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Deficiency Records for Crest View Lutheran Home
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.
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? |
|---|---|---|---|---|
| Provide activities to meet all resident's needs. | Health | 2024-10-30 | 2024-11-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-10-30 | 2024-11-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-30 | 2024-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-29 | 2024-09-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-23 | 2024-06-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-02 | 2024-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-04 | 2024-05-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-04 | 2024-05-20 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-04 | 2024-05-20 | 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 | 2024-04-04 | 2024-05-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-04-04 | 2024-05-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-04 | 2024-05-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-04 | 2024-05-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-02 | 2024-04-24 | N |
| 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 |
| 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 |
| 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 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 |
| 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 safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-02 | 2023-04-10 | 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 | 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 each resident?s drug regimen must be free from unnecessary drugs. | 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 |
| Ensure proper usage of power strips and extension cords. | 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 |
| Have approved installation, maintenance and testing program for fire alarm systems. | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 safe and appropriate respiratory care for a resident when needed. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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