Crestwood Ridge Skilled Nursing and Rehab

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on resident record review, staff interview, review of hospital records, and review of facility policy, the facility failed to ensure a resident was transferred in a manner which prevented accidents. This affected one resident (#16) out of the four residents reviewed for falls. The facility census was 47.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure residents were free from abuse. This resulted in an Actual Harm when Resident #12 was assaulted by Resident #39 on 01/11/25. Resident #12 was punched in the face and was temporarily unconscious. Resident #12 was evaluated at the local hospital, diagnosed with mild closed head injury, lip abrasion, and cervical strain. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 47.

Inspectors wroteBased on observation, review of dietary menus, and staff interview, the facility failed to serve all food items from the preplanned menu during meal service. This had the potential to affect all 44 residents in the facility. The census was 44.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) staff sign-in sheets and staff interview, the facility failed to have QAPI meetings at least quarterly and failed to have all required members in attendance. This had the potential to affect all 44 residents in the facility. The census was 44.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure a resident's dignity was maintained by placing a cover over a urinary catheter drainage bag. This affected one (#28) of three residents the facility identified as having indwelling urinary catheters. The facility census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed notify a physician of resident blood glucose levels when the level was above 400 milligrams per deciliter (mg/dL) as ordered. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) after receiving Medicare Part A services at the facility as required. This affected three (#04, #28, and #40) of three residents reviewed. The facility census 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a Significant Change in Status Assessment for a resident enrolled in a hospice program. This affected one (#44) of three residents reviewed for Minimum Data Set assessments. The facility census was 44.

Inspectors wroteBased on staff interview and medical record review, the facility failed to to ensure Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (#23 and #27) of two residents reviewed for PASARR documents. The census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed develop a plan of care to address a resident's post traumatic stress disorder. This affected one (#31) of one residents reviewed for behavior and emotional needs. The facility identified five residents with a diagnosis of post traumatic stress disorder. The facility census was 44.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #49's legal guardian was provided, in writing a transfer/discharge notice at the time the resident was transferred to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47.

Inspectors wroteBased on record review and interview the facility failed to provide a written bed-hold notice to Resident #49 and Resident #49's legal guardian at the time of the resident's transfer to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47.

Inspectors wroteBased on record review, hospital record review and interview, the facility failed to allow Resident #49 to return to the facility upon discharge from the hospital. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47.

Inspectors wroteBased on record review, policy review, review of the weather condition, review of Centers for Disease Control and Prevention (CDC) guidance, and resident and staff interviews, the facility failed to ensure staff provided adequate supervision to prevent a resident from be treated for hyperthermia during extreme weather conditions. This affected resident (Resident #8) of three residents reviewed for accidents. The facility census was 48.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure quarterly care conferences were held and included the resident. This affected one resident (#25) of three residents reviewed for care conferences.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #24, who was dependent on staff for activity of daily living care, received adequate and timely assistance with routine nail care to promote proper hygiene. This affected one resident (#24) of four residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, record review and interview the facility failed to comprehensively assess and monitor multiple areas of bruising for Resident #232. This affected one resident (#232) of one resident reviewed for skin conditions.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure respiratory equipment was stored properly and to prevent infection for Resident #30 and Resident #232. This affected two residents (#30 and #232) of two residents reviewed for oxygen therapy. The facility identified four residents receiving respiratory treatments.

Inspectors wroteBased on record review and interview the facility failed to ensure recommendations from a psychiatric consult were implemented timely for Resident #24, who had diagnoses of major depressive disorder and psychosis. This affected one resident (#24) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on medical record review and interview the facility failed to ensure pharmacy recommendations were addressed timely for Resident #2, Resident #22 and Resident #24. This affected three residents (#2, #22 and #24) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, review of Nursing Handbook guidance and interview the facility failed to ensure the cardiac medication, Digoxin was only administered to Resident #22 when necessary and administered with adequate/proper monitoring. This affected one resident (#22) of five residents reviewed for unnecessary medication use. Findings Include: Review of Resident #22's medical record revealed an admission date of 03/25/22 with diagnoses including myocardial infarction, angina pectoris, atrial fibrillation, congestive heart failure, generalized muscle weakness, CVA with left sided hemiplegia, dysphagia, speech disturbances, constipation, hypertension, hyperlipidemia, atrial flutter, GERD and protein-calorie malnutrition. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure adequate justification and ineffective non-pharmacological interventions prior to the administration of psychoactive medications for Resident #24. This affected one resident (#24) of five residents reviewed for unnecessary medication use.