Crestview Healthcare Residence

In the surveyor’s words

From the most serious findings on record at Crestview Healthcare Residence, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 23, 2022

  Based on observation, interview, and record review the facility failed to keep one (Resident #1) of six residents free from abuse. The facility failed to: - Protect Resident #1 from being abused by the Registered Nurse who willfully and deliberately placed a urine-soaked towel to Resident #1's face. On 12-20-22 at 4:29 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12-21-22 at 7:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of J identified due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, harm, and a decline in their psychosocial well-being. […]

• Immediate jeopardy, isolatedF607Dec 23, 2022

  Based on observation, interview, and record review the facility failed to develop and implement abuse and neglect policies that prohibited and prevented one (Resident #1) of 16 residents from abuse. The facility failed to: Develop and implement abuse and neglect policies that prohibited and prevented Resident #1 from being abused by the Registered Nurse who placed a urine-soaked towel to Resident #1's face. On 12-20-22 at 4:29 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12-21-22 at 7:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of J identified due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF689Dec 23, 2022

  Based on observation, interview, and record review the facility failed to keep one of twelve residents free of accident hazards and supervision. The facility failed to: Ensure Resident #2, who had exit seeking behaviors and resided on the secure unit, did not elope from the facility on 12-18-22. An Immediate Jeopardy (IJ) was determined to have existed on 12-18-22. The IJ was determined to be past noncompliance because the facility had implemented actions that corrected the noncompliance before the investigation began on 12-20-22. These failures placed residents at risk of accidents, harm, a decline in their psychosocial well-being, hospitalization or death. […]

• Actual harm, patternF697May 24, 2023

  Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents (Resident #1) reviewed for pain. 1. The facility failed to assess, reassess, and/or take steps to manage Resident #1's pain when she informed them of the pain to her left stump. 2. […]

• No harm, potential for more than minimal, widespreadF812Mar 2, 2023

  Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that: 1. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 2. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 3. […]