Crestwood Manor - Fremont

Inspectors wroteBased on interview, and record review, the facility failed to provide care in a manner that maintains dignity and respect for one resident (Resident 1) of three sampled residents when: Registered Nurse (RN 1) grabbed and struggled with Resident 1 ' s arm to take away a cup of water. This failure caused Resident 1 to feel like a child, emotional distress, and injury.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to ensure the temperature of the [NAME] Hall nourishment refrigerator was maintained at 41 degrees Fahrenheit (F) or below and food items in the nourishment refrigerator were dated and labeled for the 64 of the 111 residents who resided on the [NAME] Hall.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to protect a resident's right to be free from abuse perpetrated by staff for 1 (Resident #103) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to implement their policy to complete a thorough investigation, which affected 1 (Resident #103) of 1 sampled resident reviewed for abuse. Specifically, the facility failed to interview additional cognitively intact residents to determine if there was a history of inappropriate behaviors by Certified Nursing Assistant (CNA) #3 or other staff following an incident of abuse which involved CNA #3 and Resident #103.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of misappropriation of resident property to the state survey agency for one (Resident #93) of 22 sampled residents. The facility further failed to timely report an allegation of abuse to the state survey agency and submit the results of the investigation to the state survey agency for 1 (Resident #103) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, the facility failed to notify the physician of a change in the medical condition for one of 23 sampled residents (Resident 74). The failure to notify the physician about marked increase in swelling of Resident 74 's right leg and right ankle delayed treatment and had the potential to result in Resident 74's condition worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The consultant pharmacist (CP) established and implemented a system to provide for disposition of expired/discontinued to prevent unauthorized access and use of controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: there was no permanently affixed, locked container for storage of the expired/discontinued controlled medications, and individual, unpackaged tablets were not destroyed or stored in a sealed, tamper-resistant, locked container before transfer to the disposal company. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the medication error rate at less than five percent. 1. Registered Nurse (RN) 1 attempted to administer furosemide (a medication used to reduce extra fluid in the body) 20 milligrams (mg-a unit of measure) instead of 40 mg as prescribed to Resident 33. 2. RN 1 administered two puffs of the metered-dose inhaler (MDI) Ventolin Hydrofluoroalkane (HFA) (an inhaled medication used to prevent and treat wheezing and shortness of breath caused by breathing problems) 90 micrograms (mcg, a unit of measure) per actuation (act, a single inhaled dose) to Resident 33 without first shaking the cannister per manufacturer's instructions. These failures resulted in two medication errors during 36 medication administration observations. Calculation of the error rate: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the secure storage of controlled substances (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when the East Side nursing station medication room had the following controlled substances in unsecured locations: 1. A unlocked drawer contained an unlocked box with controlled substances (schedule II-V medication with high risk of abuse and addiction) and narcotic medications (medications used to treat pain with high risk of abuse and addiction) 2. An unlocked refrigerator contained an unlocked container with 41vials of lorazepam (a schedule IV-controlled medication used to treat anxiety, insomnia, and seizures). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate and promote the rights of two (Resident 79 and Resident 21) of 23 sampled residents who requested privacy for meetings together. The facility failure to provide a private space for intimate meetings despite requests by Resident 79 and Resident 21 resulted in public displays of affection between Resident 79 and Resident 21 which caused Resident 79 to feel embarrassed and guilty for the public displays, and Resident 79 to feel ignored and disrespected by the facility.

Inspectors wroteBased on interviews and record review the facility failed to ensure one (Resident 66) of 23 sampled residents was free of a significant medication error when Registered Nurse (RN 2) administered medications that were not prescribed for Resident 66 during a medication pass. The failure to ensure Resident 66 only received medications prescribed for Resident 66 resulted in a transfer to the hospital emergency room (ER) for evaluation, emotional distress from the event, and had the potential to result in adverse side effects from administration of unprescribed and unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its call light policy and procedure (P&P) for one (Resident 60) of 23 sampled residents. For Residents 60, the facility failure to provide an accessible call light at the bedside or other means to alert staff to resident needs after the request of Resident 60 for such a device, resulted in Resident 60 feeling ignored and had the potential to result in injury or delayed treatment in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed policy and procedure for use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) for one of two residents (Resident 1) when two staff members attempted transfer of Resident 1 instead of the four staff members as per Resident 1's care plan. These failures resulted in the mechanical lift tipping over, causing Resident 1 to fall and break her femur (the thigh bone) during a transfer from her bed to her wheelchair. Resident 1 ' s broken femur resulted in a five-day hospitalization, pain and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to use proper hygiene practices and ensure food was prepared and stored under sanitary condition when: 1. There were multiple food items that were stored beyond their use-by date inside the walk-in refrigerator. 2. A dietary staff entered the kitchen, donned on hair cover and proceeded to touch food items in the walk-in refrigerator without washing hands. These failures placed residents at risk for food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage and refuse were properly stored in dumpster when the lid of one of two dumpsters was broken and did not securely cover the bin. This failure had the potential for pests infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview and record review for one of one sampled resident (Resident 76), the facility failed to provide Resident 76 privacy, when Licensed Vocational Nurse (LVN 1) performed wound treatment without closing the privacy curtain. Resident 76's buttock area was exposed for people passing by the hallway. This deficient practice placed Resident 76 at risk for body exposure.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage of medications when: 1. three eye drops were not stored in accordance to the manufacturers recommendation. 2. injectable medications were co-mingled with eye drop medications. These deficient practices had the potential for the medications to be less effective, the potential for not getting the full therapeutic benefit of the medications, and the potential for cross-contamination.