Crestwood Manor - 104

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' right to be free from physical abuse (causing bodily harm, pain, or impairment, such as hitting, slapping, or pushing) for 2 of 4 sampled residents (Resident 2, and Resident 3) when:Resident 1 had a physical altercation (a fight between residents) with Resident 2 on 9/6/25, during which Resident 1 hit Resident 2 on the head with a belt; and,Resident 3 had a physical altercation with Resident 4 in Resident 3's bathroom on 9/3/25, after Resident 4 used Resident 3's bathroom without permission and hit Resident 3 in the face with a closed fist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned interventions (a written plan that guides staff on the resident's care, needs, and services) to provide continued psychosocial support (emotional and mental well-being care) for one of three residents (Resident 3) when Resident 3 was assaulted by another resident on 9/3/25 and the care plan indicated Social Services would follow up with Resident 3 once a week for ninety days, but the follow up was not implemented. This failure resulted in Resident 3 expressing fear of the resident who assaulted her and placed Resident 3 at risk for unmet psychosocial needs (the interaction between an individual's thoughts, emotions, behavior, and their social environment), increased anxiety, and delayed identification of emotional distress following the assault.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Resident 2, who had a known history of assaultive, destructive, and intrusive behaviors entered Resident 1's personal space and smeared feces on Resident 1's face on 11/19/25. This failure resulted in Resident 1 experiencing unwanted physical contact with feces, which placed Resident 1 at risk for loss of dignity, psychosocial (emotional and social well-being including how a person feels, thinks, and interacts with others) harm, and potential exposure to infection, and placed other vulnerable residents in the facility at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) when, Resident 1 did not continue to walk in the corridor out of fear of falling and no care plan was developed to address Resident 1's fear of falling and refusal to walk. This failure placed Resident 1 at risk of not receiving the appropriate care and services to include interventions which could result in a physical decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided services to maintain the ability to carry out an activity of daily living (ADL's), specifically mobility (walking) when, staff did not consistently document an attempt to walk Resident 1 or a refusal, staff did not always walk with Resident 1 with supervision as recommended according to the documentation, and a care plan with interventions (actions nursing staff and others take to help a resident reach their health goals and improve outcomes) was not created regarding Resident 1's fear of falling. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods were stored, prepared, and served in accordance with professional standards for food service for 176 residents who ate facility prepared meals when: 1. Red onions were found to have mold (a type of fungus that grows in moist environments); and 2. Food products lacked an open date, complete labeling, and/or expiration dates on labels; and 3. Walk-in freezer found with ice buildup; and 4. Washed items were stacked and stored wet; and 5. Fixed can opener had visible food particles and metal worn off the cutting tip, had worn/missing metal on the base, and metal shavings were located on ledge behind the cutting tip; and 6. Coffee cups and pitchers found to be discolored and/or deglazed (no longer having a finished surface), and cutting boards found with deep gouges on both sides; and 7. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 4 of 39 sampled residents (Resident 119, Resident 19, Resident 106 and Resident 80) had their rights related to treatment choices known and protected when: 1. Resident 119's signed Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) documentation was not found in the chart; 2. Resident 19 wanted to formulate an Advance Directive and no follow-up documentation was found in the chart; 3. Resident 106's chart did not contain documentation regarding Advance Directive discussion; and 4. Resident 80's code status (a medical directive that specifies what actions medical professionals should take in the event of a life-threatening emergency) was not found in both the electronic health record (EHR) and physical chart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a healthy nutrition status for two residents (Resident 140 and Resident 126) when: 1. Resident 140's weight was not maintained when an 8 pound (#)/5.8% weight loss occurred in one month; and, 2. Resident 126 was not offered a replacement lunch meal in a timely manner. These failures had the potential for leading to malnutrition, nutrient deficiencies, loss of muscle mass and independence, and increased susceptibility to illness for Resident 140, and had the potential for Resident 126 to experience food insecurity, negatively affecting Resident 126's health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a vegetarian (a person who does not eat meat, and sometimes other animal products) menu for the four residents for which a vegetarian diet had been ordered (Residents 30, 99, 129, and 165). This failure had the potential for leading to weight loss and nutrient deficiencies for those residents avoiding animal products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection prevention practices were implemented and followed for a resident census of 176 when: 1. There was no separation between clean area and dirty area in three of three utility rooms observed. 2. A bucket stocked with clean supplies, used for insulin (a drug used to treat blood sugar disease) administration and blood sugar measurement, were taken inside residents' room without consideration for risk of contamination. 3. Drug administration platform inside the medicine cart was not cleaned with brownish residues. 4. The pill cutter stored in medication cart had white powder-like residue inside the lid. 5. Kitchen swamp cooler vent covers had peeling paint with dust and debris above food preparation areas. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards when facility did not provide drug information resources as reference for nursing staff. This failure could contribute to unsafe use of medication and nursing ability to provide quality care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 39), in a sample of 39 residents, received accurate post fall and comprehensive fall assessments. This failure potentially resulted in Resident 39's subsequent fall 14 days later, negatively impacting Resident 39's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management, and develop and implement a resident centered care plan (tool that outlines the plan of action that will be implemented during a resident's care) for 1 of 39 sampled residents (Resident 22) when: 1. The pain management services was not adequately provided to Resident 22; and, 2. The facility did not develop and implement a comprehensive person-centered care plan for pain for resident 22. These failures led to Resident 22 experiencing unnecessary pain that potentially affected his physical and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure safe medication use practices in three out of 39 sampled residents (Resident 134, Resident 19 and Resident 160) when: 1. Resident 134's long term use of a medication called Protonix (or pantoprazole, belongs to a class of drugs called Proton Pump Inhibitor [PPI], a type of medication that reduces the amount of acid stomach produces) was not re-assessed or evaluated for continued use based on standards of practice and Food and Drug Administration's (FDA, a federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of drugs) risk warnings on long term use of PPI's. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 176. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 32 opportunities which resulted in a facility wide medication error rate of 9.37% in 3 out of 13 residents (Resident 111, Resident 21 and Resident 163) observed for medication administration as follow: 1. Resident 111's eye drop administration did not follow standards of practice on ophthalmic (eye) drug medication administration. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices in three out of three medication rooms and one out of 4 medication carts when: 1. Unlabeled and discontinued medications were stored in active storage areas in the medication rooms at Station 2 and Station 3. 2. Hazardous (drugs known to pose a health risk to healthcare workers due to their toxic properties upon skin contact) liquid medication with spills on the outer body of the medication bottle was stored in medication cart A at Station 3. 3. The pre-pour medication bins were observed to have sticky looking brownish spills in the top drawer of medication cart B at Station 1. 4. Supplies and discontinued medications were stored under the sink in medication rooms at station 1 and Station 2. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted to return to the facility after Resident 1 was transferred from the facility to an acute care facility (hospital) for stabilization. This failure resulted in Resident 1 being held in a temporary facility (acute care) for five days and not returning to the facility she had been at for nearly nine months, which could have resulted in emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received dental services for 2 of 35 sampled residents (Resident 166 and Resident 75), when: 1. Dental services were not provided for Resident 166; and, 2. Dental recommendations were not followed up on for Resident 75. These failures resulted in Resident 166 and Resident 75 not obtaining dental services and had the potential to cause health complications for Resident 166 and Resident 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 19) was treated with dignity and respect when Certified Nursing Assistant (CNA) 2 stood over Resident 19 while assisting her with her lunch meal on 5/20/24. This failure had the potential for CNA 2 to miss a choking event and result in a loss of dignity for Resident 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 35 sampled residents (Resident 141)'s needs were met when his call light was found on the floor and not within reach. This failure could have resulted in a fall, injury, and/or immediate needs not being met for Resident 141.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an evaluation or assessment was documented in the medical record for 1 of 35 sampled residents (Resident 75) when the use of a lap buddy (a device used to secure a resident in a seated position in a wheelchair) was initiated on 10/13/21, after multiple falls, without a documented initial evaluation for its use, or documented assessments for continued use of the lap buddy for Resident 75. These failures resulted in Resident 75 never being assessesed for a device that could potentially be a restraint.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's assessment was completed accurately for one of 35 sampled residents (Resident 166) when Resident 166's comprehensive assessment did not accurately reflect his dental condition. This failure increased the potential for a delay in dental care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to 1 of 35 sampled residents (Resident 166), when Resident 166 did not have oral hygiene supplies and did not receive oral hygiene from staff. This failure resulted in poor oral hygiene and had the potential to cause health complications for Resident 166.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 35 sampled residents (Resident 75 and Resident 141) were free from potential accidents and injury when: 1. A fall mat (a soft mat laid on the floor to cushion a fall) was not laid on the floor while Resident 75 was in bed on 5/21/24 per Resident 75's care plan; and, 2. Resident 141's bed side rails (metal rail attached to the sides of the bed that could be used for assistance with repositioning) was left in an unsafe position (sticking out from the bed at the floor level).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on [DATE], which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 177 of 177 residents who received food from the facility kitchen, when: 1. One jug of lemonade, one jug of cranberry juice and one jug of tea in the kitchen refrigerator were available for use after the labeled use by date, and one expired bread bag with five whole wheat breads was available to use on the bread rack in the kitchen; 2. Four bags with 12 burger buns in each bag on the bread rack were not dated when taken out of the freezer and 13 boxes with 24 ice cream cups per box in the kitchen freezer were not labeled with a received date and use by date; 3. The kitchen thermometer was not calibrated weekly; 4. Expired test strips were used to test dishwasher solution; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean and safe manner, when four ovens had baked-on grease and food. This failure had the potential to cause a fire, food contamination and health hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional and hydration status for 2 of 36 sampled residents (Resident 119 and Resident 174) when: 1. Resident 119's order to be fed by staff and nutritional care plan was not followed; and, 2. Resident 174's fluid intake was not monitored. These failures had the potential to cause further weight loss for Resident 119 and risk for dehydration for Resident 174; with the potential for a decline in each residents' physical health and functional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices for a census of 177, when the medication error rate was over 5% (% or percentage was a fraction of a number out of 100) during medication administration. The calculated medication error rate was 10.71%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. 1a. Licensed nurse administered a topical prescription medication to Resident 42 when it belonged to, and was labeled for Resident 70. 1b. Licensed staff pre-poured 10 medications for Resident 54 and: i. documented the administration 40 minutes after it was given, ii. did not follow the doctor's order and manufacturer instruction during medication administration of Zyprexa Zydis (Olanzapine, a mind altering/calming medication) iii. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices when: 1. Expired medications were found in one of three medication rooms (Medication room Unit 2). 2. Multiple unopened injectable medication called Ozempic (diabetic drug in a pen-style injection delivery system) labeled, Refrigerate Until Opened, were stored at room temperature in a storage area in one out of three medication rooms (Medication room Unit 1). 3a. Food items were stored along with medications in three of three medication room refrigerators (located in Unit 1, Unit 2, and Unit 3), where refrigerated ophthalmic (for eyes), oral, and injectable medications were kept in a storage container inside each refrigerator. 3b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of thirty six sampled residents (Resident 174) with dignity and respect when his request for drinking fluids was not honored. This failure had the potential to cause emotional distress and dehydration for Resident 174.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure daily quality control monitoring was completed for one of three glucometer devices in facility's Station 3. This failure had the potential for a resident to receive an inaccurate blood glucose test result and an incorrect amount of blood glucose medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure high-risk blood thinning medication (medications with bleeding risk) monitoring was completed on a daily basis for two of the five sampled residents (Resident 33 and Resident 69). This failure had the potential to result in undetected adverse effects that could occur when blood thinning medications were administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for a census of 177 when water drainage (the system or process by which water or other liquids are drained from a place) from the washing machines was overflowing into the laundry area. This failure had the potential for clean laundry to be contaminated and increased the risk of infection for residents in the facility.