Viewcrest Health Center

In the surveyor’s words

From the most serious findings on record at Viewcrest Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 21, 2025

  Based on interview and document review, the facility failed to follow manufacturer's recommendation on EZ Way sling usage, facility policy, and transfer care plan for 1 of 3 (R1) residents reviewed for mechanical lift transfers. Additionally, the facility lacked a system to assess and document appropriate resident sling size. R1 fell out of the sling, sustained a laceration to the back of her head and was sent to the Emergency Department (ED). The IJ began on 3/13/25 at 11:00 p.m., when R1 fell from a mechanical lift causing a laceration to her head and the liklihood for potnetial serious harm. The administrator and director of nursing (DON) were informed of the IJ on 3/21/25 at 10:30 a.m. […]

• Immediate jeopardy, isolatedF760May 14, 2024

  Based on interview and document review, the facility failed follow medication administration policy for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an immediate jeopardy (IJ) for R1 when LPN-B administered R2's medications to R1, which resulted in severe bradycardia (slower than normal heart rate) for R1 leading to hospitalization and a surgical intervention of a temporary pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. […]

• Actual harm, isolatedF689Jun 2, 2026

  Based on observation, interview, and record review the facility failed to follow its policy to adequately supervise 1 of 3 residents (R1) prior to a successful elopement who was reviewed for accidents. R1 eloped from the facility wearing a WanderGuard system, was found four blocks away and was hospitalized with abrasions.Findings include:Upon observation on 6/2/26 at 8:30 a.m. the facilities camera recording revealed at 3:52 p.m. on 5/19/26 the maintenance director checked the WanderGuard that was going to be placed on R1. The WanderGuard set off the door alarm, a staff member in the front office heard the alarm and ran to the door. At 5:35 p.m. R1 walked up to the front door and the magnetic light came on. R1 turned around and walked away. […]

• Actual harm, isolatedF689Feb 14, 2024

  Based on observation, interview, and document review, the facility failed to ensure the care plan was followed to prevent and/or reduce the risk of burns from hot liquid for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained three 2nd degree burns (damage to outer and second layers of skin) to both thighs. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure use of assistive devices/adaptive equipment when dining. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had indicated R1 had Alzheimer's disease, dementia, and severe stage of open angle glaucoma to bilateral eyes. […]

• Actual harm, isolatedF697Jun 10, 2021

  Based on interview and document review, the facility failed to effectively provide pain management for 1 of 1 residents (R1) reviewed for acute post surgical pain. This resulted in actual harm to R1, when R1's narcotic pain medication was not administered per orders resulting in uncontrolled pain. Findings include: R1's Admission Record printed on 6/10/21, indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 48 Hour Baseline Care Plan initiated on 6/4/21, indicated R1's reason for admission was related to recent pacemaker and Coronary Artery Bypass Graft (CABG). R1 was to have assist of 1 staff for toileting, ambulation, toileting, bathing, and bed mobility. Pain interventions included ice, medications, distraction, massage, and conversation. […]