CRESTVIEW HOME

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to immediately inform a
resident’s responsible party after the resident fell and sustained an injury for one
sampled resident (Resident #2) out of three sampled residents. The facility census was 54.
Review of the facility policy for Event Investigation, dated 3/2016, showed in part:
-Procedure for completing the Report of Event Form: description of the event – describe
the event and include pertinent comments made by the person involved and any witness
comments, primary diagnoses, cognitive state, exact location of the event, type of event,
observations, exact location of the injury, vital signs, mental and neurological status,
range of motion, complaints of pain, first aid given, seen by the physician, transferred
to the hospital, notification of the physician (must be documented in the medical record),
notification of the responsible party (must be documented in the medical record), actions
taken to prevent recurrence – what was done immediately to prevent event from happening
again.
1. Review of Resident #2’s medical record showed a letter of incapacitation (a letter
signed by two physicians who have determined the resident has lost his/her decisional
capacity and invoking the power of attorney) dated 11/28/17.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 6/5/18, showed staff assessed the resident as:
-Alert with some confusion;
-Required limited assistance of one with transfers and ambulation;
-Occasionally incontinent of urine, continent of bowel;
-[DIAGNOSES REDACTED].
-One fall with fracture.
Review of the resident’s fall event report, dated 6/12/18 at 2:32 A.M. and signed by
Licensed Practical Nurse (LPN) D, showed:
-The resident was observed on the floor;
-No pain, bruising or hematoma present and unable to complete range of motion (ROM), no
rotation, deformity or shortening of extremities noted;
-Alert, speech clear;
-Contributing factors to fall: orthopedic condition;
-Receives antihypertensives and antipsychotic medication;
-Interventions: rest;
-Outcome of interventions: effective and resident stated his/her understanding of the call
light;
-Physician and family notified;
-Care plan reviewed.
Review of the nurses’ note, dated 6/12/18, showed staff did not document the fall or that
they notified the resident’s physician or responsible party at the time of the fall.
Review of the nurses’ note, dated 6/12/18 at 9:51 A.M. and signed by LPN A, showed:
-Resident doing well at this time. Received reply from nurse practitioner related to fall
and he/she advised that the resident should be seen at the emergency room (ER) for a head
CT (computed tomography) scan if he/she would go. The nurse spoke with the resident again
about this and the resident stated I’m doing ok, I don’t need to go. The nurse contacted
the responsible party who stated that he/she would come and check on the resident.
Review of the telephone order, dated 6/12/18, showed:
-Send the resident to ER for evaluation post fall, head injury and left hand bruising and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents’ grievances
were fully addressed and failed to maintain complete documentation of grievances received,
steps taken to resolve the grievance, notification of the residents of the results of the
grievance and follow up with the residents to ensure the problem/concern was resolved for
three sampled residents (Resident #8, #9 and #20). The facility census was 55.
Review of the facility’s undated policy for Grievance Protocol showed:
-The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written
record of each resident and family concern and to ensure proper follow-up through the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to update the comprehensive
care plan after falls with the causes of the falls and new interventions to prevent future
falls for three sampled residents (Residents #2, #3 and #4) out of 11 sampled residents.
The facility census was 54.
Review of the facility policy for Care Plans, dated 3/15, showed:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental and
psychosocial well-being;
-The interdisciplinary care plan team with the input from the resident, family, and/or
legal representative will develop and maintain a comprehensive care plan for each resident
that identifies the highest level of functioning the resident may be expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is
not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument
completed by staff;
-Assessment of each resident is an ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
-A well developed care plan will be oriented to: preventing avoidable declines in
functioning or functional levels; managing risk factors to the extent possible or
indicating the limits of such interventions; addressing ways to try to preserve and build
upon resident strengths; applying current standards of practice in the care planning
process; evaluating treatment of [REDACTED]. abilities; involving the resident, resident’s
family and other resident representatives as appropriate; assessing and planning for care
to meet the resident’s medical, nursing, mental and psychosocial needs; involving the
direct care staff with the care planning process relating to the resident’s expected
outcomes; addressing additional care planning areas that are related to meeting the
resident’s needs in the long-term care setting;
-The interdisciplinary care plan team is responsible for the periodic review and updating
of the care plans when a significant change in the resident’s condition has occurred, at
least quarterly and when changes occur that impact the resident’s care.
1. Review of Resident’s #2 medical record showed the resident was admitted to the facility
on [DATE] after sustaining a fractured right clavicle (collar bone) while walking through

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews and record reviews, the facility failed to assure staff
followed acceptable standards of practice for two additionally sampled residents (Resident
#7 and #40) when staff recorded [MEDICATION NAME] (narcotic pain medication) and
[MEDICATION NAME] (an anti-anxiety medication in the benzodiazepine family), scheduled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided complete perineal care (cleaning the genital and rectal areas) to three
dependent, incontinent residents (Resident #6, #36 and #38) out of 15 sampled residents,
failed to assure they had a sufficient number of staff to provide at least two showers a
week and assure residents who preferred to be shaven were shaved for four sampled
residents (Resident #23, #37, #39 and #51). The facility census was 58.
1. Review of the facility’s policy on perineal care, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Purpose: to cleanse the perineum and to prevent infection and odor;
– Lie the resident on his/her back, wet the washcloth, make a mitt with it, and apply soap
lightly;
– Use one hand to stabilize and separate the perineal folds, with the other hand, wash
from front to back, rinse and pat dry.
– Does not address how many times to fold and reuse the washcloth;
– If uncircumcised, pull back the perineal fold, wash, dry and return to the normal
position;
– Turn the resident on his/her side, use a new washcloth, wash around the rectum, rinse
and dry.
2. Review of Resident #6’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 4/29/18, showed:
– [DIAGNOSES REDACTED].
– Required extensive assistance of two staff for all activities of daily living (ADLs);
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, updated on 4/30/18, showed:
– Problem: Risk for pressure ulcers related to [MEDICAL CONDITION] and decreased mobility
[MEDICAL CONDITION] of bowel and bladder;
– Provide perineal care after each incontinent episode;
– Need two assist with cares: mechanical lifting, transferring, dressing, toileting,
perineal care and repositioning.
Observation on 4/30/18, at 12:30 P.M., showed:
– Nurse Aide (NA) A opened a wet brief, wiped across the resident’s supra pubic area once,
wiped each groin once, retracted the perineal fold and cleaned around the skin folds, and
repositioned the perineal fold;
– Wiped under the perineal fold and rolled the resident onto his/her side, and wiped a
large amount of fecal material away from the rectum;
– Did not wash the buttocks, upper thighs, or all areas wet with urine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to assure staff
used proper techniques and follow their facility policy to reduce the possibility of
accidents and injuries during mechanical lift transfers. This affected two of 15 sampled
residents (Resident #6 and Resident #36). The facility census was 58.
Review of the facility’s policy on Hydraulic Lifts, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Open the lift legs to the widest point, at the closest location to the resident (bed or
chair);
– Position the sling under the resident and move the lift with the base under the bed;
– Attach the S hooks to the overhead bar and raise the resident, when the resident has
been lifted clear of the bed, grasp the bar, and move to the chair;
– Position the wheelchair and lock the wheelchair brakes.
Review of the facility’s manufacturer’s instructions on the battery operated mechanical
lift, dated 12/3/12, showed:
– Operating instructions: Open the base legs, move the lift slowly towards the resident,
and position the overhead bar over the resident’s chest;
– Attach the sling and lift the resident above the bed using the hand control;
– Pull lift away from the bed, move the resident over the wheelchair (chair wheels locked)
opening the base for stability and fit, and lower the resident into the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to provide care
to prevent urinary tract infections (UTIs) for residents with a suprapubic catheter (a
urinary catheter that is inserted into the abdominal wall and into the bladder), and an
indwelling catheter. This affected three of 15 sampled residents (Residents #14, # 23 and
#36). The facility census was 58.
Review of the facility policy on catheter care, dated (MONTH) (YEAR), showed:
– Purpose: To prevent infection and reduce irritation;
– Use a warm water and soap to cleanse all perineal skin folds;
– Use one area of the washcloth for each downward, cleansing stroke and change the
position of the washcloth with each downward stroke;
– Change the position of the washcloth and cleanse at the insertion site; do not allow the
washcloth to drag on the resident’s skin or bed linen;
– With a clean washcloth, rinse with warm water using the above technique;
– Use a clean wash cloth with warm water and soap to cleanse and rinse the catheter from
insertion site to approximately four inches outward;
– Ensure that the catheter remains secured utilizing a leg strap;
– Check drainage tubing and bag to ensure that the catheter is draining properly;
– Discard disposable items; remove gloves and wash hands.
1. Review of Resident #23’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/1/18, showed:
– No cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, and personal
hygiene;
– Indwelling urinary catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan last updated 3/5/18, showed:
– Staff assistance with activities of daily living (ADLs) due to a [DIAGNOSES REDACTED]. A
contracture occurs when a joint becomes permanently fixed in a bent or straightened
position, which can impact the function and range of motion of the joint);
– At risk for UTIs related to having a catheter;
– Catheter and perineal care every shift and as needed.
Observation on 5/1/18, at 7:45 A.M., showed Certified Nurse Aide (CNA) B and Nurse Aide
(NA) D entered the resident’s room to provide catheter and incontinent care as the
resident lay in bed and staff did the following:
– Both staff washed their hands and put on clean gloves.
– CNA B cleansed the resident’s frontal perineal skin folds with a hand towel then removed
his/her gloves and did not wash his/her hands before he/she informed NA D that he/she
needed to leave the resident’s room to obtain additional disposable gloves as he/she did
not have any more gloves in his/her pockets.
– CNA B exited the resident’s room without washing his/her hands;
– CNA B returned shortly, did not wash his/her hands before reaching into his/her pocket
to obtain a pair of disposable gloves and he/she put on the clean gloves without washing
his/her hands.
– CNA B cleansed the resident’s buttock with a hand towel and did not remove his/her

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
dated multi-dose bottles of [MEDICATION NAME] (a mediation used to treat anxiety and often
used during end of life) and [MEDICATION NAME] (narcotic pain medication) when opened for
two out of fifteen sampled residents (Resident #56 and #210). The facility census was 58.
Review of the facility policy, dated (MONTH) (YEAR), titled Storage of Medications,
showed:
-Staff are directed to record the expiration date based on date opened on the label of
medication with shortened expiration dates and follow manufacturer medication
administration guidelines.
-Medications may not be prepared in advance and must be administered within one hour of
preparation;
-The person administering the drugs must chart medications immediately following the
administration;
-The date, time administered, dosage, etc must be entered in the medical record and signed
by the person entering the data.
Review of the package insert provided by the facility for [MEDICATION NAME] showed to
discard opened bottle 90 days after opening the bottle.
1. Review of Resident #210’s (MONTH) (YEAR), physician order sheet (POS) showed:
-[MEDICATION NAME] 2 mg/ml (milligrams/milliliters), give ,[DATE] ml orally every every
four hours as needed for anxiety;

the west side parked by the nurses’ station with the evening snacks. One resident sat at a
table in the area and ate his/her snack.
During an interview on 5/2/18, at 7:50 P.M., RN A said the aide was supposed to pass the
snacks.
During an interview on 5/2/18, at 8:00 P.M., Family Member A said no snacks were passed to
their mother/father.
Based on observation, record review and interview, the facility failed to ensure all
residents were offered an evening snack. This affected all residents that were unable to
go to the snack cart and get their own snacks. The facility census was 58.
Review of the facility’s bedtime snack policy dated March, (YEAR), showed an aide assigned
will take the hydration cart and bedtime snacks to each resident room and offer each
resident a snack and drink.
During a group resident interview on 4/30/18, at 10:10 A.M., all 10 of the residents in
attendance said the facility did not pass evening snacks room to room.
During an interview on 5/2/18, at 7:30 P.M., Dietary Aide A said they had already taken
the snacks to each nurses’ station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
followed infection control protocols to prevent the spread of infection, when staff did
not change gloves and wash their hands when going from a soiled to a clean task, which
affected three of 15 sampled residents (Resident #6, #19, and #23). The facility also
failed to change nebulizer tubing monthly which affected residents (Resident #13 and
Resident #39). The facility census was 58.
Review of the facility’s policy on Handwashing, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Purpose: To reduce transmission of organisms from resident to resident, nursing staff to
resident, and resident to nursing staff.
Review of the facility’s policy on Gloves, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, wound drainage oral
secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or a
person with a rash.
– Gloves must be changed between residents and between contacts with different body sites
of the same resident.
– Gloves are not a cure-all. They should reduce the likelihood of contaminating the hands,
but gloves cannot prevent injuries due to needles or sharp objects.
– Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of
a glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves is not acceptable.
– Change gloves between contacts (as defined above) with different residents or with
different body sites of the same resident.
1. Review of Resident #6’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 4/29/18, showed:
– Required extensive assistance of two staff for all activities of daily living (ADLs);
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, updated on 4/30/18, showed:
– Risk for pressure ulcers related to [MEDICAL CONDITION] (weakness or inability to move
one side of the body) from a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) and
incontinence of bowel and bladder;
– Frequently incontinent, provide care after each incontinent episode.
Observation on 4/30/18, at 12:30 P.M., showed Nurse Aide (NA) A did the following:
– Opened a wet brief, wiped across the resident’s suprapubic area with a washcloth; folded
it, wiped the right groin once; folded the washcloth again, wiped the left groin; folded