Crestwood Wellness and Recovery Center

Inspectors wroteBased on interviews and record reviews the facility failed to protect the rights of one out of four sampled residents (Resident 1) to be free from physical abuse by Resident 2 when Resident 2 hit Resident 1 in the face. This resulted in Resident 1 sustaining bruising to the right side of the face that lasted for 15 days.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH, state agency dedicated to protecting and improving the health of Californians), the police department, and to the local Ombudsman [a person who worked to maintain resident rights] for one out of two sampled residents (Resident 3) when Resident 3 made statements about being sexually abused. This had the potential to negatively impact health status and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food product bags after opening the bags for use. The open, unlabeled, and undated product bags contained frozen soy chicken patties, frozen fried eggs, and frozen soy beef patties. This failure had the potential for the food products to be used for meals in an untimely manner leading to bacterial or fungal growth resulting in food borne illnesses amongst residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one of 25 sampled Residents (Resident 56) was protected from verbal and physical abuse when Resident 38 yelled at Resident 56 calling him names and hit Resident 56 with a closed fist to his head, then continued to chase Resident 56 down the hall until staff could intervene. This failure resulted in increased anxiety, and the potential to result in emotional stress, anger, depression, feelings of neglect, and the potential for negative clinical outcomes for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety and security for one of two clients (Client 1) when: 1. The facility security door locking system malfunctioned and Client 1 eloped from the facility. 2. The Temporary-Office Assistant (TOA) did not recognize Client 1 as a client, when she passed through the front lobby and eloped out the front doors. 3. Program Staff (PS, an employee that does activities with clients), saw Client 1 outside the facility and made no inquiries as to why Client 1 was outside. This disregard for client safety allowed Client 1 to go missing from the facility and her whereabouts were unknown for 8 hours, which put Client 1 at risk for injury and exposure to cold weather and had the potential to negatively impact on Client 1's health, safety, and welfare.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of 20 sampled residents (Residents 3 and 82) were protected from physical abuse when: 1. On 6/12/24, Resident 84 struck Resident 82 in the face. 2. On 5/22/24, Resident 84 placed their hands around Resident 3's throat. This failure resulted in bleeding injuries to Resident 82, and had the potential to threaten the physical, emotional and psychological health and well-being of both residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food containers/ product bags of frozen breaded fish, frozen fried eggs, frozen hashbrowns, frozen frenchtoast, pepperoni, and peeled garlic cloves with open dates after the packages were open and the products being used for meals. This failure had the potential to allow food products to sit an inappropriate amount of time after the packaging was open with no dating label adehered leading to bacterial or fungal growth causing food borne illnesses amongst residents if the product was served for meals and not used by an appropriate date following guidelines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurate for two out of two sampled clients (Client 1 and Client 2) when there was not a process in place for updating and maintaining the Personal Property Inventory sheet (PPI, a document that described what personal items a client had at the facility). This failure had the potential to inaccurately capture client personal property which could cause frustration for clients.

Inspectors wroteBased on interview and record review the facility did not report a Clients allegation of rape to the California Department of Health as required. By not reporting the allegation of rape the facility created the possibility for ongoing abuse of the Client potentially causing mental anguish and physical injuries leading to adverse clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of one sampled residents had complete admission orders when Resident 185 had a urinary catheter (a tube that drains urine from the bladder) and there were no Physician's Orders that included the use of a catheter. This had the potential for Resident 185 not to receive the necessary care he needed to prevent malfunctioning of the catheter and avoid bladder infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 22 sampled residents had Baseline Care Plans developed within 48 hours after admission. (Resident 185) This failure to identify Resident 185's immediate basic health and safety needs had the potential to negatively impact his physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans for 3 of 22 sampled residents (Residents 185, 75 and 81) when: 1. Resident 185 had one care plan developed for his isolation problem but no other problems were identified or care planned. 2. Resident 75 did not have a care plan developed for his need to be straight cathed (insertion of a tube in the bladder to remove urine intermittently as needed, instead of having a permanent catheter in the bladder). 3. Resident 81's care plans did not identify medications, symptoms to monitor or report, or any non-pharmacological interventions. These failures had the potential for these Resident's needs to go unrecognized and untreated and negatively impact their ability to attain or maintain their highest practicable level of physical and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a post fall injury, including a bump on the head, was monitored according to facility policy, and a fall assessment done, upon readmission, was completed accurately, for one of two residents (Resident 48), with a history of falls. This had the potential to result in a delay in the recognition of a worsening injury and result in more falls with major injuries.

Inspectors wroteBased on interview and record review: 1. The facility's pharmacy consultant failed to identify drug irregularities which included duplicate therapy (more than one medication for the same purpose without a clear distinction of when one medication should be given over another medication), for one of six sampled residents (Resident 48) whose records were reviewed for unnecessary drugs. Resident 48 had orders, for two as needed (prn) medications, used to treat anxiety or agitation, without any direction from the physician, as to which medication to use first or why both medications were needed, on a prn basis. This had the potential to result in Resident 48 receiving unnecessary drugs with potential adverse side effects. 2. The facility failed to ensure their pharmacy consultant provided documentation for each resident when the medication regimen review was done on a monthly basis. [...]