North Crest Living Center
North Crest Living Center in Council Bluffs, IA — inspection on August 26, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the email dated 8/22/25 from Staff C, Medical Records Staff to the DON documented Staff C understood she was a part of the fail safe for lab results processing.
Results with no signatures get printed out and given to the nurses.On 8/26/25 at 8:31 AM the Director of Nursing (DON) acknowledged she could not find when the lab results were sent to the physician once received by the facility from the lab.
The DON stated as the results come back from the lab the results should be sent off to the doctor for review.
The DON stated she had noticed the missed physician notification on 8/22/25 and started educating the nurses at the facility about physician notification and handling of lab results.
The DON stated she had updated the nurses on the follow up portions for the lab results to the physician.
The DON explained it was a situation that warranted a mass audit to be sure nothing was missed in the process.
Review of policy updated 9/24 titled, Physician Order Guideline documented it was the policy of the facility to secure physician orders for care and services for residents as required by state and federal law.
Physician orders will be dated and signed according to state and federal guidelines.
Unclear or incomplete written orders will be reviewed with the physician.
Any order clarification will be documented on the physician's telephone order form.
Faxed orders will be accepted under the following conditions: the physician signs and retains the original copy of the faxed order and the physician provides the original copy, if requested.Review of document updated 8/22/25 titled, Labs documented when lab results are received the receiving nurse was to send to the physician and update the awaiting physician section.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
North Crest Living Center
34 Northcrest Drive Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
stated she felt like the concern was a documentation issue.
The DON stated if there was a decrease in output the nurse should have been notified.
The DON acknowledged no output from Resident #1's catheter could indicate dysfunction or the catheter was clogged.Review of policy updated 10/24 titled, Catheters documented the policy was to provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control policy.
The facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infection.
Catheters are to be changed per orders.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
North Crest Living Center
34 Northcrest Drive Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #1's EHR titled, Orders documented a physician's order started 7/29/25 to change indwelling catheter with 16 French monthly and as needed.
Observation on 8/25/25 at 3:10 PM of catheter care completed on Resident #3 by Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA with EBP signage posted in Resident #3's room revealed Staff H present in the room with Resident #3 sitting on the commode.
Staff H left the room and asked another staff member to help with peri care.
Staff H returned to Resident #3's room with Staff I.
Staff H and Staff I applied gloves, neither staff completed hand hygiene or applied a gown, Staff H utilized a gait belt to assist Resident #3 with standing, Staff I obtained wipes, Staff I removed peri wipes from the bag, cleansed catheter and penis while standing behind Resident #3, cleansed buttocks with 2 peri wipes, pulled Resident #3's brief up, pulled Resident #3's pants up, Staff H assisted Resident #3 with transfer to the wheelchair, Staff H removed gloves, Staff H completed hand hygiene, Staff I removed gloves, Staff I gathered trash in trash bag, Staff I removed the trash bag, Staff I exited Resident #3's room, Staff I walked down the hall to the soiled utility room, Staff I opened the door, placed garbage in the trash barrel and Staff I completed hand hygiene in the hall outside the soiled utility room. On 8/25/25 at 3:30 PM Staff H stated he was not required to wear a gown when Resident #3 was on the commode.
Staff H stated when he was not working directly with the bodily fluids the gown would not be expected.
Staff H acknowledged that other CNA was not wearing the gown at the time of catheter care and peri care.
Staff H explained Resident #3 was having a BM there is no expectation for gown application.
Staff H stated with Enhanced Barrier Precautions (EBP) he was supposed to gown and glove for catheter and peri cares but not required when Resident #3 was having a bowel movement. On 8/25/25 at 3:56 PM Staff I, stated the only time she would apply a gown was when she emptied Resident #3's catheter. On 8/25/25 at 4:05 PM the DON stated the facility's expectation was that gowns would be worn by the staff that transferred the resident and the staff completing care on the resident. On 8/26/25 at 2:16 PM Staff F, Licensed Practical Nurse (LPN) stated when there was any care provided to a resident with catheters the staff are required to wear a gown, gloves and complete hand hygiene before and after application of gloves or resident contact. On 8/26/25 at 4:17 PM the DON stated hand hygiene should be completed prior to resident care, after resident care, before applying gloves and after removal of gloves.
The DON stated the staff should have worn gowns with the resident cares on Resident #3.
Review of policy updated 11/24 titled, Enhanced Barrier Precautions (EBP) documented EBP was used to prevent the spread of Multi-Drug Resistant Organisms (MDRO) to residents.
EBP precautions apply when a resident is not known to be infected or is known to be infected with a CDC-targeted MDRO and has a wound or indwelling medical device.
Indwelling medical devices include urinary catheters.Review of policy updated 8/24 titled, Hand Hygiene documented hand hygiene will be completed before anticipated contact with resident, after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects in the residents room, after removing Personal Protective Equipment (PPE).
Facility ID: