Crestwood Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Nov 18, 2025

  Based on interview and record review, the facility failed to provide on-going monitoring and close supervision of Resident #11, who had a history of being non-compliant with facility rules and policies by obtaining unauthorized and/or illegal drugs for both his/her own use as well as distribution to other residents. On [DATE], cardiopulmonary resuscitation (CPR, an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until spontaneous breathing and heartbeat can be restored) was initiated on Resident #11, Resident #1, and Resident #2 after an overdose. […]

• Immediate jeopardy, isolatedF600Mar 19, 2024

  Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when one resident (Resident #4) was involved in a physical altercation with another resident (Resident #3). In two separate incidents, Resident #3 hit Resident #4 in the mouth when Resident #4 wandered into Resident #3's room. The sample size was 5. The census was 139. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. […]

• Immediate jeopardy, isolatedF760Feb 6, 2024

  See F760 cited at 7FZ112. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on 12/24/23 and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. […]

• Immediate jeopardy, isolatedF600Dec 8, 2023

  This deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. […]

• Immediate jeopardy, isolatedF600Dec 8, 2023

  This deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. […]