Crestwood Manor - Fremont

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure nursing staff followed policy and procedure for use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) for one of two residents (Resident 1) when two staff members attempted transfer of Resident 1 instead of the four staff members as per Resident 1's care plan. These failures resulted in the mechanical lift tipping over, causing Resident 1 to fall and break her femur (the thigh bone) during a transfer from her bed to her wheelchair. […]

• No harm, potential for more than minimal, patternF812Apr 18, 2025

  Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure the temperature of the [NAME] Hall nourishment refrigerator was maintained at 41 degrees Fahrenheit (F) or below and food items in the nourishment refrigerator were dated and labeled for the 64 of the 111 residents who resided on the [NAME] Hall. Findings included: A facility policy titled, Labeling and Dating of Foods, dated 2023, revealed, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The policy specified, Leftovers will be covered, labeled, and dated. […]

• No harm, potential for more than minimal, patternF580Sep 29, 2023

  Based on observation, interview, record review, the facility failed to notify the physician of a change in the medical condition for one of 23 sampled residents (Resident 74). The failure to notify the physician about marked increase in swelling of Resident 74 's right leg and right ankle delayed treatment and had the potential to result in Resident 74's condition worsening. Findings: A review of Resident 74's admission record indicated Resident 74 was admitted to the facility in 2019 with diagnoses that included peripheral vascular disease (PVD is narrowing or blockage of the blood vessels that carry blood from the heart to the legs, impeding circulation.) A review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an… […]

• No harm, potential for more than minimal, patternF755Sep 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure: 1. The consultant pharmacist (CP) established and implemented a system to provide for disposition of expired/discontinued to prevent unauthorized access and use of controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: there was no permanently affixed, locked container for storage of the expired/discontinued controlled medications, and individual, unpackaged tablets were not destroyed or stored in a sealed, tamper-resistant, locked container before transfer to the disposal company. 2. […]

• No harm, potential for more than minimal, patternF759Sep 29, 2023

  Based on observation, interview and record review, the facility failed to keep the medication error rate at less than five percent. 1. Registered Nurse (RN) 1 attempted to administer furosemide (a medication used to reduce extra fluid in the body) 20 milligrams (mg-a unit of measure) instead of 40 mg as prescribed to Resident 33. 2. RN 1 administered two puffs of the metered-dose inhaler (MDI) Ventolin Hydrofluoroalkane (HFA) (an inhaled medication used to prevent and treat wheezing and shortness of breath caused by breathing problems) 90 micrograms (mcg, a unit of measure) per actuation (act, a single inhaled dose) to Resident 33 without first shaking the cannister per manufacturer's instructions. […]