Crimson Heights Health & Wellness

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his for 3 of 3 residents (Resident #1, Resident #2, Resident 5) reviewed for resident rights. The facility failed to ensure staff assisted Resident #1, Resident #2, Resident 5 by failing to answer call lights in a timely manner to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures to accurately administer medications to meet the needs of each resident for 1 of 1 resident (Resident 1) reviewed for pharmacy services. The LVN A failed to properly administer a narcotic medication to Resident 1 and documented that the medication was wasted. The LVN A failed to properly dispose of the unused narcotic medication by leaving the medication on the resident's side table without supervision. The LVN A failed to properly document a controlled drug in the narcotic record or receipt and disposition established for Resdent 1. These failures could impact residents who receive medications based on pharmaceutical recommendations.

Inspectors wroteBased on interview and record review, the facility failed to ensure that controlled medications, were properly secured, as evidenced by medications being left unattended and unsecured for 1 of 1 resident (Resident 1) reviewed for accurate labeling of drugs. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption, for 1 resident (Resident #1) of 8 residents reviewed in that:Resident #1's personal refrigerator located in Resident #1's room observed on 11/19/2025, revealed two undated containers of ice cream that had liquified and leaked onto the shelves of the refrigerator unit. Additionally, a clear plastic cup containing a red liquid was observed to have a lid on it with a date that read 10/28. This failure could place residents at risk of foodborne illness due to consuming foods that might be spoiled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 5 residents (Resident #8), reviewed for care plans. The facility failed to: - Update Resident #8's care plan with her correct code status and had both full code and DNR on it. The care plan also was not updated with the correct tube feeding. These failures could place residents at risk for not obtaining/maintaining their highest practicable wellbeing.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for 2 of 23 residents (Resident #27, Resident #14) reviewed for environmental concerns. - The facility failed to ensure the wall in Resident #27's bedroom wall was repaired when the sheetrock was damaged.- The facility failed to ensure the air conditioning unit in Resident #14's bedroom was free of dirt and debris. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 27 opportunities, which involved 1 of 6 residents (Resident #11) reviewed for medication errors. MA V administered Oyster shell calcium instead of Calcium with Vitamin D to Resident #11 and administered Visine eye drops to both eyes instead of to the left eye only according to the Physician orders on 7/30/25. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 for 3 of 8 residents (Residents #48, #11 and #79) reviewed for infection control. The facility failed to ensure contents from Resident #48's consumed breakfast tray did not spill onto Resident #11's and #79's unconsumed lunch tray on 7/29/25. This failure could place residents at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for Resident #1. The facility failed to update Resident #1's care plan to reflect she was a two plus person physical assist that resulted in an improper transfer on 07/15/2025. This led to Resident #1's, left shoulder fracture. An immediate jeopardy (IJ) was identified on 07/20/2025. The IJ template was provided to the facility on [DATE] at 10:39 am by the Investigator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received supervision and assistive devices to prevent accident for Resident #1. On 07/15/2025, CNA D transferred Resident #1 unassisted using a stand and pivot method instead of a mechanical lift (a device used to aid in the transfer and movement of individuals especially those with mobility limitation) device as required by her care plan dated 12/06/2024. During the transfer there was audible pop from Resident #1's left shoulder. Resident #1 had pain and sustained a fracture. An immediate jeopardy (IJ) was identified on 07/18/2025. The IJ template was provided to the facility on [DATE] at 05:34 pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for one (Resident #1) of five residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #1 had a functioning toilet. This failure could place residents at risk of unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #1) reviewed for pressure ulcers in that: -The facility failed to ensure Resident #1's right buttock stage 2 pressure wound had a dressing covering the wound on 12/04/2024. This failure could affect residents with wounds placing them at risk of infection, a decline in health, pain, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assist with activities of daily life, for 2 of 8 residents (Resident #50 and Resident #98) who was observed for assistance with ADLs. The facility failed to: - Provide supervision, or touching assistance, for Resident #98 during food service. - Answer Resident #50's call light for 50 minutes after repeated verbalizations/request for help as he was soiled with urine and bowel movement subsequently making him feel helpless and neglected. This failure placed residents at risk of poor nutrition, dehydration, skin breakdown, and unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to effectively conduct food and nutrition services for the facility's main dining room. The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth.

Inspectors wroteFACILITY Environment Based on observations, interviews, and record review, the facility failed to accommodate the needs and preferences for four (Resident #50, Resident #56, Resident #57 and Resident 66) of 10 residents reviewed for accommodation of needs, in that: The facility failed to ensure Resident #56, Resident #57, and Resident #66 had their call lights within reach. This deficient practice could place residents at risk for falls, not receiving care and nursing interventions in a timely manner, and subject them to skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #97) reviewed for resident assessments. The facility failed to ensure Resident #97's most recent admission MDS reflected that Resident #97 received dialysis services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #3) of 16 residents reviewed for care plans. The facility failed to ensure Resident #3 comprehensive care plan was updated when her IV medication was discontinued. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 (Crash cart #1) of 8 medication/treatment carts reviewed for medication storage in that: The facility failed to ensure Crash Cart #1 was not left unattended and unlocked. This failure could allow residents, unsupervised access to medical equipment including sharps. Findings Include: Observation on 6/11/2024 at 2:20 pm of Crash cart # 1 revealed the handle was in the unlocked position and unattended on hallway three hundred not in view of the nursing station. Cart # 1 was in a frequently used hallway used by Staff, residents and visitor. Drawers were labeled drawer #1 IV started kit, needles, flashlight, Drawer # 2 Misc. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received the diet ordered per physician order for 1 of 3 residents (Resident #2) reviewed for therapeutic diets. The facility failed to provide Resident #2 with 1 Cream Soup at all meals as ordered by a physician. This failure could affect residents who had physician orders for 1 cream Soup at all meals and could put the residents at risk for weight loss and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for 1 of 13 residents (Resident #44) reviewed for accurate medical records, in that: 1. The facility failed to ensure Resident #44's vitals documentation accurately reflected her mealtimes and food intake. This deficient practice could result in errors in care and treatment and place residents at risk for low blood sugar, malnutrition, and potential inaccurate treatment for weight gain or loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Residents #1) reviewed for adequate supervision. The facility failed to provide Resident #1 with adequate supervision and monitoring related to his wandering behaviors which resulted in an elopement to an apartment complex by EMS. Resident #1 was absent from the facility for approximately 7 hours before he was noticed by staff that he was missing. This failure could affect residents who and place them at risk for physical harm and or pain. An Immediate Jeopardy (IJ) was identified on 3/28/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 of 6 staff reviewed for provision of respiratory care. -The facility failed to assist Resident #1 in expelling mucous from lungs. This failure could place resident at risk for potential respiratory distress, emotional harm, and untimely care.

Inspectors wroteBased on interview and record review the facility failed to promote care for resident in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 3 residents reviewed for dignity. -The facility failed to provide dignity and respect for Resident #1 by allowing a staff member to provide direct patient care whom Resident #1 had petitioned verbally and via formal grievance not to be involved with his care or have any contact with him. This failure could place residents at risk for suppression of residents' rights, intimidation, retaliation, increased anxiety, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 1 (Resident #1) out of 4 residents reviewed for care plan accuracy. -The facility failed to ensure Resident #1's comprehensive care plan identified his need cough assistance related to quadriplegia. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on interview, and record review the facility failed to coordinate assessments with the PASARR program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 2 of 4 residents (Residents #83 and #57) reviewed for PASARR Level I screenings. The facility failed to ensure an accurate PASARR Level I screening was completed for Residents #83 and #57 (A PASARR Level I screening is a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability). This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents reviewed for therapeutic diet (Resident #57). The facility failed to obtain weekly weight monitoring as ordered for Resident #57 after she was identified with severe weight loss resulting in delayed nutrition and medical intervention for continued weight loss. The facility failed to provide therapeutic diet in appropriate portion sizes per menu resulting in provision of inadequate calories. Failure to weigh residents as ordered could place all residents at risk of delayed nutrition and medical intervention for malnutrition and health management. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved 2 of 3 residents (Resident #68 and #11) reviewed for medication errors. MA G administered 5 mL of Megace (a prescription medicine used to treat the symptoms of loss of appetite and wasting syndrome) to Resident #68 instead of 10 mL as ordered by the physician. CNA I (who is also a medication aide) administered Calcium + D3 600 mg / 400 IU to Resident #11 instead of Calcium + D3 600 mg / 200 IU as ordered by the Physician. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply for 1 of 1 facility. -The facility failed to ensure enough emergency water was available. The facility's emergency water supply consisted of 21 cases, each case with 40 bottles each with 16.9 fluid ounces (500 milliliters) in the bottle for a census of 95 residents and 38 employees stored in a closet in the building. This failure could place residents at serious risk for complications from dehydration and poor sanitation.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #68 and #11) reviewed for beneficiary notices. The facility failed to give Residents #68 and #11 a SNF ABN when they were discharged from skilled services at the facility before their covered days were exhausted. This failure could place residents at risk of not being fully informed about services covered by Medicare.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #73) reviewed for oxygen therapy. - Resident #73's oxygen setting was on 3 L continuous instead of 4 L continuous as ordered by the physician. This failure could place residents at risk of respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in a form designed to meet the individual resident needs for 1 (Resident #28) of 30 residents reviewed for dietary meals. -The facility failed to ensure that Resident #28's lunch was prepared and served per MD orders in a form (texture) to meet the resident's needs during dining observation. This failure could affect all residents who eat from the kitchen, causing a decrease in nutrition and enjoyment of meals, and increased risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 (Resident #1) of 6 residents reviewed for infection control. -The facility failed to have signage and PPE set up outside of Resident #1's room in a timely manner to indicate she was on contact isolation. -The facility failed to inform Resident #1's CNA that she was on contact isolation in a timely manner. These failures could place residents in the facility at risk of contracting an infectious disease. Findings Include: Record review of Resident #1's face sheet revealed a [AGE] year-old female readmitted to the facility on [DATE]. [...]