/6/26 at 10:17 a.m., staff member F stated resident #43 was to have all four rails up while in bed. Staff member F stated…

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 record review, the facility failed to ensure a resident's medical record was accurate for 1 (#36) of 15 sampled residents when an unsigned POLST was removed, but then replaced, in the residents active medical record. Findings Include: During an observation and record review on 4/8/25 at 10:06 a.m., resident #36's hard chart had a green POLST form under the front tab. The POLST showed the selections of DNR, selective treatment, and no tube feeding, and it was signed by resident #36 on 5/20/24. There was no physician signature, therefore, the POLST would be invalid. During an interview on 4/9/25 at 10:09 a.m., staff member F stated in the event of a resident emergency they would check the POLST in the hard chart unless they already had the EMR pulled up to check the code status. The POLST was checked because that, and the facesheet, would be provided to emergency services. During an interview on 4/9/25 at 10:18 a.m., staff member C stated since she started in the position she was directed to have the residents fill out a new POLST and advance…

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 record review, the facility failed to remove or replace binding arbitration language as required from the facility admission agreement, for 2 (#s 36 and 198) of 2 sampled residents for arbitration agreements. This deficiency had the potential to affect all residents being admitted to the facility signing the admission agreement. Findings Include: During an interview on 4/7/25 at 11:50 a.m., staff member A stated the facility did not do arbitration at all. Staff member A stated the arbitration information was taken out of the admission agreements when the law was changed. During an interview on 4/8/25 at 4:35 p.m., staff member A stated she was directed to leave in the arbitration parts of the admission agreement and just handwrite an 'N/A' by each section related to arbitration. She directed her staff not to review the arbitration information since they no longer did arbitration. During an interview on 4/9/25 at 10:18 a.m., staff member C stated from her understanding, since she started, she was to use the admission agreement copies with the N/A by the binding…

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 record review, the facility failed to ensure licensed nursing staff adhered to accepted standards of practice by only administering oxygen within the parameters of provider's orders for 3 (#s 4, 5, and 6) of 3 sampled residents prescribed supplemental oxygen. Findings include: 1. Resident # 5 Review of resident #5's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 03/12/2024 RESPIRATORY TREATMENT: Oxygen 1lpm via NC to maintain Sp02 >90% for hypoxemia.at bedtime NOC noc O2 Sat: AM am O2 Sat: PM pm O2 Sat. [sic] - All occurrences for resident #5, from 9/2024 through 3/20/25, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed one liter per minute. - September 2024 showed 14 occurrences out of 89 entries, - October 2024 showed 45 occurrences out of 90 entries, - November 2024 showed 42 occurrences out of 88 entries, - December 2024 showed 55 occurrences out of 91 entries, - January 2025 showed 21 occurrences out of 86…

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 record review, the facility failed to ensure a portable oxygen tank was replaced when the metered volume was empty, with the resident's oxygen saturation at 86%, for 1 (#6); and failed to ensure licensed nursing staff documented provider notification, nursing assessments, and/or nursing interventions of resident's oxygen saturation levels below the parameters set forth in written orders of 90% for 2 (#s 5 and 6) of 3 sampled residents receiving supplemental oxygen. Findings include: 1. Resident #6 During an observation on 3/24/25 at 11:17 a.m., resident #6 was seated in her wheelchair, in the hallway, outside of her room. Resident #6 had a portable oxygen tank attached to her chair, which showed the pressure gauge needle at approximately 1,500 psi. During an interview on 3/24/25 at 12:33 p.m., staff member D stated all staff were responsible for checking the oxygen levels on the resident's portable oxygen tanks. Staff member D stated, regarding the pressure gauge of the oxygen tanks, when the needle on the gauge was in the red, the tank needed 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 observation, interview, and record review, the facility failed to change and label resident oxygen tubing for 4 (#s 4, 28, 33, and 34) of 5 sampled residents for respiratory care. This deficient practice had the potential to increase the incidence of respiratory disease for residents using supplemental oxygen in the facility. Findings include: 1. During an observation on 3/26/24 at 2:58 p.m., resident #34 was lying in bed with a nasal cannula on. The cannula tubing was labeled and dated, on a piece of tape, as 3/13, thirteen days prior. During an interview on 3/26/24 at 3:27 p.m., NF2 stated he had concerns about resident #34's oxygen. NF2 stated he felt the staff had not been paying attention to the resident's oxygen level and did not think they were looking at her tubing. During an observation and interview on 3/27/24 at 1:28 p.m., staff member G was changing the tubing on resident #34's oxygen concentrator. Staff member G stated resident #34's tubing was changed every Wednesday and was dated with a piece of tape on the tubing. Staff member G stated resident #34's oxygen…

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 record review, the facility failed to ensure a resident's GDR request was responded to by the physician, and completed, for 1 (#34) of 5 sampled residents for unnecessary medications. Findings include: Review of resident #34's MAR showed a physician order for, FLUoxetine HCI 40MG Capsule dose ordered: (1 capsule / 40mg) by mouth daily AM FOR: Depression. Administration Instructions: MEDICATION TO BE GIVEN WITH FLUOXETINE 20MG FOR A TOTAL OF 60MG. Review of resident #34's Consultant Pharmacist's Progress Notes showed: - January 2024: GDR for fluoxetine: Started on 20 mg daily on May 2, 2022 for 14 days, then increased to 40 mg daily. Dose reduced to 20 mg once daily on March 2, 2023. Dose increased to 40 mg once daily on May 3, 2023. Dose increased to 60 mg once daily on May 31, 2023. - February 2024: GDR for fluoxetine: . Dose increased to 60 mg once daily on May 31, 2023. No response to request sent in [DATE]. - March 2024: GDR for fluoxetine: . No response to request sent in [DATE].…

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.