Crestwood Rehabilitation and Nursing

Inspectors wroteBased on observation, interview and record review, for 1 of 40 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident developed a shearing injury related to a Hoyer lift transfer. This will be cited at a Harm level at past non-compliance with a completion date of 3/6/26. Resident identifier: 10.

Inspectors wroteBased on observation, interview and record review, for 2 of 40 sampled residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident's pain medications were decreased after admission and no appointment was made after the resident requested an appointment with the pain clinic. This example will be cited at a harm level. In addition, another resident's pain to her thumb knuckles was not addressed. Resident identifiers: 4 and 8.

Inspectors wroteBased on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility dish machine was not reaching the required temperature, dirty dishes were loaded from the clean side, gloves were not changed between touching dirty dishes and then clean, there were foods in the refrigerator that had been in there longer than 7 days and there were soiled areas in the kitchen.

Inspectors wroteBased on observation, interview and record review, for 12 of 40 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not palatable or attractive, and there were resident council minutes and grievances with complaints of food quality. Resident identifiers: 1, 8, 10, 33, 50, 52, 54, 63, 66, 76, 78 and 92.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of cross-contamination and improper hand hygiene practices during wound care, and Enhanced Barrier Precautions (EBP) was not implemented during wound care. Additionally, multiple observations were made of resident drinks being delivered throughout the facility while uncovered during transport. Resident identifier: 76.

Inspectors wroteBased on observation and interview the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, for 1 of 40 sampled residents, the facility did not clean a resident's window which was covered in dryer lint. Resident identifier: 63.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not ensure that prompt efforts to resolve grievances made by the residents were completed, tracked through the conclusion with a summary of the findings, and a statement as to whether the grievance was confirmed or not confirmed with any corrective action taken and the date it was completed. Specifically, the facility did not promptly resolve the grievance made by the resident and the grievance did not contain the investigation, summary of findings, or the conclusion of the investigation with dates. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the prescribing practitioner or attending physician documented a rationale in the resident's medical record and indicated the duration for the PRN order. Specifically, a resident's PRN order for Trazodone exceeded 14 days and the resident's medical record did not have a documented indication to extend the use with a duration for the order. Resident identifier: 8.

Inspectors wroteBased on interview and record review, the facility did not ensure that allegations of neglect, including events that caused reasonable suspicion of neglect, were reported immediately to the State Survey Agency (SSA). Specifically, for 1 of 40 sampled residents, the facility did not report a resident injury that occurred during a staff-assisted transfer with a mechanical lift to the SSA. Resident Identifier: 10.

Inspectors wroteBased on interview and record review the facility did not provide an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Specifically, for 1 of 40 sampled residents, a resident was not provided discharge planning. Resident identifier: 52.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, the facility did not provide a resident timely orders and treatments after they sustained a shearing wound. Resident identifier:

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not provide each resident the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not demonstrate reasonable attempts to provide or arrange behavioral health services for a resident who was monitored for depressive statements and had tearfully expressed his lack of independence since suffering a stroke. Resident identifier: 54.

Inspectors wroteBased on observation and interview it was determined that the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Specifically, a medication cart was observed unlocked and unattended outside of resident rooms.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain a Basic Metabolic Panel (BMP) when ordered by the provider. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 residents sampled, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's urinalysis laboratory report was not located in the medical records. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, the resident's chest x-ray report was not located in the medical records. Resident identifier: 6.

Inspectors wroteBased on interview and record review it was determined the facility did not employ a full-time, designated person to serve as the director of food and nutrition services. Specifically, the facility did not have a qualified food service director.

Inspectors wroteBased on interview and record review, for 1 of 40 sampled residents, the facility did not arrange timely services for outside resources that met professional standards and principles that applied to professional providing services. Specifically, a resident was not scheduled for a pain clinic appointment when pain was identified and the resident requested. Additionally, resident records were not secured, left unattended, and visible to any passerby. Resident identifier: 8.

Inspectors wroteBased on interview and record review, for 1 of 40 sampled residents, the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident had an order for 12 tablets of an antidepressant when the physician ordered 1 tablet. Additionally, the medication cart had the computer open to resident records and left unattended and a nurse report sheet with resident medical information was visible. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 19 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not attractive or palatable, and there were complaints in the resident council meetings. Resident identifiers: 2, 16, and 17.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, a sign was hung in the elevator instructing residents that water was the only beverage available between meals and coffee was served at specific times.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure that each resident received supervision to prevent accidents. Specifically, a resident who was assessed as high risk for exit seeking and had a wanderguard alarm system placed on his body eloped from the facility and was missing for multiple hours. Resident identifier: 1.

Inspectors wroteBased on interview and record review, it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to report the results of all investigations to the State Survey Agency (SSA), within 5 days of the incident. Specifically, for 2 out of 7 sampled residents, the facility did not thoroughly investigate an allegation of abuse from misappropriation of funds and an allegation of neglect from a fall with serious injury. Resident Identifiers: 1 and 2.

Inspectors wroteBased on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, a resident desired to return to the community through the New Choice Waiver (NCW) program and the facility did not submit the required paperwork for a whole year. Resident identifier: 6. Findings Included: [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 of 33 residents sampled, the facility did not provide care to a resident who sustained a head laceration after a fall and requested to be sent to the hospital via ambulance for treatment. The deficient practice identified was determined to have occurred at a harm level. Resident identifier 35.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that the medication error rates was not 5 percent or greater. Observations of 31 opportunities revealed 2 medication errors which resulted in a 6.45 percent medication error rate. Specifically, a resident was administered a multivitamin supplement instead of the ordered multivitamin with mineral, and a resident was administered a fiber suppliment when the order did not specify the dosage to be administered. Resident identifiers 23 and 218.

Inspectors wroteBased on interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, a resident had an order for a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a Thyroid Stimulating Hormone (TSH) level that was not obtained, a resident had an order for an iron level to be drawn every six weeks and a lipid panel every six months that was not obtained, and a resident had an order for a CBC to be drawn monthly that was not obtained. Resident identifiers: 3, 35, and 37.

Inspectors wroteBased on observation and interview it was determined, for 9 of 33 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, residents sitting at the same table in the dining room were not served meals at the same time and food was served in disposable cups. Resident identifiers: 25, 28, 29, 31, 50, 54, 55, 61 and 165.

Inspectors wroteBased on interview and record review it was determined that the facility did not consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment. Specifically, for 1 of 33 sampled residents, the facility did not notify the Medical Director (MD) when blood sugar results were outside of the physician ordered parameters for notification. Resident identifier 49.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 33 sampled resident, that the facility did not ensure that residents remained free from abuse, neglect, and misappropriation of property. Specifically, there were residents in a relationship that had not been evaluated to have the capacity to consent. Resident identifier: 3 and 55.

Inspectors wroteBased on interview and record review it was determined that when the facility transferred a resident the facility did not ensure that the transfer was documented in the resident's medical record and the information communicated to the receiving provider included: the basis for the transfer, the contact information of the practitioner responsible for the care of the resident, the resident representative information, the Advanced Directive information, all special instructions for ongoing care, the comprehensive care plans, and a copy of the resident's discharge summary. Specifically, for 2 of 33 sampled residents, the facility did not document a transfer or discharge assessment/note or what documentation was provided to the receiving provider to ensure a safe and effective transition of care. Resident identifiers 35 and 37.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure that services provided by the facility met professional standards of quality and care. Specifically, for 2 of 33 sampled residents, a Licensed Practical Nurse (LPN) was observed to attempt to change a physician medication order without direction by the medical provider and the LPN confirmed that another medication order was modified without direction by the medical provider. Resident identifier: 23 and 218.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 33 sampled resident, that the facility did not provide necessary services to maintain good nutrition for a resident who was unable to carry out activities of daily living. Specifically, a resident waited 35 minutes to be fed by staff after her meal was served to her. Resident identifier: 13.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not provide adequate supervision to prevent accidents. Specifically, a resident was observed to be yelling for help from a staff bathroom located by the therapy department. Staff were not aware there was a call light for the bathroom. Resident identifier 51.

Inspectors wroteBased on interview and record review it was determined, for 2 out of 33 sampled residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, lab results for a iron level, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Hemoglobin A1c, and a lipid panel were obtained but the reports were not filed in the residents medical records. Resident identifier: 3 and 37.

Inspectors wroteBased on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, a resident's chest x-ray (CXR) results were not filed in their medical records. Resident identifier 4.

Inspectors wroteBased on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not keep confidential information contained in the resident's medical record. Specifically, a residents name was used in another resident's medical record. Resident identifiers: 6 and 53.

Inspectors wroteD. Medication Pass: On 4/19/22 at 9:08 AM, an observation was made of LPN 1. LPN 1 dropped a sublingual medication film on the top of the medication cart. LPN 1 donned a glove, picked up the sublingual film and placed it in the medication cup that held resident 33's other morning medications. LPN 1 then administered all the medications to resident 33. On 4/20/22 at 8:25 AM, an observation was made of the ADON. The ADON placed his pointer and middle finger on the back side of resident 17's medication card. Each medication touched the ADON's fingers when pressed out of the medication card into the medication cup. The ADON administered the medications to resident 17. Hand hygiene was not used prior to medications being placed in the cup. On 4/20/22 at 8:35 AM, an observation was made of the ADON. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to remedy identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L.

Inspectors wroteResident medical records were reviewed. 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity due to excess calories, cirrhosis of liver, essential hypertension, generalized anxiety disorder, asthma, pain in right hip, post traumatic stress disorder, cognitive communication deficit, liver disease, irritable bowel syndrome without diarrhea, and major depressive disorder. Resident 50's medical record was reviewed on 4/19/22. No documentation of resident or family notification of a positive COVID-19 test within the facility on 4/16/22 was located within the medical record. 2. [...]

Inspectors wroteBased on observation and interview it was determined, for 6 of 34 sample residents, that the facility did not ensure that the resident's medical records were secure and confidential. Specifically, observations were made of computer screens left unattended and displaying resident's personal information. Resident identifier: 17, 25, 29, 33, 46 and 51.

Inspectors wroteBased on observation, interview, and record review it was determined, for 4 of 34 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, two residents did not have updated care plans for pressure sores, and two residents had care plans that did not address their dental needs. In addition, a residents was not evaluated for a bowel and bladder program. Resident identifiers: 5, 41, 49, and 56.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 34 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not changing the residents oxygen tubing and humidifier bottles per physician's order. Resident identifiers: 34, 38 and 55.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility menus were not prepared in advance, followed, and reviewed by the facility dietitian for nutritional adequacy. Specifically, menu items were changed without notifying the facility dietitian and the portion sizes were not served according to the menu. Resident identifiers: 15, 39 and 56.

Inspectors wroteBased on observation and interview, it was determined that the facility did not distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a refrigerator and multiple freezers were not dated or were past the use by date, logs on refrigerators and freezers were not completed, and there were cracked tiles in the dish machine area.

Inspectors wroteBased on observation and interview it was determined that the facility did not have adequate outside ventilation by means of window, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility during the survey.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 of 34 sample residents, a resident was observed to have medication in a lock box available for use in the resident's room and the resident was not evaluated to determine if she was safe to self administer medications. Resident identifier: 50.

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure that each resident received an accurate assessment that reflected the status, needs, strengths, and areas of decline for each resident. Specifically, for 2 of 34 sample residents, the facility did not provide an accurate assessment of the resident's dental status resulting in the resident's dental needs not being identified. Resident identifiers: 5 and 56.

Inspectors wroteBased on observation, interview and record review, it was determined for 1 of 34 sample residents, that the facility did not ensure the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident was observed not being supervised during smoking and dropped cigarettes and ashes onto his lap. Resident identifier: 54.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 34 sampled residents, that the facility did not ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. Specifically, the facility did not assess a resident for possible bowel and bladder retraining. Resident identifier: 56.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 34 sampled residents, that the facility did not offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, the facility was not offering fortified diets for residents. Resident identifier: 49.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 34 sampled residents, a resident's medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifier: 50.

Inspectors wroteBased on interview and record review it was determined that for 1 out of 34 sampled residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, a resident was provided medications when their blood pressure was outside of the physician's ordered parameters. Resident identifier: 49.

Inspectors wroteBased on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, an expired medication was administered to a resident. Resident identifier: 29.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility did not ensure that each resident obtained needed dental services. Specifically, for 2 of 34 sample residents, the facility did not provide needed dental services for a resident with dentures that did not fit experiencing mouth pain and a resident with missing teeth experiencing mouth pain. Resident identifiers: 5 and 56.