Crestwood Manor

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be a high risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on [DATE]. Resident 1 was assessed to have an unsteady gait, educated on the need to call for assistance, had falls on [DATE], [DATE], [DATE]and fell on [DATE]. On [DATE], Resident 1 went to the bathroom unassisted, staff became aware of her presence in the bathroom alone, did not assist her with toileting, left her alone in the bathroom and Resident 1 fell and injured her right ankle. [...]

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a written consent was obtained for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was implemented for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions when they performed wound care for 1 (Resident #113) of 1 sampled resident reviewed for pressure ulcer/injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 administered psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications not prescribed to Resident 1 in error. This failure resulted in Resident 1's transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for decreased mental status and treatment of an accidental overdose (dangerous and excessive dose of a drug). (Cross reference F 726, F 760)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of significant medication errors when Licensed Vocational Nurse (LVN) 1 did not correctly identify Resident 1 and administered Resident 4's psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications to her in error. This failure resulted in Resident 1 experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 726)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to assure residents maintained their highest practicable physical, mental, and psychosocial well-being when one of three Licensed Vocational Nurses (LVN 1) did not correctly identify one of four sampled residents (Resident 1) during medication administration. This failure resulted in Resident 1 receiving Resident 4's medication and experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 760)

Inspectors wroteBased on interview and record review, the facility failed to report an alleged employee to resident physical abuse per their Policy and Procedure (P&P), Resident Allegations of Abuse by Staff for one of three sampled residents (Resident 1), when: 1. The facility did not notify the local law enforcement within 24 hours of the alleged abuse. 2. The facility did not perform a physical assessment of Resident 1 and did not notify a Physician, nor Psychiatrist of the alleged abuse incident. This failure placed Resident 1's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and their Responsible Party (RP) were informed of psychotropic (affecting mental activity, behaviors, and perceptions) medications dosages and frequency in accordance with the facility policy and procedure and professional standards of quality for three of seven sampled residents (Resident 146, Resident 148, and Resident 471) when: 1. Resident 146 and the Responsible Party (RP) were not informed of the dosage amount and frequency duration of Resident 146's three psychotropic medications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the Recertification, Abbreviated surveys and State agency (Department of Public Health Licensing and Certification -CDPHL&C) hotline phone number were located in a place readily accessible to the residents and the public for two of two sampled residents (Resident 16 and Resident 63). This failure denied residents and the public the right to be aware of Recertification, Abbreviated survey investigation results and access to the State agency hotline phone number.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline resident-centered care plans were developed and implemented to address residents' preference and safety while smoking for 14 of 14 sampled residents (Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162) when residents' smoking care plans were not developed within 48 hours of admission. This failure had the potential to negatively affect residents quality of care by not addressing the resident's smoking preference and safety while smoking.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive resident-centered care plans (a plan that provides direction for individualized care of the resident) were developed and implemented to address residents' preference and safety while smoking for 14 of 14 sampled residents (Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162) when 14 sampled residents did not have an individualized smoking care plan. This failure had the potential for residents smoking safety needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food services when: 1. Dietary [NAME] (DC) 1 served ready to eat food using gloved hands that had touched objects and surfaces outside of the trayline. 2. DC 2 did not perform hand hygiene before placing gloves on hands during lunch trayline service. 3. There were two steel pans not properly air dried in the dishware storage area. 4. The ice machine lid hinge was found dirty. 5. There was no open date on a lemon juice bottle. 6. There were spoiled lemons in the walk in refrigerator. These failures placed the residents at risk for consumption of unsafe food handling and storage of receptacles used for food preparation.

Inspectors wrote2. On 12/12/18 at 3:15 p.m., during a concurrent medication administration observation and interview in station one, LVN 9 removed Amlodipine Besylate tablet (cardiac medication) from the prepared medications in a cup. LVN 9 stated Resident 11 refused to have blood pressure (BP) taken by a Certified Nursing Assistant. LVN 9 did not attempt to retake Resident 11's BP and did not administer the BP medication. Review of Resident 11's physician's order dated 12/18, indicated, Amlodipine Besylate tablet Give 10 mg [milligrams, unit of measurement] by mouth in the evening (1600) related to ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] . Hold if pulse < [less than] 60 & [and] if BP <100/60 [physician order date] 10/31/18. On 12/13/18 at 5:45 p.m., during a review of Resident 11's medication administration record (MAR) with LVN 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was five percent or lower for 12 of 52 sampled residents (Resident 24, Resident 39, Resident 43, Resident 53, Resident 59, Resident 60, Resident 103, Resident 107, Resident 121, Resident 125, Resident 146, and Resident 164) when: 1. Licensed Vocational Nurse (LVN) 9 did not follow the manufacturer's guideline for the administration of the inhalation medication for Resident 39. 2. LVN 9 administered expired Vitamin B6 on seven times to Resident 43. 3. LVN 5 administered medications past the physician prescribed medication administration time for Resident 24, Resident 59, and Resident 121. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label drugs in accordance with currently accepted professional principles when: 1. A bottle of Vitamin B6 was stored with other over the counter drugs with an expiration date of 10/18. This failure placed the Resident 43 at risk of lowered efficacy with the potential use of expired drugs. 2. Licensed Vocational Nurse (LVN) 7 failed to appropriately secure medications when an unlocked medication cart was left unattended and out of sight of the licensed nurse. This failure had the potential for medications to be taken by residents, visitors, or staff and the potential for adverse effects if consumed. 3. Resident 32's medication, Lithium (a medication used to treat certain psychiatric illnesses) did not have an expiration date label on the bottle. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered diets were followed for two of three residents (Resident 95 and Resident 126) when salt packets were included on the residents' meal trays for residents ordered a no added salt (NAS) prescribed diet. This failure to follow physician ordered diets had the potential to further compromise the medical status of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program affecting seven of seven sampled residents (Resident 10, Resident 46, Resident 49, Resident 73, Resident 112, Resident 115, and Resident 132) when the residents' hands were not washed nor sanitized before breakfast and lunch were served. This failure placed the residents' health and safety at risk for cross contamination and/or spread of infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in operating condition when ice build-up was in the walk in freezer. This failure had the potential for the quality of food to be compromised for the residents.