North Crest Living Center

In the surveyor’s words

From the most serious findings on record at North Crest Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 5, 2022

  Based on observation, record review and resident, family and staff interviews the facility failed to ensure the resident environment remains as free of accident hazards as possible. Boiling water from a pot was used to make hot chocolate and then served to Resident #1 which resulted in burning of the resident's mouth. The resident required hospitalization and pain control for the [CONDITION(S)]. The facility's failure resulted in an immediate jeopardy to resident's health and safety. The facility reported a census 46 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool dated 6/27/22 documented a Brief Interview Mental Status (BIMS) score of 13. A BIMS score of 13 suggested Resident #1 had no cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF865Jul 24, 2025

  Based on document review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 3 areas and corrections developed in a Performance Improvement Plan (PIP) that remained incomplete in a reasonable time frame. The facility reported a census of 61 residents. Findings include:Review of document titled, Provider History Report documented previous recertification survey on 9/18/24 with deficiencies F0625 notice of bed hold policy before/upon transfer with a correction date of 10/19/24, F0656 Develop/implement Comprehensive care plan with correction date of 10/19/24, and F0658 services provided meet professional standards with correction date of… […]

• No harm, potential for more than minimal, widespreadF880Jul 24, 2025

  Based on observation, interview and record review the facility failed to follow infection control standards of practice. Laundry staff failed to wear Personal Protective Equipment (PPE) while sorting laundry, and the facility failed to ensure that they had consistent implementation of the responsibilities of the Infection Preventionist (IP). The facility reported a census of 61 residents. Findings include:On 7/24/25 at 6:48 AM, observed Staff L, Environmental Aide in the laundry room sorting dirty laundry items without a gown or gloves. She quickly went to get a gown but was unsure how to put it on. She first put it on backwards, with the ties in the front, then she took it off and put it on the correct way with the ties in the back. […]

• No harm, potential for more than minimal, widespreadF725Sep 19, 2024

  Based on staffing reviews, interviews, and Facility Assessment review the facility failed to provide adequate nursing staff to assure residents safety and well-being. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #7 dated 7/23/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognition. Resident #7 on 9/16/24 at 1:09 PM stated call lights can take longer than 15 minutes to answer. The resident stated he would watch the clock to determine the length of time for answering. Staff C, Certified Nursing Assistant (CNA), on 9/18/24 at 1:05 PM stated working on the weekends was more difficult as there were less staff. […]

• No harm, potential for more than minimal, widespreadF880Sep 19, 2024

  Based on observation, resident interview, staff interview, and policy review the facility failed to follow standard precautions while separating laundry, and following enhanced barrier precautions (EBP). The facility further failed to establish a facility wide written infection prevention control policy. The facility reported a census of 56 residents. Findings include: 1. Observation 9/17/24 at 11:17 AM Staff E revealed laundry is being separated without gloves and gowns. Staff E further revealed that laundry is separated, and then hand sanitizer is utilized. Gloves were noted around the corner from the washing machines on a shelf at this time. During this observation it was also noted there were no gowns in the laundry room. […]