Crestwood Care Center

Inspectors wroteBased on observation, medical record review, interview, and review of the facility policy, the facilty failed to ensure medications were administered per physician's orders. This affected one (#15) of three residents reviewed for medication administration. The facility census was 113. Review of the medical record for Resident #15 revealed this resident was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur. Review of the care plan dated 07/09/26 revealed Resident #15 had complaints of acute and chronic pain and was at risk for pain. Interventions included administering non-pharmacological interventions and evaluating the effectiveness of interventions, observing for pain each shift, and following physician's orders for complaints of pain. Review of the physician's order revealed an order on 07/09/26 for oxycodone 5 milligrams (mg); [...]

Inspectors wroteBased on record review, admission agreement review, and interview the facility failed to ensure the consent to treat was signed timely. This affected one (#89) of three residents reviewed for consent to treat. The facility also failed to ensure admission agreements were signed timely. This affected one (#51) of three residents reviewed for admission agreements. The facility census was 86.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure wound treatment orders were obtained in a timely manner. This affected three (#11, #51, and #89) of three residents reviewed for wounds. The facility census was 86.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure pressure ulcer wound treatment orders were obtained in a timely manner. This affected one (#11) of three residents reviewed for wounds. The facility census was 86.

Inspectors wroteBased on record review, review of the late administration medication report, interview, and facility policy review the facility failed to ensure medications were administered per physician order. This affected three (#11, #16, and #51) of seven residents reviewed for medications. The facility census was 86.

Inspectors wroteBased on observations, review of facility policy, and staff interviews, the facility failed to ensure clean food service areas and beard restraints were worn during food preparation. This had the potential to affect all 96 residents who received meals from the kitchen. The facility did not identify any residents who received nothing by mouth.

Inspectors wroteBased on staff and resident interview, medical record review, and review of facility policy, the facility failed to ensure personal property was secured and returned timely to the resident. This affected one (Resident #18) of one resident reviewed for missing personal property. The facility census was 96.

Inspectors wroteBased on staff interview, review of facility policy, and record review, the facility failed to ensure baseline care plans were developed and/or summaries of the baseline care plan were provided to the residents and/or their representatives. This affected two (#79 and #81) of five residents who were reviewed for baseline care plans. The facility census was 96.

Inspectors wroteBased on observations, staff, family, and resident interview, review of facility policy, and record review, the facility failed to ensure activities were offered and provided to all the residents routinely. This affected two (Residents #15 and #79) of three residents reviewed for activities. The facility census was 96.

Inspectors wroteBased on review of the medical record, observation, resident and staff interview, and policy review, the facility failed to ensure wound treatments were completed per physician orders. This affected two (#28 and #54) of three residents reviewed for wounds. The facility identified 21 residents with non-pressure wounds. The facility census was 96.

Inspectors wroteBased on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure the residents received appropriate catheter care. This affected two (#46 and #69) of two residents reviewed for catheter care. The facility identified seven residents with catheters. The facility census was 96.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen was administered per physician orders and further failed to ensure oxygen tubing was routinely changed. This affected two (Resident #12 and #18) of two residents reviewed for oxygen administration. The facility identified 11 residents who received oxygen therapy. The facility census was 96.

Inspectors wroteBased on resident and staff interviews, record review, and review of facility policy, the facility failed to monitor weights and vital signs before and after dialysis and maintain adequate communication with the outside dialysis center for Resident #66. This affected one (Resident #66) of one resident reviewed for dialysis. The facility identified four residents receiving dialysis. The facility census was 96.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure medications were administered according to physician orders resulting in a medication error rate which exceeded five percent (%). 27 opportunities were observed with two medication errors resulting in a 7.41% error rate. This affected two (Resident #57 and #69) of four residents observed for medication administration. The facility census was 96.

Inspectors wroteBased on observation, record review, resident and staff interview, and policy review, the facility failed to ensure that residents were free from significant medication errors. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 96.

Inspectors wroteBased on observation, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure glucometers were properly disinfected, failed to implement enhanced barrier precautions (EBP) by donning personal protective equipment (PPE) when completing wound care, and failed to change gloves properly during wound care This affected one (Resident #57) of four residents observed for medication administrations and one (#54) of two residents observed for wound care. The facility identified five residents receiving blood glucose monitoring on the unit. The facility census was 96.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure annual performance evaluations were completed as required for certified nursing assistants (CNAs). This affected three of three CNAs reviewed for annual performance evaluations. This had the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure resident's advance directives were readily available and communicated to the interdisciplinary team. This affected one (#100) of three residents reviewed for advance directives. The facility census was 86.

Inspectors wroteBased on resident and staff interviews, record review and observation, the facility failed to ensure Resident #78's continuity of care was reviewed and implemented timely. This affected one (#78) of three residents reviewed for medications. The facility census was 86.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to provide effective pain control relief to a resident. This resulted in Actual Harm to Resident #100 when her physician discontinued the use of a narcotic pain medication (Oxycodone) without notifying the resident resulting in Resident #100 experiencing withdrawal symptoms including nausea and trembling hands and Resident #100 experiencing severe pain. This affected one (Resident #100) of three residents reviewed for pain management. The facility census was 91.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 91.

Inspectors wroteBased on medical record review, resident and staff interviews and policy review, the facility failed to timely inform and allow the resident to participate in their treatment. This affected one (#100) of three residents reviewed participation of their treatment/care. The facility census was 91.

Inspectors wroteBased on medical record review, staff interviews, and review of the facility policy, the facility failed to timely implement effective and individualized interventions to address a resident's behavioral health concerns. This affected one (Resident #200) of three residents reviewed for behavioral health services. The facility census was 91.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 107.

Inspectors wroteBased on observation, interview, record review, policy review, and self reported incident (SRI) review, the facility failed to report, investigate and document allegations of resident-to-resident abuse. This affected six (Residents #100, #97, #98, #80, #83, and #101) of eight residents reviewed for abuse, neglect, and misappropriation of property. The facility census was 107.

Inspectors wroteBased on record review, staff and resident interview, policy review, and self-reported incidents (SRI) review, the facility failed to maintain accurate resident records. This affected four (Residents #84, #98, #101 and #100) of eight residents reviewed for accuracy of medical records. The facility census was 107.

Inspectors wroteBased on observation, staff and resident interview, record review and policy review, the facility failed to ensure timely and appropriate incontinence care was provided for a resident. This affected one (Resident #27) of three residents reviewed for activities of daily living. The facility census was 107.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure physician-ordered treatments were applied as ordered. This affected two (Residents #45 and #50) of three residents reviewed for treatment administration. The facility census was 107.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure physician-ordered laboratory testing was completed timely. This affected one (Resident #100) of three residents reviewed for laboratory testing. The facility census was 107.

Inspectors wroteBased on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected two (#14 and #110) of five residents reviewed for medications. The facility census was 104.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure medication administration was accurately documented in the medical record. This affected one (#14) of five residents reviewed for medications. The facility census was 104.

Inspectors wroteBased on medical record review, review of a self-reported incident, staff interview, and policy review, the facility failed to ensure residents were free from improper physician restraints. This affected one (#85) of three residents reviewed for restraints. The facility census was 104.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were stored in a safe and proper manner. This affected one (#17) of five residents reviewed for medications. The facility census was 104.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain daily posted nurse staffing data as required. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure implementation of their abuse policy and obtain an employee background check was completed for Culinary Aide #423 prior to working with residents and failed to keep the background check log up to date. This had the potential to affect all residents who reside in the facility who can receive service from Culinary Aide #423. The facility census was 104.

Inspectors wroteBased on interview, observation, and policy review, the facility failed to serve foods at the appropriate temperatures. The had the potential to affect all residents that resided in the facility as the facility identified all residents received food from the kitchen. The facility census was 104.

Inspectors wroteBased on record review, review of personnel records, and staff interview the facility failed to provide training on the rights of the residents to the staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility.

Inspectors wroteBased on record review, review of personnel records, and staff interviews, the facility failed to provide abuse, neglect, exploitation and misappropriation of resident property training for staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility.

Inspectors wroteBased on staff and resident interviews, record review, and policy review, the facility failed to ensure physician visits were completed as required. This affected four (Residents #01, #40, #43, and #200) of six residents reviewed for physician visits. The facility census was 104.

Inspectors wroteBased on observation, staff, resident, and family interviews, record review, policy review, and review of a local police report, the facility failed to ensure Resident #200 was not unnecessarily discharged from the facility and failed to ensure complete and accurate documentation related to Resident #200's discharge was recorded in the resident's medical record. This affected one (Resident #200) of three residents reviewed for discharge. The facility census was 104.

Inspectors wroteBased on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). [...]

Inspectors wroteBased on observation, review of open and closed medical records, hospital record review, review of self-reported incidents (SRI), resident and staff interviews, and review of facility policies, the facility failed to ensure residents were adequately supervised and interventions were put in place to prevent a resident-to-resident altercation. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when, on 10/19/23, one resident (#06) was involved in an altercation with another resident (#100) which resulted in Resident #06 being pushed to the floor by Resident #100 who had a documented history of aggression and past incidents of physical altercations with other residents. [...]

Inspectors wroteBased on resident interview, staff interview, medical record review, review of food committee minutes, and policy review, the facility failed to ensure snacks were available in the evening and at bed time. This had the potential to affect all 96 residents. The facility census was 96.

Inspectors wroteBased on medication storage observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure controlled substances and narcotic medication were disposed of in a timely manner. This affected four (#30, #88, #91, and #92) of four residents reviewed for disposition of controlled substances and narcotics upon discontinuation of orders or discharge. The facility census was 96.

Inspectors wroteBased on observation, resident interview, facility staff interview, the facility failed to provide a clean and sanitary environment for one (Residents #10) of seven residents reviewed for environment. The facility census was 93.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to maintain the proper position of a urinary catheter drainage bag for one (Resident #10) of one reviewed for urinary catheters. The facility census was 93.

Inspectors wroteBased on observation, review of the facility policy, and resident and staff interviews, the facility failed to serve food at a safe and palatable temperature. This had the potential to affect all 101 residents residing in the facility who received food from the kitchen. The facility census was 101.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store dishware appropriately for food service safety and follow the facility's warewashing procedures. This had the potential to affect all 101 residents in the facility who received food from the kitchen.

Inspectors wroteBased on medical record review, observation, review of the facility policy, and family and staff interviews, the facility failed to maintain a resident's privacy during incontinence care. This affected one (Resident #5) of six residents observed for personal care. The facility census was 101.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to provide written notification to a resident and/or resident representative and to the Office of the State Long-Term Care Ombudsman for the reason for a residents' transfer or discharge from the facility. This affected one (Resident #15) of two residents reviewed for hospitalizations. The facility census was 101.

Inspectors wrote3. Review of medical record for Resident #56 revealed an admission date of 07/19/17. Diagnoses included acute gastroenteropathy, type II diabetes mellitus, heart failure, major depressive disorder, and anxiety disorder. Interview on 09/26/22 at 11:36 A.M. with Resident #56 revealed he would like to participate in his care plan meetings. Interview 09/27/22 at 10:59 A.M. with Social Service Designee (SSD) #340 confirmed she was only doing care plan meetings on admission and had no idea she should be doing the meetings on a quarterly basis. Review of the facility's policy titled Plan of Care Overview, revised 07/26/18, revealed the facility will review care plans quarterly and schedule meeting to accommodate resident's representative that may include conference calls, video conference sessions, or live sessions. 2. [...]

Inspectors wroteBased on medical record review, review of the facility policy, observation, and family, resident, and staff interviews, the facility failed to ensure an ambulation program was established for two (Resident #5 and #38) of three residents reviewed for therapy discharge. The facility census was 101.

Inspectors wroteBased on observations, resident and staff interview, review of the facility policy, and record review, the facility failed to ensure a resident who required limited assistance from staff with activities of daily living, received adequate and timely assistance with personal hygiene. This affected one (Resident #2) of two residents reviewed for activities of daily living. The facility identified 99 residents required assistance from staff for bathing and 101 residents required assistance from staff with dressing. The facility census was 101.

Inspectors wroteBased on resident and staff interview and record review, the facility failed to ensure residents received timely treatment and care for a resident exhibiting signs and symptoms of urinary tract infection. Additionally, the facility failed to ensure a resident with an indwelling catheter received routine catheter care as physician ordered. This affected one (Resident #53) of six residents reviewed for quality of care and affected one (Resident #40) of two residents reviewed for catheter care. The facility identified 13 residents with an indwelling or external catheter. The facility census was 101.

Inspectors wroteBased on medical record review, review of facility anti-psychotic dose reduction/elimination records, and staff interviews, the facility failed to ensure a resident was not receiving an anti-psychotic medication without indication of continued use. This affected one (Resident #5) of six residents reviewed for unnecessary medication. The facility identified 20 residents who receive anti-psychotic medications. The facility census was 101.

Inspectors wroteBased on staff interview, observation, and record review, the facility failed to ensure a resident's urine sample for a urine analysis and culture and sensitivity was obtained per the physician's orders. This affected one (Resident #93) of four residents reviewed for urinary tract infections. The facility census was 101.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary antibiotic use. This affected one (Resident #5) of six residents reviewed for unnecessary medications. The facility census was 101.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident care plans were updated. This affected three residents (#70, #79, and #83) of 25 residents revealed for plans of care. The facility census was 125.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to ensure medication carts were maintained secured. This had the potential to affect 18 residents (#10, #12, #13, #23, #26, #40, #47, #49, #75, #83, #91, #92, #94, #99, #112, #116, #120 and #174) whom the facility identified as confused and mobile. The facility census was 125.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure fall interventions were in place for two residents (#9 and #66) of five reviewed for falls. The facility census was 125.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure oxygen therapy was completed as ordered for one resident (#69) of two reviewed for respiratory care. The facility census was 125.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of antibiotic stewardship policy, the facility failed to ensure a pharmacy recommendation was acted upon to discontinue a medication for one resident (#25 of five reveiwed for unnecessary medication. The facility census was 125.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to communicate a resident's behavior to hospice care takers. This affected one resident (#59) of one reviewed for hospice services. The facility census was 125.