Crestwood Manor

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure documentation of cardiopulmonary resuscitation (CPR) status for five out of 14 residents reviewed for advance directives (Resident (R) 16, R34, R56, R6, and R41) out of a total sample of 21 residents. This failure created a risk that residents would receive CPR or other life-sustaining interventions that were inconsistent with their expressed wishes, potentially resulting in unwanted treatment, emotional distress, and compromised quality of care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) and failed to handle soiled linen in a manner to prevent cross contamination for one of 21 sampled residents (Resident (R) 10) reviewed for infection control. These failures placed all residents of the facility at risk for the transmission and spread of infections.

Inspectors wroteBased on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the development of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 09/03/24 at 08:30 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) and the facility Executive Chef (EC). The surveyor observed the following: The Preparation Box refrigerator contained a 1 (one) gallon container of thousand island dressing and a 1-gallon container of tartar sauce with no opening date or use by date. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life specifically by not providing a privacy cover for a urinary catheter drainage bag. The deficient practice was identified for 2 of 2 (Residents # 29, # 31) residents reviewed for Dignity. The deficient practice was evidenced by the following: On 09/03/2024 at 09:24 AM during the initial tour of the facility, the surveyor observed Resident # 29 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed. There was no privacy cover. There was residual urine visible in the bag. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 06/12/2023 at 9:25 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled food items throughout the kitchen such as potatoes, a crate of milk, sugar, bagel, and cheese. The FSD observed at the time of the tour that these items were not labeled and confirmed the items should have been labeled appropriately. The surveyor further observed two items of french toast and french fries that had expiration dates that were dated out for one month. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include the location of a elopement alarm. This deficient practice was identified for 1 of 17 residents reviewed for resident-centered care plans (Resident #6), and was evidenced by the following: On 06/13/23 at 11:40 AM, the surveyor observed Resident #6 in a wheelchair with a wander guard (a device to ensure a resident does not exit the facility) on the right ankle. According to the admission Record, Resident #6 was admitted with diagnosis that included, but were not limited to, dementia and hypertension. (High blood pressure) A review of Resident #6's annual Minimum Data Set, an assessment tool dated 06/12/23, revealed that he/she had severe cognitive impairment and utilized a wander/elopement alarm daily. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to check a resident's wander guard device for functioning for 1 of 2 residents reviewed for wander guards (Resident #41) and was evidenced by the following: On 06/12/23 at 11:10 AM, during the initial tour of the facility, Resident #41 was in the activity room in a wheelchair. The surveyor observed a wander guard (an alarm device to ensure the resident cannot exit the facility) on the resident's left ankle. Review of Resident #41's Face Sheet indicated the resident was admitted to the facility in November 2021. Medical diagnoses included, but were not limited to heart failure, heart disease, dementia, and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interviews, record review and other facility documentation, it was determined that the facility failed to: a) maintain accurate accountability and reconciliation for controlled medications in a medication cart and automated medication dispensing system b) maintain the integrity of emergency medication boxes in a safe manner in accordance with the facility policy. This deficient practice was identified in 1 of 2 medication carts, 1 of 1 automated medication dispensing system, and 2 of 2 emergency medication boxes on 1 of 1 nursing unit. This deficient practice was evidenced by the following: 1. On [DATE] at 12:02 PM, the surveyor inspected the high side medication cart in the presence of the agency Registered Nurse (RN). [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to properly store and dispose of controlled medications in accordance with the facility policy and standards of professional practice. This deficient practice was identified for 1 of 2 medication carts on 1 of 1 nursing unit. This deficient practice was evidenced by the following: On 06/14/23 at 12:02 PM, the surveyor inspected the high side medication cart in the presence of the agency Registered Nurse (RN). The RN removed a pill bottle from the locked drawer where controlled substances were stored and identified the medication as Ativan (used to treat anxiety) 0.5 mg. The RN removed two clear sealed plastic bags from the pill bottle which each contained ten tablets. [...]