Crestpark Stuttgart, LLC

In the surveyor’s words

From the most serious findings on record at Crestpark Stuttgart, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 30, 2021

  Based on observation, record review, and interview, the facility failed to ensure resident's safety, to prevent elopement with known exit seeking behavior and failed to ensure residents were assessed for elopement risk upon admission, readmission and at least quarterly thereafter to ensure elopement risk was identified and addressed for 1 (Resident #4) resident who was at risk for elopement. This failed practice resulted in immediate jeopardy that caused or was likely to cause serious harm, injury or death to Resident #4 who had repeated exit seeking behavior and eloped the facility and had the potential to affect 3 residents who were elopement risk per the list provided by the Administrator on 4/29/21. […]

• Immediate jeopardy, isolatedF603Jan 12, 2024

  Based on record review and interview, the facility failed to ensure a resident remained free of involuntary seclusion by staff and to ensure all other residents were protected from further involuntary seclusion for 1 of 1 (Resident #34) sampled residents who had been involuntary secluded. The Administrator was informed of the Immediate Jeopardy on 01/09/24 at 3:07 PM The failed practice had the potential to affect all 45 residents currently in the facility. The findings are: On 01/08/24 at 3:59 PM, Surveyor notified the family member by phone for a family interview. During the interview the daughter said last week on Wednesday it was reported a staff member locked him (Resident #34) in his room. The staff member was fired, and an investigation is under way. […]

• Immediate jeopardy, isolatedF689Jan 12, 2024

  Based on observation, record review and interview, the facility failed to ensure an effective fall prevention program that included adequate supervision and a system for residents who were at risk for falls was developed and consistently implemented, as evidenced by:failure to ensure anti-rollbacks were consistently monitored to ensure they were in working condition to prevent falls to the extent possible and reduce the potential for further injury from falls that did occur for 1 (Resident #148) of 1 (Resident #148) sampled Resident who sustained a fracture; failed to ensure falls were thoroughly investigated for causative factors and interventions were developed and implemented based on those causative factors to decrease the potential for further falls / injuries for 2 (Residents #18 and… […]

• Immediate jeopardy, isolatedF689Apr 2, 2021

  Complaint # (AR 391) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) safely transported a resident in a wheelchair in the facility ' s van to prevent potential injury for 1 (Resident #1) of 2 (Resident (R) #1 and R #2) sample residents who required transport in a wheelchair facility ' s van in the past 2 weeks. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who slipped out of the wheelchair when the van accelerated after stopping at a railroad track, and had the potential to cause more than minimal harm to 2 residents who required wheelchairs during transport in the facility van in… […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2024

  Based on observation, interview and record review, the facility failed to ensure that meats were stored properly during the thawing process to prevent the potential for food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure expired food items were promptly removed from the stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure dented food cans were promptly removed or discarded to prevent the growth of bacteria, The facility failed to ensure interventions were in place to prevent possible cross contamination during the meal preparation to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. […]