Crestwood Ridge Skilled Nursing and Rehab

In the surveyor’s words

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

• Actual harm, isolatedF600Jan 16, 2025

  Based on record review, interview and policy review, the facility failed to ensure residents were free from abuse. This resulted in an Actual Harm when Resident #12 was assaulted by Resident #39 on 01/11/25. Resident #12 was punched in the face and was temporarily unconscious. Resident #12 was evaluated at the local hospital, diagnosed with mild closed head injury, lip abrasion, and cervical strain. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 47. Findings include: Review of the medical record for Resident #12 revealed an admitted on 03/22/24. […]

• No harm, potential for more than minimal, widespreadF803Dec 12, 2024

  Based on observation, review of dietary menus, and staff interview, the facility failed to serve all food items from the preplanned menu during meal service. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the dietary menu for week one, which contained the date of 12/11/24, revealed the meal was to include spaghetti sauce with meatballs, pasta, green beans, wheat bread, margarine, and cake. Observation on 12/11/24 at 11:32 P.M. revealed the cook was preparing the meals which included spaghetti sauce with meatballs, pasta, green beans, and cake. Further observation revealed the cook was not serving bread with the meals as indicated on the menu. Interview with Dietary Manager (DM) #167 on 12/11/24 at 2:07 P.M. […]

• No harm, potential for more than minimal, widespreadF868Dec 12, 2024

  Based on review of Quality Assurance and Performance Improvement (QAPI) staff sign-in sheets and staff interview, the facility failed to have QAPI meetings at least quarterly and failed to have all required members in attendance. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the QAPI meeting sign-in sheet dated 01/11/24 revealed the facility's administrator, owner, board member, or other individual in a leadership role was not in attendance for this meeting. Further review of the QAPI sign-in sheets revealed a meeting was held 03/12/24 and the next meeting was not held until 08/22/24. […]

• No harm, potential for more than minimal, widespreadF727Jul 6, 2023

  Based on document review, staff interview, and review of the facility policy, the facility failed to ensure a Registered Nurse (RN) worked in the facility for eight consecutive hours daily. This had the potential to affect all residents residing in the facility. The census was 42 residents. Findings include: Review of the staffing schedules revealed the facility did not have an RN working on 06/17/23, 06/18/23, and 07/01/23. Interview on 07/05/23 at 3:15 A.M. with the Director of Nursing (DON) confirmed the facility did not have a RN working on 06/17/23, 06/18/23, and 07/01/23. […]

• No harm, potential for more than minimal, patternF921Aug 15, 2023

  Based on observation and staff interview, the facility failed to ensure a safe environment when furniture obstructed the view of hallway's call lights and the handrails on both sides of the 100-unit hallway. This affected 24 residents, (#01, #02, #07, #08, #09, #10, #11, #12, #13, #14, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #35, #40, #41 and #45) for call light obstruction and five residents (#14, # 22, #24, #25, and #40) who required the use of the handrails. The total facility census was 45. Findings Include: Observation on 08/14/23 at 5:30 P.M. and on 08/15/23 at 8:12 A.M. to 4:00 P.M., revealed wardrobe furniture, measuring approximately three feet wide and seven feet tall, were on both sides of the resident occupied 100-unit hallway. […]