Crestmoor Care Center

In the surveyor’s words

From the most serious findings on record at Crestmoor Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 2, 2025

  Based on observations, record review and interviews, the facility failed to protect four (#12, #5, #9 and #15) of seven residents from abuse out of 12 sample residents.Resident #6 was admitted on [DATE] with a diagnosis of bipolar disorder (mental illness), depression, and dementia.Resident #12 was admitted on [DATE] with a diagnosis of dementia, other behavioral disturbance, anxiety disorder and depression.On [DATE], Resident #6 and Resident #12 were in the dining room when the residents began yelling at each other and hitting each other. On [DATE], Resident #6 grabbed Resident #12 on both of her arms. On [DATE], Resident #6 began yelling at Resident #12. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, activities room, and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen. Findings include: I. Failure to safely and appropriately store food items A. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), were retrieved on [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Feb 6, 2025

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff performed appropriate hand-hygiene; -Ensure enhanced barrier precautions (EBP) were in place for Resident #52 and Resident #284; -Follow infection control procedures for catheter care; -Follow infection control procedures for endotracheal tube care; and, -Clean equipment between use with residents. […]

• No harm, potential for more than minimal, widespreadF761Mar 7, 2024

  Based on observation and interviews, the facility failed to ensure medications and biologicals were labeled properly on four of four medication carts. Specifically, the facility failed to ensure insulin (medication used for blood glucose control) pens were labeled with the resident's name and open dates. Findings include: I. Professional reference According to the Humalin N kwikpen instructions for use, retrieved on 3/10/24 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf, Do not remove the Insulin Pen Label, unused Pens may be used until the expiration date printed on the label. II. Facility policy and procedure The Medication Labeling and Storage policy, dated February 2023, was provided regional quality mentor (RQM) on 3/6/24 at 2:00 p.m. […]

• No harm, potential for more than minimal, widespreadF761Mar 24, 2021

  Based on observations, record review, and interviews, the facility failed to ensure all medications and biologicals were stored and labeled properly in two out of four medications carts and two out of two medication storage room refrigerators. Specifically, the facility failed to: -Ensure opened undated medications were labeled and expired medications and treatments were removed from the South medication room; -Ensure expired treatments and [MEDICATION(S)] was removed from the North medication room; and, -Ensure expired medications and [MEDICATION(S)] syringes were removed from two of four medication carts. Findings include: I. […]