Crestmoor Care Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure an environment free of accident hazards for one (#3) of three residents reviewed for accidents/hazards out of 16 sample residents. Specifically, the facility failed to prevent Resident #3 from eloping from the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to protect four (#12, #5, #9 and #15) of seven residents from abuse out of 12 sample residents. Resident #6 was admitted on [DATE] with a diagnosis of bipolar disorder (mental illness), depression, and dementia. Resident #12 was admitted on [DATE] with a diagnosis of dementia, other behavioral disturbance, anxiety disorder and depression. On [DATE], Resident #6 and Resident #12 were in the dining room when the residents began yelling at each other and hitting each other. On [DATE], Resident #6 grabbed Resident #12 on both of her arms. On [DATE], Resident #6 began yelling at Resident #12. Resident #6 then lunged at Resident #12 and pushed her to the ground, where she (Resident #6) attempted to hit Resident #12 in the face. [...]

Inspectors wroteBased on record review and interviews, the facility failed to investigate allegations of abuse for one (#1) of five residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to complete a thorough and timely investigation after Resident #1 made abuse allegations that staff and other residents were trying to harm her.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, activities room, and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff performed appropriate hand-hygiene; -Ensure enhanced barrier precautions (EBP) were in place for Resident #52 and Resident #284; -Follow infection control procedures for catheter care; -Follow infection control procedures for endotracheal tube care; and, -Clean equipment between use with residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for three (#15, #69 and #64) of six residents reviewed for dignity out of 47 sample residents. Specifically, the facility staff failed to treat Resident #15, Resident #69 and Resident #64 in a dignified manner.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for three (#80, #1 and #53) of 10 residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to: -Provide appropriate repositioning for eating and eating supervision for Resident #80; -Provide timely eating assistance for Resident #1; and, -Provide timely repositioning, bathing and oral care for Resident #53.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for four (#26, #31, #15 and #54) of nine residents reviewed for accident hazards out of 47 sample residents. Specifically, the facility failed to: -Ensure person-centered interventions were in place to prevent elopement incidents for Resident #26 and Resident #31; -Ensure staff provided appropriate supervision and implemented care-planned interventions for Resident #15 while smoking; and, -Ensure care-planned interventions for falls were consistently implemented for Resident #54.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure injectable medications were labeled with the date they were opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Ensure the resident's personal refrigerator temperatures were monitored correctly for appropriate temperatures; and, -Implement the facility policy for food brought by visitors and ensure food that was kept in residents' refrigerators had safe and sanitary storage.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#24) of one resident out of 47 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to provide prompt resolution to grievances for Resident #24.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#77 and #69) of eight residents reviewed for abuse out of 47 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #77 from verbal abuse by Resident #23; and, -Protect Resident #69 from physical abuse by Resident #235.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#184 and #75) of seven residents reviewed for pressure ulcers out of 47 sample residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries. Specifically, the facility failed to: -Provide dressing changes for consecutive days for Resident #184, who was admitted to the facility with an unstageable pressure wound to his coccyx; -Ensure Resident #184's care plan was updated in a timely manner; and, -Provide timely wound prevention interventions and ensure interventions were consistently implemented for Resident #75, who was admitted to the facility with pressure ulcers to his coccyx and both heels.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#52) of four residents reviewed for catheters of 47 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use of Resident #52's catheter; -Create a care plan addressing Resident #52's use of the catheter; and, -Maintain documentation for Resident #52's catheter care and maintenance.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologicals were labeled properly on four of four medication carts. Specifically, the facility failed to ensure insulin (medication used for blood glucose control) pens were labeled with the resident's name and open dates.

Inspectors wroteBased on record review, and interviews, the facility failed to perform regular control substance solution tests for four of 15 glucometers. Specifically, the facility failed to perform a control solution test on all glucometers used for monitoring resident's blood glucose.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents. Specifically, the facility failed to ensure: -Resident rooms and unit hallways were clean, comfortable, free of urine odors and in good repair throughout the facility; and -Resident bed linens were in clean, stain-free condition.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that drugs/biologicals were stored and disposed properly upon expiration. Specifically, the facility failed to dispose of expired Cephalexin (antibiotic medication) and Levemir injection pen (insulin medication device).

Inspectors wroteBased on observation, interviews and record review the facility failed to store food in a sanitary manner in one of two residents' snack refrigerators. Specifically, the facility failed to ensure proper unit refrigerator temperatures were maintained in the south hall for resident snack refrigerators that contained ready to eat perishable foods intended for resident consumption.

Inspectors wroteBased on record review and interview, the facility failed to ensure immediate notification to the resident's representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for one (#120) resident reviewed out of 33 sample residents. Specifically, the facility failed to make timely notification of Resident #120's change of condition to the resident's legal representative.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a written notice of bed hold was provided at the time of hospitalization to two (#121 and #122) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #121 and Resident #122 and their representative(s) were provided a bed hold notice informing them of their right for timely readmission after a therapeutic leave and appeal procedures for denial of readmission when sent to the hospital for mental health treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide services by qualified persons for one (#64) out of 35 sample residents. Specifically, the facility failed to ensure Resident #64 was assessed by a registered nurse (RN) after a fall.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure resident were free from accidents and hazards situations for one (#25) of three residents reviewed out of 35 sample residents. Specifically, the facility failed to ensure: -Resident #25 had the ability to access the call light to call for staff assistance during showering; and, -Staff responded to resident #25 when the resident had been in the shower room for over 45 minutes coughing and unable to get to the call light for staff assistance.

Inspectors wroteBased on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for one (#46) of one resident reviewed for supplemental oxygen use out of 35 sample residents. Specifically, the facility failed to acquire a physician's order before administering oxygen to Resident #46.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure drugs and biologicals were stored in locked carts when unattended for 1 of 4 medication carts and 2 of 3 treatment carts.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to accommodate and individualize the physical environment of the resident's bathroom for 1 of 1 resident (Resident #59) reviewed for accommodation of needs. Specifically, the facility failed to provide adequate space in the resident's bathroom to allow the resident to safely transfer themself from a wheelchair to the commode.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 (Resident #28) of 1 resident reviewed for PASARR.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 1 (Resident #53) of 1 resident observed during medication administration via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure medications, enteral formula, and water were allowed to flow into the PEG tube via gravity, rather than being pushed into the tube with a syringe.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents (Residents #53 and #54) observed during medication administration. Four errors in medications were observed during 28 opportunities for errors in medication administration. This resulted in a medication error rate of 14.28%.