Crestwood Nursing & Rehabilitation Center Inc

In the surveyor’s words

From the most serious findings on record at Crestwood Nursing & Rehabilitation Center Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 15, 2023

  Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #2, resulting in the death of Resident ID #1. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] ,d+[DATE] [secondary to] door being closed. Abuser [Resident ID #2] was found to be blocking entry into the room however upon gaining access, the RN noted the room looked like bed linens were spread around the room and general disorder. […]

• Immediate jeopardy, isolatedF689May 15, 2023

  Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receive adequate supervision based on the resident's assessed needs and risks identified to protect residents from accidents, relative to an incident that occurred between Resident ID #1 and Resident ID #2, resulting in the death of Resident ID #1. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] ,d+[DATE] [secondary to] door being closed. […]

• Actual harm, isolatedF740May 15, 2023

  Based on record review and staff interview it has been determined that the facility failed to address signs of behaviors that the resident was exhibiting such as disrobing self, wandering, pacing the unit and declining care/medications since his/her admission to the facility, as documented in the medical record. Additionally, the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 1 resident reviewed, Resident ID #2. […]

• No harm, potential for more than minimal, patternF698Nov 15, 2024

  Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed on a fluid restriction, Resident ID #17. Findings are as follows: Record review revealed the resident was readmitted to the facility in July of 2023, with diagnoses including, but not limited to, end stage renal disease (a condition in which your kidneys are damaged and lose the ability to filter waste and fluid from the blood properly) and is dependent on renal dialysis. […]

• No harm, potential for more than minimal, patternF695Sep 16, 2021

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Resident ID #s 1 and 2. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. Review of the facility policy titled Oxygen Administration states in part, Check the physician's order for liter flow and method of administration .Documentation: 1. […]