Crestwood Manor - 104

In the surveyor’s words

From the most serious findings on record at Crestwood Manor - 104, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 18, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a census of 183 was free from physical abuse when another resident (Resident 2), who had been displaying an increase in behaviors, grabbed Resident 1 and held her head in a headlock (a hold in which the aggressor encircles a victim's head with one arm). This failure resulted Resident 1 sustaining redness to her neck area, and had the potential to negatively affect her long-term emotional well-being. Findings: Review of Resident 2's Admission Record indicated Resident 2 admitted to the facility in 2005 with diagnoses, which included [CONDITION(S)] disorder (a mental health disorder characterized by abnormal thought processes and an unstable mood). […]

• Actual harm, isolatedF600Aug 17, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a census of 184 was free from physical abuse when another resident (Resident 2), with a history of assaultive behavior, pushed Resident 1 to the ground. This failure resulted in Resident 1 sustaining swelling and discoloration to the left hand. Findings: Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in 2005, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's care plan for assaultive behavior, initiated on 2/24/19, indicated Resident 2 pushed a resident on 2/24/19, kicked a Certified Nurse Assistant (CNA) on 1/31/20, kicked a CNA on 3/15/20, and slapped a resident on 4/10/20. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  Based on observation, interview, and record review the facility failed to ensure foods were stored, prepared, and served in accordance with professional standards for food service for 176 residents who ate facility prepared meals when: 1. Red onions were found to have mold (a type of fungus that grows in moist environments); and 2. Food products lacked an open date, complete labeling, and/or expiration dates on labels; and 3. Walk-in freezer found with ice buildup; and 4. Washed items were stacked and stored wet; and 5. Fixed can opener had visible food particles and metal worn off the cutting tip, had worn/missing metal on the base, and metal shavings were located on ledge behind the cutting tip; and 6. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2023

  Based on observation, interview, and record review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 177 of 177 residents who received food from the facility kitchen, when: 1. One jug of lemonade, one jug of cranberry juice and one jug of tea in the kitchen refrigerator were available for use after the labeled use by date, and one expired bread bag with five whole wheat breads was available to use on the bread rack in the kitchen; 2. Four bags with 12 burger buns in each bag on the bread rack were not dated when taken out of the freezer and 13 boxes with 24 ice cream cups per box in the kitchen freezer were not labeled with a received date and use by date; 3. […]

• No harm, potential for more than minimal, widespreadF908May 5, 2023

  Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean and safe manner, when four ovens had baked-on grease and food. This failure had the potential to cause a fire, food contamination and health hazards. Findings: During the initial kitchen tour with Assistant Dietary Services Supervisor (ADSS) 1 on 5/2/23, at 8:51 a.m., double wall ovens and two under range ovens were not clean, had baked-on dark brown grease and food on the racks, oven doors and on the bottom of the ovens. During a continued initial kitchen tour with the Dietary Services Supervisor (DSS) on 5/2/23, at 10:17 a.m., the DSS confirmed all four ovens were not clean and had baked-on grease and food. The DSS stated, That's dirty. […]