Crest Manor Living and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Crest Manor Living and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 15, 2024

  Based on observations, interviews, and record review conducted during the Recertification Survey from 10/07/2024 to 10/15/2024, for two (Resident #13 and #59) of two residents reviewed, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #13 did not have documented evidence of a bowel movement for more than three days, that bowel medications were ordered and/or administered per the facility's protocol, or that a medical provider was notified. […]

• Actual harm, isolatedF692Oct 15, 2024

  Based on observations, record review, and interviews during the Recertification Survey conducted from 10/7/2024 through 10/15/2024, the facility failed to ensure acceptable parameters of nutritional status for two (Residents #38 and #11) of three residents reviewed. Specifically, Resident #38 did not receive assistance at meals per their care plan, did not have their nutritional needs reassessed timely, and had poor meal intakes resulting in significant weight loss. Additionally, Resident #38 developed a stage three pressure ulcer (full thickness tissue loss) following the weight loss. […]

• No harm, potential for more than minimal, widespreadF725Oct 15, 2024

  Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigations (NY00354611 and NY00349191), for two (Second Floor and Third Floor) of two resident units, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for residents in the facility. Specifically, there were several observations of residents who were in bed and wearing hospital gowns during the late morning hours, residents with dirty, unkept fingernails, and residents that were not provided assistance with meals as care planned. […]

• No harm, potential for more than minimal, widespreadF726Oct 15, 2024

  Based on interviews and record review conducted during the Recertification Survey from 10/07/2024 to 10/15/2024, for one (Resident #59) of two residents reviewed, the facility did not ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessments and described in the plan of care. Specifically, Resident #59 who had nephrostomy tubes (thin, flexible tubes that drain urine from the kidney into a bag outside the body), nursing staff reported not having received training related to the care and management of nephrostomy tubes and the facility was unable to provided documented evidence of any trainings or related competencies. […]

• No harm, potential for more than minimal, patternF565Oct 15, 2024

  Based on interviews and record review conducted during the Recertification Survey from 10/07/2024 to 10/15/2024, for seven (Residents #1, #2, #6, #26, #31, #51, and #65) of seven residents, the facility did not ensure that grievances and recommendations by the resident group (Resident Council) concerning issues of resident care and life in the facility were acted on promptly. Specifically, during a special Resident Council meeting, seven residents voiced multiple concerns. A review of the previous three months of meeting minutes included issues such as call bell response, inability to find staff during various periods of the day, staff phone use during care, dietary concerns, and missing laundry items. […]