Crestwood Manor

In the surveyor’s words

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

• Actual harm, isolatedF689May 2, 2025

  Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be a high risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on [DATE]. Resident 1 was assessed to have an unsteady gait, educated on the need to call for assistance, had falls on [DATE], [DATE], [DATE]and fell on [DATE]. […]

• Actual harm, isolatedF658Mar 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 administered psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications not prescribed to Resident 1 in error. This failure resulted in Resident 1's transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for decreased mental status and treatment of an accidental overdose (dangerous and excessive dose of a drug). […]

• Actual harm, isolatedF760Mar 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of significant medication errors when Licensed Vocational Nurse (LVN) 1 did not correctly identify Resident 1 and administered Resident 4's psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications to her in error. This failure resulted in Resident 1 experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. […]

• No harm, potential for more than minimal, patternF656Dec 5, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan with measurable interventions for four of 14 sampled residents (Resident 3, 4, 7, and 10) when: 1. Residents 3, 4, and 7 did not have a specific care plan monitoring for side effects for their prescribed psychotropic (drugs that alter brain function, affecting mood, behavior, thoughts, and perception, used to treat mental health conditions) medications.This failure had the potential to cause staff to be unaware of any side effects brought on by psychotropic medications prescribed to Residents 3, 4, and 7.2. Resident 10 had a foley catheter (a soft flexible tube inserted into the bladder to drain urine) inserted on 9/17/25. […]

• No harm, potential for more than minimal, patternF755Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with accepted professional standards of practice for seven of seven sampled residents (Residents 7,19,75,76,113,132), when during a medication pass observation, a licensed nurse removed medications from original packaging, placed the medications into unlabeled cups with a removable label with only residents last name and first letter of first name, and stored the cups for later administration. The medication cups were poured for multiple residents at the same time and the pre-poured medication cups were unlabeled with the residents' name, drug, and dose. […]