Crestwood Terrace

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy and failed to protect a resident during an incident of resident-to-resident physical abuse. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R1 physically assaulting R2 by punching R2 in the head and face and pulling R2's hair. R2 sustained a closed head injury, neck and back pain, facial scratches, and psychosocial harm, including expressing fear that R1 would kill her; R2. Due to the injuries sustained, R2 was transferred to the hospital for further evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to supervise a resident who was diagnosed with bilateral eye blindness, used a white cane and required supervision and touching assistance with ambulation to prevent an avoidable accident and altercation. This affected two of three residents (R1, R2) reviewed for supervision. This resulted in R1 tripping over R2's wheelchair and the resident engaging in a resident-to-resident altercateion. Findings Include:R1 was diagnosis with category five blindness to the right eye, category four blindness to the left eye, atrophy of globe of right eye. Minimal Data Set Section B (vision) document severely impaired. Section C (cognitive pattern) dated 12/29/25 documents: brief interview for mental status summary score of fifteen which indicate cognitively intact. Section GG (functional abilities) documents mobility device: cane/crutch. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R3) from both physical and sexual abuse by R2. This failure affected one (R3) of seven residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for abuse. These failures resulted in R3 being physically and sexually assaulted by R2 and R3 also suffering psychosocial harm stating feelings of fear and nightmares.

Inspectors wroteBased on interview and record review, the facility failed to follow hospital orders for a fluid restriction after a resident (R1) was hospitalized for low sodium and failed to complete additional laboratory work for a resident's (R1) low sodium levels for one out of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 suffering a syncopal episode twice within four days and needing to be hospitalized each episode for low sodium and bradycardia. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, type 2 diabetes, schizoaffective disorder, bradycardia, and syncope/collapse. R1 no longer resides in the facility. A Nursing note dated 5/ 31/ 25 document R1 was found lying on the floor in R1's room. The fall was unwitnessed. Vital signs were within normal limits except the heart rate. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to follow their abuse policy and procedures by restricting a resident from returning to their room with their personal items and physically restraining them against their will. This failure applies to one of three residents (R1) reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse (R2) from another resident with known history of aggressive behavior (R3) for one (R2) of five residents reviewed for abuse in a sample of eight. This failure resulted in R2 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma.

Inspectors wroteBased on interviews and record review, the facility failed to prevent a physical altercation between a resident (R1) with a history of delusions, agitation, and aggressive behavior towards peers, and his roommate (R2) by failing to adequately monitor the two residents inside their room with the door closed, during lunchtime. This lack of supervision resulted in a failed opportunity to identify delusional and aggressive behavior from R1 that led to R1 hitting R2 in the head with his hands, grabbing him by the shirt, and pulling him out of his room.

Inspectors wroteBased on interview and record review, the facility failed to identify a resident (R1) as a high fall risk after new onset shuffling of gait and failed to put interventions on the care plan in regards to the shuffling. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 getting up unassisted and falling causing a laceration to the forehead that needed repair at the hospital with three to four stitches.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for developing a comprehensive care plan by not updating care plan interventions as needed and not implementing personalized and effective care plan interventions for a resident exhibiting a pattern of increasing anxiety, agitation, and verbal and physical aggression. This failure applies to one of four residents (R4) reviewed for care planning.

Inspectors wroteBased on interview and record review, the facility failed to prevent an employee from engaging in verbal abuse with a resident and failed to follow their abuse policy of immediately reporting abuse to the abuse coordinator. This failure affects two (R4 and R5) of four residents reviewed for verbal abuse and has the potential to affect all 109 residents currently in the facility.

Inspectors wroteBased on interview and record review, the facility failed to address the pharmacist recommendation for a gradual dose reduction of anti-depressant medication and failed to ensure the pharmacist recommendations were readily available to review in the resident's electronic health record. This failure applied to one (R1) of three residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to update care plan of residents with COVID infection. This deficiency affects all six (R1, R14, R16, R53, R54 and R89) residents in the sample of 23 reviewed for Care plan revision.

Inspectors wroteBased on observation interview and record review the facility failed to implement infection control protocol for resident with COVID infection and implementation of COVID surveillance in the facility. This deficiency affects all ten (R1, R6, R14, R16, R41, R50, R53, R54, R89 and R103) residents in the sample of 23 reviewed for Infection Control Prevention Program.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy in notifying the residents' family when the resident was sent out to the hospital. This failure affected one (R63) of four residents in the sample of 23 reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents are free of any significant medication error. This deficiency affects 1 (R55) of 6 residents in a sample of 23 reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to provide effective supervision to monitor and intervene before a resident-to-resident verbal altercation escalate into an avoidable physical altercation. This affected two of four residents reviewed for supervision and monitoring. This failure resulted in R1 and R2 having a verbal disagreement, escalating into a physical altercation, resulting in R1 observed with bleeding at back of head. R1 was sent to hospital with diagnosis of subdural hematoma and facial contusions.

Inspectors wroteBased on interviews, observations, and records reviewed the facility failed to prevent one resident (R3) from being physically attacked by another resident with identified anger problems and mood swings. This affected two of four residents (R3, R4) reviewed for physical abuse. This failure resulted in R4 physically attacking R3 resulting in visible, bleeding, scratches on her chest, arms, and head.

Inspectors wroteBased on interview and record review, the facility failed to ensure a lab draw for an antiseizure medication was completed as ordered for two residents (R1, R2) out of three reviewed for physician orders in a total sample of five. This failure resulted in R2 suffering a seizure and being sent to the hospital where the antiseizure medication level was low. Findings Include: R2 is a [AGE] year old with the following diagnosis: idiopathic epilepsy and paranoid schizophrenia. On 3/13/24 at 12:00PM, R2 was unable to remember when R2 went to the hospital last, but reported it was due to having a seizure while at the facility. R2 stated R2 was born with seizures and R2 has to take medications to control them. R2 was not aware of any missed blood draws. R2 does not remember the last time R2's blood was drawn at the facility. R2 was unaware if any seizure medication levels were low. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the physician a low lab level for an antiseizure medication for one resident (R1) out of three reviewed for physician notification in a total sample of five. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia disorder, bipolar disease, and epilepsy with seizures. On 3/13/24 at 11:46AM, R1 stated R1 takes an antiseizure medication (Dilantin) to manage seizures. R1 denied being aware R1 had a low level of Dilantin when R1 had laboratory work on 10/20/24. R1 reported R1 went to the hospital on 3/9/24 and then R1 discovered R1 had a low level Dilantin after the hospital completed laboratory work. R1 stated R1 was giving an injection of Dilantin in the hospital before returning to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by other residents. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for abuse and resulted in R3 sustaining a nosebleed after being punched by R4 and resulted in R2 sustaining a closed fracture of the right ankle, which required a surgical procedure, after being involved in a physical altercation with R1.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the Manual Ware Washing Policy by not ensuring the Bleach (Chlorine) was 50-100 ppm in the sanitizing machine. This failure has the capacity to affect all 112 residents with oral diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and develop a care plan for residents currently smoking for two of nine residents (R8, R23) reviewed for smoking in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food portions as listed on the menu spreadsheets; failed to follow daily spread sheet menus and failed to offer foods from the always available menu. This failure applies to all 101 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain food within temperature range to prevent spoilage of products in the pantry; failed to secure milk and food products in an outside storage area; failed to monitor and maintain an adequate supply of emergency food items; failed to maintain kitchen equipment to be clean and in good working condition; failed to keep coolers and freezers free of personal food items; failed to thaw raw food items separately from pasteurized or ready to eat foods; failed to prevent cross contamination of raw foods while preparing ready to eat foods; and failed to provide kitchen environment free of old food items on the floor, dust over prep area, leaking sinks, standing water, and black matter on walls and piping. These failures affect all 101 residents who receive dietary services in this facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on infection control regarding hand hygiene while distributing lunch trays to residents. This failure has the potential to affect all 101 residents currently in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have an effective pest control program in place to ensure that the facility remains free of pests. This failure applied to three (R8, R27, and R57) residents reviewed for environment and has the potential to affect all 101 residents currently in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their maintenance and housekeeping policies and procedures to maintain a safe, clean, and homelike environment by not keeping furniture, equipment, and resident rooms in good repair and by not keeping rooms in a clean, sanitary condition. This failure applied to nine (R11, R17, R27, R35, R37, R42, R44, R57, and R68) of nine residents in a sample of 21 reviewed for environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a resident's care plan interventions related to unplanned weight loss by not providing the resident with cueing and encouragement during mealtimes. This failure applied to one (R88) of one resident reviewed for nutrition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and protocol for providing therapeutic diets by not acquiring the necessary equipment to prepare mechanical soft diets and not following physician orders and dietitian recommendations for providing mechanical soft diets. This failure applied to two (R73 and R97) residents in a total sample of 21 residents reviewed for food preparation.