Crest View Lutheran Home

In the surveyor’s words

From the most serious findings on record at Crest View Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Mar 2, 2023

  Based on interview, and record review, the facility failed to ensure a do-not-resuscitate (DNR) order was accurately reflected throughout the medical record for 1 of 26 residents (R81) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R81 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when the facility obtained a physician's order for R81 to have a full code status even though the physician order for life sustaining treatment (POLST) indicated do not resuscitate (DNR). The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:15 p.m. […]

• Immediate jeopardy, isolatedF600Dec 9, 2021

  Based on interview and document review, the facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R1) reviewed for sexual abuse allegations. R1's family member (FM)-B engaged in sexual touching with R1. This resulted in an immediate jeopardy for R1, when FM-B sexually abused her. The immediate jeopardy (IJ) began on [DATE], when staff observed FM-B kissing and cuddling R1 in the dining room. Later in the day, another staff observed FM-B touching R1's genitals over clothing in her room. R1 was not able to give consent for sexual contact due to advanced dementia The administrator and assistant director of nursing (ADON) were notified of the IJ on [DATE], at 6:20 p.m. The IJ was removed on [DATE], at 1:25 p.m. […]

• Immediate jeopardy, isolatedF689Dec 9, 2021

  Based on observation, interview and document review, the facility failed to provide interventions to prevent elopements for 1 of 3 residents (R4) reviewed for elopement. This resulted in an immediate jeopardy for R4, who eloped from the facility. The immediate jeopardy (IJ) began on [DATE], when R4 eloped from the facility and was found by local law enforcement 0.6 miles from the facility. The WanderGuard did not alert staff that R4 left the facility unsupervised as the device was not working. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 10:15 a.m. The IJ was removed on [DATE] at 3:30 p.m. […]

• Immediate jeopardy, isolatedF745Nov 5, 2021

  Based on interview and document review, the facility failed to provide medically related social services prior to discharge for 1 of 1 resident (R10). This resulted in an immediate jeopardy (IJ) for R10 when she was discharged home alone, upon request of her family member (FM)-A without appropriate discharge plans in place to a potentially unsafe environment. The immediate jeopardy began on 10/22/21, when R10 was discharged from the facility without appropriate nursing services and interventions in place prior to discharge. R10 required 24/7 supervision due to her mental illness and assistance with Activities of Daily Living (ADL). The administrator was notified of the immediate jeopardy on 11/4/21, at 3:50 p.m. The immediate jeopardy was removed on 11/5/21, at 3:45 p.m. […]

• Actual harm, isolatedF684Aug 13, 2026

  Based on interview and document review, the facility failed to ensure a physician-ordered ultrasound was obtained, and the results were communicated to the provider timely for 1 of 1 resident (R2) reviewed for diagnostic testing follow up and provider notification. The delay from the initiation of the ultrasound order on 7/29/26 until the provider received the results resulted in delayed evaluation and treatment of R2's continued left groin pain and swelling. R2 was subsequently transferred to the emergency department (ED), hospitalized , treated with intravenous (IV) antibiotics, and underwent surgical exploration and drainage of a scrotal abscess. […]