A list of the most recent deficiencies for Crest View Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-06 | 2023-08-06 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-02 | 2023-04-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-02 | 2023-04-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-02 | 2023-04-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-02 | 2023-04-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-02 | 2023-04-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-02 | 2023-04-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-02 | 2023-04-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-02 | 2023-04-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-04-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-02 | 2023-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-18 | 2023-03-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-04 | 2022-12-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-04 | 2022-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-31 | 2022-03-04 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-01-31 | 2022-03-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-07 | 2022-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-07 | 2022-01-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-07 | 2022-01-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-07 | 2022-01-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-07 | 2022-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-07 | 2022-01-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-07 | 2022-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2022-01-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-09 | 2022-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-05 | 2022-01-04 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-11-05 | 2022-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-26 | 2022-01-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-26 | 2022-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-26 | 2022-01-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-21 | 2020-01-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-11-21 | 2020-01-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-11-21 | 2020-01-06 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-21 | 2020-01-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-21 | 2020-01-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-21 | 2020-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-21 | 2020-01-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-21 | 2020-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2020-01-06 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
