Crestwood Rehabilitation and Nursing

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Apr 25, 2022

  Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of Coronavirus disease (COVID-19). Specifically, the facility failed to ensure that staff members were screened for COVID-19 prior to entering the facility to work. The facility failed to ensure a symptomatic staff member, who subsequently tested positive for COVID-19, was screened accurately and notification and evaluation was completed per the facility protocol. The failure resulted in 3 residents being exposed to COVID-19. […]

• Actual harm, isolatedF689Apr 27, 2026

  Based on observation, interview and record review, for 1 of 40 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident developed a shearing injury related to a Hoyer lift transfer. This will be cited at a Harm level at past non-compliance with a completion date of 3/6/26. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of right lower leg, paraplegia, cirrhosis of liver, rhabdomyolysis, and mild protein-calorie malnutrition. […]

• Actual harm, isolatedF697Apr 27, 2026

  Based on observation, interview and record review, for 2 of 40 sampled residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident's pain medications were decreased after admission and no appointment was made after the resident requested an appointment with the pain clinic. This example will be cited at a harm level. In addition, another resident's pain to her thumb knuckles was not addressed. Resident identifiers: 4 and 8. Findings included: 1. […]

• Actual harm, isolatedF684Jan 29, 2024

  Based on interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 of 33 residents sampled, the facility did not provide care to a resident who sustained a head laceration after a fall and requested to be sent to the hospital via ambulance for treatment. The deficient practice identified was determined to have occurred at a harm level. […]

• No harm, potential for more than minimal, widespreadF812Apr 27, 2026

  Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility dish machine was not reaching the required temperature, dirty dishes were loaded from the clean side, gloves were not changed between touching dirty dishes and then clean, there were foods in the refrigerator that had been in there longer than 7 days and there were soiled areas in the kitchen. Findings include: 1. On 4/19/26 at 8:26 AM, an observation was made of the facility kitchen. The following was observed: a. There were 2 sanitizer buckets. Dietary Aide (DA) 1 stated she had changed the sanitizers 15 minutes prior. DA 1 was observed to use chlorine sanitizer testing strips. […]