Crestview Nursing & Residential Living

In the surveyor’s words

From the most serious findings on record at Crestview Nursing & Residential Living, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 24, 2024

  The facility identified a census of 23 residents. The sample included 12 residents with seven residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4 remained free from a preventable accident during a sit-to-stand mechanical lift transfer. This deficient practice resulted in a fractured finger and placed R4 at risk for further complications. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, low back pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),dementia (a progressive mental disorder characterized by failing memory and confusion), paraplegia (paralysis characterized by motor or sensory loss in… […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2021

  The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for 23 residents who received meals from the facility kitchen. Findings included: -On 11/02/21 at 08:02 AM, observation revealed three half gallons of vanilla Greek yogurt with expiration date of 10/28/21 in the silver refrigerator in the main part of the kitchen. The dry storage room had 40 - 4 ounce boxes of juices with an expiration date of 07/20/21, a white grocery sack with ten (sandwich size) bags of popcorn without dates or labels, 20 - 4 ounce containers of vanilla pudding with use by date 04/07/21, four packages of hot dog buns without a received date or expiration dates. […]

• No harm, potential for more than minimal, patternF880Nov 4, 2021

  - On 11/02/21 at 12:05 PM, observation revealed Licensed Nurse (LN) G put on clean gloves, gathered the glucometer and container of blood sugar test strips, entered Resident (R) 123's room and obtained a blood sugar reading. Further observation revealed LN G went back to the medication cart and placed the multi-use glucometer back in the plastic basket in the cart without disinfecting the glucometer before or after use. On 11/02/21 at 12:15 PM, LN G stated she had not used any wipes to clean the meter before she used it and verified she had not disinfected the glucometer between residents. On 11/04/21 at 01:30 PM, Administrative Nurse E stated the facility glucometer should be cleaned with disinfectant wipes before and after each resident use. […]

• No harm, potential for more than minimal, isolatedF657Oct 24, 2024

  The facility had a census of 23 residents. The sample included 12 residents, with one reviewed for post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash, or physical torture). Based on observation, record review, and interview the facility failed to revise the care plan for Resident (R) 21, to provide direction to staff to ensure R21 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for impaired care due to uncommunicated care needs. […]

• No harm, potential for more than minimal, isolatedF883Oct 24, 2024

  The facility identified a census of 23 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 6, R8, and R21. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R6's clinical record revealed the PCV13 was administered on 01/29/18 and the Pneumococcal Polysaccharide Vaccine (PPSV23) was administered on 02/19/19. […]