Crestwood Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Jan 8, 2024

  Based on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). […]

• Immediate jeopardy, widespreadF835Jan 8, 2024

  Based on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). […]

• Immediate jeopardy, patternF760Apr 11, 2024

  Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected two (#14 and #110) of five residents reviewed for medications. The facility census was 104. Findings include: 1. Review of Resident #14's medical record revealed admission to the facility occurred on [DATE] with diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary disease. Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely alert and oriented. Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication to treat arthritis Humira subcutaneous (SQ) every 14 days. […]

• Immediate jeopardy, patternF600Jan 10, 2023

  Based on observations, review of medical records, Self-Reported Incidents (SRI) review, witness statement review, staff schedule review, police call report review, review of the Centers for Medicare and Medicaid (CMS) guidance related to sexual activity and consent, facility policy review and interviews with staff, residents, and a resident's legal representative, the facility failed to ensure five cognitively impaired residents (#98, #81, #101, #13, #15) were free from resident-to-resident sexual abuse. […]

• Immediate jeopardy, isolatedF689Jan 8, 2024

  Based on observation, review of open and closed medical records, hospital record review, review of self-reported incidents (SRI), resident and staff interviews, and review of facility policies, the facility failed to ensure residents were adequately supervised and interventions were put in place to prevent a resident-to-resident altercation. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when, on 10/19/23, one resident (#06) was involved in an altercation with another resident (#100) which resulted in Resident #06 being pushed to the floor by Resident #100 who had a documented history of aggression and past incidents of physical altercations with other residents. […]