Crestway Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Crestway Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 20, 2024

  Based on observations, interviews, and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 79 residents (Resident #5, #7, #10, #11, and #12) reviewed for elopement. 1. Resident #5 was admitted on [DATE] with diagnoses which included dementia and was assessed on 02/26/2024 as a wander risk at 9 out of a possible 11 for high risk. Resident #5 walked out of the facility on 03/16/2024 around 3:00 to 4:00 PM and was discovered 13 miles away on a public street and returned to the facility at 9:40 PM. 2. […]

• Immediate jeopardy, isolatedF689Mar 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. Resident #1 was transferred without a mechanical lift on 10/25/24 and experienced pain to her right leg/sustained a distal fracture 2. Resident #2 was transferred by a single staff member instead of the required two during a mechanical lift on 09/25/2024 and the mechanical lift tipped over, dropping the resident, and resulting in a bump and laceration to her nose. The noncompliance was identified as PNC. The IJ began on 9/24/2024 and ended on 11/27/2024. […]

• Immediate jeopardy, isolatedF600Feb 25, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #2) of four residents reviewed for abuse. The facility failed to keep Resident #2 free from abuse when CNA A roughly provided bed mobility assistance and incontinent care on 02/11/2025 and 02/13/2025. The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began. This deficient practice could affect any resident and result in emotional and physical abuse. […]

• Actual harm, isolatedF689Dec 29, 2023

  Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. Resident #1 sustained a fall on 12/17/2023 during an attempted transfer when CNA B opted not to follow facility policies and procedures and care plan which require a 2 person physical assist. Resulting is Resident #1 having intense pain requiring PRN medications This failure could place residents requiring assistance with ADLs in danger of injury. Findings included: Record review of Resident #1's electronic facesheet revealed Resident #1 was originally admitted on [DATE] and was [AGE] years of age. […]

• Actual harm, isolatedF689Nov 9, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 11 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was not transferred properly to prevent a fall with injury of left femur fracture. 2. Resident #2 was not provided personal care in a manner to prevent a fall without injury. These failures could place residents who were at risk for falls at risk for avoidable accidents and could result in a decline in physical condition. The non-compliance was identified as past non-compliance. The non-compliance began on 08/09/2023 and ended on 10/24/2023. […]