Every finding on record at Crystal Bluffs Rehabilitation and Health Care Cent

Based on record review, observations and staff interviews, the facility failed to post a nurse staffing sheet for 1 of 4 days of the recertification survey (1/4/25).The findings included:During the initial tour on Sunday 1/4/26 at 11:30 AM the staffing sheet posting on the wall by the South nursing station was observed to be dated Friday 1/2/26.On 1/7/26 a review of the facilities daily posted nursing sheets from 1/1/26 through 1/6/26 was completed and no issues were found.During an interview on 1/7/26, at 8:15 AM, the Staffing Coordinator explained that the Scheduler prepared the nurse staffing sheets, and the Staffing Coordinator verified them. The Staffing Coordinator explained at the end of each day, the Scheduler placed the staffing information in the staffing book at the South side nursing station for the night shift nurse to post each night around midnight. For the weekends, the Schedular placed the staffing information for Saturday, Sunday, and Monday in the staffing book at the South side nursing station on Friday before the Schedular left for the weekend. The Staffing Coordinator further revealed either licensed nurse scheduled for the South side was able to exchange the staffing information for the next day and it was considered part of the night shift nursing duties. The Staffing Coordinator further indicated that on Sunday 1/4/26 she exchanged the staffing information and noted the one hanging was dated for Friday 1/2/26.An interview with Nurse #1 on 1/7/26, at 10:00 AM indicated that she worked the nightshift on 1/2/26. She further indicated she was not used to working on Fridays and typically worked Monday through Thursday. Nurse #1 indicated it was a busy Saturday morning, and she forgot to post the new staffing information for Saturday 1/3/26. An interview with Nurse #2 on 1/7/26 at 11:27 AM revealed that she had worked the night shift on 1/3/26. She further revealed she had intended to update the staffing information on Sunday (1/4/26) around 12:00 AM, however she was interrupted to assist with care and forgot to do it.An interview with the Director of Nursing (DON) on 1/7/26, at 8:25 PM confirmed the night shift nurse was expected to hang the nurse staffing information for the next day around midnight as part of their nursing duties. The DON further revealed that he had completed spot checks to ensure the correct staffing information was posted in the past and had not had any issues.An interview with the Administrator on 1/7/26 at 9:03 AM indicated there had not been an issue with the nurses remembering to change the posting sheets in the past, he stated he had spoken with both of the nurses, and they had simply forgotten to do it. He further indicated that the staffing sheets were to be changed every night.

Based on staff interview and record review, the facility failed to refer a resident for a level II Preadmission Screening and Resident Review (PASRR) when diagnosed with a newly evident serious mental illness for 1 of 2 residents reviewed for PASRR (Residents #12). Findings included: Resident #12 was admitted to the facility on [DATE] with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12 ' s medical record diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12 ' s Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #12 was cognitively intact. The resident ' s current active diagnoses included, in part, anxiety disorder and depression. Resident #12 received antidepressants. The MDS indicated the resident had a level I PASRR. In an interview on 4/21/22 at 11:00 AM with the Minimum Data Set Nurse #1 (MDS Nurse #1) she stated when a resident was newly diagnosed with a mental illness the resident needed to be evaluated for a level II PASRR. She confirmed a referral was not made for a reevaluation and acknowledged there should have been a resubmission for a PASRR level II evaluation for Resident #12 when the newly evident mental health diagnoses were identified. She also stated it was a misunderstanding of when and why to resubmit the data for the level II PASRR when a newly diagnosed mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the facility ' s Administrator on 4/21/22 at 11:54 AM. He expressed the PASRR information was expected to be resubmitted immediately by the MDS Nurse to the Social Worker so follow up documentation could be sent forward for reevaluation. He expressed all residents should be reviewed and screened for any needed level II PASRR assessments when mental health changes occur.

Based on observations, staff interviews, and record reviews, the facility failed to provide a resident's tube feeding in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment. She received over half of her daily calories and fluids from her tube feeding (TF). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 4/19/22 at 8:40 AM of Resident #17's TF pump turned off with the formula bottle removed from the room. An observation was made on 4/20/22 at 8:40 AM of Resident #17's TF pump turned off with the formula bottle removed from the room. During an interview on 4/20/22 at 8:45 AM, Nurse #1 revealed that Resident #7 received her TF from 5:00 PM to between 8-10 AM. She indicated that when the bottle ran out, she would turn the pump off. Nurse #1 confirmed the order was to stop the TF at 10:00 AM. During an interview on 4/20/22 at 2:10 PM, the Registered Dietitian (RD) revealed that Resident #7 should receive her TF over 17 hours starting at 5:00 PM and ending at 10:00 AM. She indicated it should not be turned off early. She further revealed Resident #7 had not lost weight. During an interview on 4/20/22 at 4:35 PM, the Regional Clinical Director of Operations revealed staff should be using a 1500 ml bottle of tube feeding formula and turning it off per order. An observation was made on 4/20/22 at 4:40 PM with assistance from the Assistant Director of Nursing (DON) of Resident #17's TF pump history. The pump indicated Resident #7 had received 1027 ml of TF over the past 24 hours. During an interview on 4/21/22 at 8:25 AM, the DON indicated that Nurse #1 should have followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed Resident #7 did not get the full TF for the past two days. During an interview on 4/21/22 at 8:30 AM, the Administrator revealed the nurse should have followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to refer resident for re-evaluation after change in mental status for Pre-Admission Screening and Annual Resident Review (PASARR) for 2 of 2 residents reviewed for PASARR. (Resident #12 and #48) 1. Resident #48 was readmitted to the facility on [DATE] with new [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] had Resident #48 coded as needing extensive assistance for most of his assisted daily living (ADL). Resident #48 was coded with the [DIAGNOSES REDACTED]. A review of the PASARR level I screen tool dated 4/1/13 did not have any mental health [DIAGNOSES REDACTED].#48 was not found. The PASARR level 1 determination notification dated 4/1/13 was reviewed and revealed a PASARR number ending in an A and did not have an expiration date. The comprehensive care plan dated 7/24/19 had focus of antidepressants to manage his [DIAGNOSES REDACTED]. Physicians orders dated 08/2019 has Quetiapine [MEDICATION NAME] 50mg tab; give one tablet by mouth twice a day for his Delusional Disorder and [MEDICATION NAME] 10 mg tablet; give one tablet by mouth daily for his Major [MEDICAL CONDITION]. During an interview with the Administrator on 08/22/19 at 10:43 AM, the Administrator stated Resident #48 did not have the [DIAGNOSES REDACTED]. During an interview with the Social Worker (SW) on 08/22/19 at 11:12 AM, the SW stated she did not realize there was an additional screening that needed to be done for residents with a PASARR determination ending in an A without an expiration date that had a new mental health diagnosis. 2. Resident #12's PASARR Level I Screen Form dated 09/08/14 revealed no noted Mental Health [DIAGNOSES REDACTED]. Resident #12's PASARR Level I Determination Notification letter dated 09/08/14 revealed the resident was assessed to be Level I. The letter had a PASARR number ending in an A and there was no expiration date. There were no further PASARR referrals for Resident #12 in the medical record. Resident #12's original date of admission to the facility was 09/11/14 and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12's cognition was severely impaired, and she was coded as needing extensive assistance for most of her assisted daily living (ADL). Resident #12 was coded with the [DIAGNOSES REDACTED]. The comprehensive care plan last updated 8/16/19 had focus problems to include: a. antianxiety medication use - at risk for side effects to manage [DIAGNOSES REDACTED]. b. cognitive/communication deficits related to Dementia with delusions. During an interview with the Social Worker on 08/22/19 at 11:12 AM, the Social Worker stated she did not realize there was an additional screening that needed to be done for residents with a PASARR determination ending in an A without an expiration date that had a new mental health diagnosis. During an interview with the Administrator on 08/22/19 at 5:20 PM, she revealed she was not aware there was an additional PASARR screening needed after a resident had an existing PASARR determination ending in A without an expiration date.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean the tray steam table under shelf for two of two steam tables observed. The findings included: 1. Review of the undated facility policy PM Cook Position Duties under Daily Cleaning: read in part #1. Tray line hot wells, check under shelf. During an observation on 7/13/16 at 10:00 AM the five well steam table in the kitchen was observed. The 5 ½ foot underside of the steam table shelf was observed to be covered with dark dried food particles. On 7/13/16 at 10:02 AM the Certified Dietary Manager/ Chef stated that the steam table should be cleaned by the PM cook. He stated he expected the underside of the shelf to be clean and would retrain staff that day. In an interview on 7/13/16 at 2:28 PM the PM cook stated that he forgot to clean the underside of the shelf as it was out of sight, out of mind. 2. During an observation on 7/14/16 at 8:40 AM the dining room steam table was observed. The 4 ½ foot underside of the steam table shelf was observed to be covered with dark dried food particles. In an interview with the CDM/Chef on 7/14/16 at 8:57 AM he stated that he expected staff to clean the whole steam table. He indicated that he should have checked both steam tables the day before. In an interview on 7/14/16 at 9:04 AM the Administrator stated that she would have expected dietary staff to check both of the steam tables the day before.

Based on observation and staff interview the facility failed to maintain a refrigerator temperature between 36 and 46 degrees Fahrenheit for one of two medication refrigerators observed. The findings included: Review of the facility policy titled, Refrigerators and Freezers dated April 2006 read in part, 1. Acceptable temperatures should be 36 (degrees) F (Fahrenheit) for refrigerators and less than 0 (degrees) F for freezers. A review of the temperature log titled, Nurse QA Log for the month of July 2016 the temperatures ranged from 30 to 35 degrees Fahrenheit. At the bottom of the sheet read, Refrigerator Temp Range: 32-40 degrees. During an observation on 7/14/16 at 8:32 AM the thermometer in the refrigerator on the 100,200 and 300 halls read 34 degrees Fahrenheit. During an interview Nurse #1 stated the refrigerator was 34 degrees and she was observed to reset the refrigerator thermostat. During the observation 1 packet of Enbrel Etanercept 25 mg (milligrams)/0.5 ml (milliliters). The instructions for storage revealed the medication should be refrigerated at 36 to 46 degrees Fahrenheit. The instructions read, Do not freeze. Also observed were 3 packets of Risperdal 25 mg. The instructions for storage revealed the medication should be stored in the refrigerator at 36 to 46 degrees Fahrenheit and 3 packages of Risperdal 50 mg. with instructions to store in the refrigerator at 36 to 46 degrees Fahrenheit. On 7/14/16 at 8:39 AM the Director of Nursing (DON) stated the temperatures documented that they have been 30 to 35 degrees on the Nurse QA log for refrigerator temperatures for July 2016. The DON further stated that staff did not notify anyone or reset the refrigerator. On 7/14/16 at 10:32 AM Nurse #1 a night shift nurse responsible for checking the temperatures for the refrigerator stated she looked at the bottom of the Nurse QA Log for monitoring the medication refrigerator and it read Refrigerator Temp Range: 32-40 degrees and that was the temperature she thought the refrigerator should be set on. On 7/14/16 at 10:55 AM the Administrator stated that the Nurse QA Log did have 32-40 degrees written on the bottom of the page and that the maintenance director did not recognize that the temperature was incorrect but he was aware of the correct temperature.

Based on record review, observation and staff interviews the facility failed to transfer a resident (Resident #5) safely while using a mechanical lift, by not positioning the resident down correctly in the wheelchair, standing to the side of the wheelchair, raising the mechanical lift bar and removing the straps from the mechanical lift bar, which resulted in the resident falling backwards in the wheelchair, for one (1) of four (4) sampled residents reviewed for falls. The findings are: Resident #5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], Resident #5 ' s memory was cognitively intact. Resident #5 required minimal to extensive assistive with activities of daily living. In the area of transfer (how resident moved between surfaces including to and from: Bed, chair, wheelchair, standing position (excludes bed and toilet), Resident #5 was totally dependent and required two person physical assistance. Review of the MDS revealed Resident #5 did not have any falls or fracture related falls during the past year. Review of the MDS under " Balance During Transitions and Walking " and " E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) " indicated that Resident #5 was coded as " 2. Not steady, only able to stabilize with human assistance. " Review of Resident #5's Care Plan, which was reviewed on 11/16/10, under, "Risk for falls will be minimized daily thru next review," read in part, " Transfer OOB (out of bed) with use of, (sit to stand mechanical lift was crossed out) or (mechanical lift.) Review of Resident #5's "Care Area Assessment Resources" dated 1/13/11, in the area of falls read, "No Fall History." Under "Review of Indicators of Falls," read, in part, "Impaired balance during transitions." Under "Supporting Documentation," read in part, "Resident is dependent upon staff for all transfers including mechanical lift." Review of a facility "Transfer Audit Tool," dated 1/13/11 at 5:00PM, revealed that Nursing Assistant #1 as well as three other Nursing Assistants were trained to transfer Resident #5 using a mechanical lift. The Transfer Audit Tool noted that staff performed the appropriate transfer method according to the resident Kardex and Care Plan, a two man transfer method was used and the transfer method was performed according to procedure. Review of an undated, "Standards of Care Kardex," (Used by Nursing Assistants to care for the resident), under "Transfer," was checked "Assist of 2," and written on the Care Kardex was (mechanical lift). Under "Alerts" read "Fall Risk." Review of the facility's Incident/Accident Report dated 1/23/11 at 10:45AM, read in part, "Resident being transferred from bed to w/c (wheelchair) by (mechanical lift), x2 CNA's (Nursing Assistants) present, one operating, the 2nd stepped to the side to hold onto the strap & the w/c (wheelchair) tipped backwards." Under "Type of Injury" read "goose egg." The incident report noted that Resident #5 complained of pain to the back of her head. Under "Additional comments and/or steps taken to prevent reoccurrence:" read, "Anti tip w/c (wheelchair d/t (due to) use of (mechanical lift), physical therapy request write up." Review of a Nursing Note dated 1/23/11 at 10:45AM, read in part, "CNA (Nursing Assistant) got the Nurse. Resident being transferred from bed to w/c (wheelchair) by (mechanical lift) (symbol for with) x 2 CNAs. W/C flipped backwards with resident sitting in w/c. Resident c/o (complained of) backpain? "I hit my head." W/C wheels were locked when this nurse removed w/c." Review of a Physician's telephone order dated 1/23/11 at 11:00AM read, Send to (emergency room ) for (evaluation) related to fall. Review of hospital report dated 1/23/11, titled "Patient Visit Information," under, "Patient Instructions Reviewed," read, "Bruise, Contusion, Cervical Strain, and Head Injuries, Adult." Review of an "Emergency Department" Report dated 1/23/11, which was dictated by an emergency room Physician, under, "Medical Decision Making:" read in part, "In the emergency room a CT scan of the head and neck were obtained, which was interpreted by Radiology and showed no evidence of acute abnormalities." During an interview on 1/26/11 at 10:15AM, the Director of Nursing stated that she had just completed an audit on transfers and both Nursing Assistants had been inserviced. She revealed that she thought when they transferred Resident #5, the mechanical lift was too high on the back of the wheelchair and top heavy and the wheelchair fell backwards. She stated that anti-tippers were put on the wheelchair the next day. During a telephone interview on 1/26/11 at 1:40PM, Staff Nurse #1 revealed that she completed Resident #5's Incident/Accident Report. She stated that two Nursing Assistants (NAs) were transferring Resident #5 from her bed to her wheelchair. She stated that Nursing Assistant #1 was in front of the mechanical lift where the controls are located. She indicated that after Nursing Assistant #1 and Nursing Assistant #2 transferred Resident #5 into a seated position in the wheelchair, Nursing Assistant #2 who stood in the back of the wheelchair let go of the back of the wheelchair and went to the side of the wheelchair to undo the straps and that's when the wheelchair flipped backwards. She indicated that Nursing Assistant #2 had to unhook the leg straps from the mechanical lift, and when she attempted to do that, the wheelchair rolled and flipped backwards. She revealed that the wheelchair wheels were locked and the wheelchair tipped straight backwards. She stated that she did not know if the wheelchair was tilted a little backwards or when Nursing Assistant #2 came around to undo the straps it was too top heavy and flipped over. Staff Nurse #1 stated that she felt that Nursing Assistant #2 used the right technique in transferring Resident #5, however she revealed that the extra weight of coming off of the mechanical lift tipped the wheelchair backwards. She stated that if the mechanical lift bar was not as low as it could go when Nursing Assistant #2 unhooked the resident's leg straps, it might have added a little extra weight or if the resident was sitting too far back with extra weight in the chair. During an interview on 1/26/11 at 2:00PM, Nursing Assistant #2 stated when they hooked up to the mechanical lift from Resident #5's bed evidently the resident was sitting too high in the wheelchair and it tilted back. She revealed that she was behind the wheelchair and she stepped to the side in order to unhook the straps from the mechanical lift bar and the wheelchair flipped. She stated that Resident #5 was sitting too high in the mechanical lift and she was top heavy. She stated that the resident was in the wheelchair and she stepped halfway to the side to release the straps and the wheelchair flipped. She stated that she asked Nursing Assistant#1, who was controlling the mechanical lift, to lower the bar so that she could release the straps and she went to the side to undo the straps and the wheelchair flipped backwards. She stated that Resident #5's legs were down. She stated that the wheelchair had a thick cushion so the back of the wheelchair touched the resident in the middle of her back. Nursing Assistant #1 was not available for interview. During an interview on 1/26/11 at 3:15PM, Resident #5 indicated that staff was getting her up from her bed to be transferred to her wheelchair using the mechanical lift. She revealed that while being transferred the bar on the mechanical lift almost hit her on the head. She stated that she did not know why the Nursing Assistant went from the back of the wheelchair to the side of the wheelchair. She stated in that split second she was over. She stated that they started using the mechanical lift on her because she could not bear weight to use the sit to stand mechanical lift. Resident #5 revealed that staff had been using the mechanical lift to transfer her for over the past month. She indicated that after staff had transferred her to the wheelchair, one person usually stood behind the wheelchair. She stated that the girl (NA#2) that stood behind the wheelchair told the other NA (NA#1) to bring the bar up a little bit and they were fiddling with it. She indicated that was when she fell . She stated that staff had not gotten her up from bed since the fall because she was still hurting from the fall. During another interview on 1/26/11 at 5:10PM, the Director of Nursing (DON) stated that the incident happened on last Saturday or Sunday and she came in Monday to start the investigation. She stated that they do transfer audits and they discuss all incident reports in morning meetings. She stated that she immediately had anti-tippers put on the wheelchair. She stated that she talked to Resident #5 about the incident and the Administrator reviewed the incident report. She stated that no one had determined how the incident happened. She stated that she put interventions in place immediately and she was convinced that the wheelchair tipped backwards and the anti-tipper bar installed on the wheelchair caught that. She stated that she did transfer audits (observation of staff doing transfers using a mechanical lift.) for Resident #5 last week and she would start inservicing staff about transferring residents correctly using the mechanical lift, (i.e., what caused Resident #5 to fall from the mechanical lift) tonight, 1/26/11. During an interview on 1/26/11 at 5:40PM, the Administrator stated the maintenance man looked at the mechanical lift immediately and that there was no problem with the mechanical lift. She stated that she felt like they had started the investigation. She revealed that she had never had anything happen like a resident falling from a mechanical lift. She stated that no one had fallen from a mechanical lift since the incident with Resident #5. She stated that they tried to look at everything.