Crestwood Terrace

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 27, 2022

  Based on interview and record review, the facility failed to protect a resident's right from being sexually abused by other residents and failed to have interventions in place to prevent a resident from being manipulated/coerced into having sex with other residents. R1 remains at risk for sexual assault due to an inappropriate behavior of trading sexual activities for cigarettes and/or money. This failure affected one resident (R1) who was assessed as being at risk for abuse, and who was sexually assaulted by other residents (R2 and R3). R1 was found unresponsive in a bathroom located in the male residential area of the facility. R1 was transported to the hospital where she reported the sexual assault incident to hospital staff and the police. […]

• Immediate jeopardy, isolatedF689Oct 27, 2022

  Based on interview and record review, the facility failed to have an effective monitoring or supervision system in place for those resident identified as needing supervising, to alert staff when residents are engaging in appropriate sexual behavior to prevent possible sexual abuse.This failure affected three of four residents (R1, R2 and R3) reviewed for supervision. As a result, R1, R2, and R3 engaged in sexual favors for money and cigarettes, which lead to R1 being sexually assaulted by another resident (R2). Facility staff members were unable to identify when R1 entered R2's room, despite R1 being on hourly monitoring. […]

• Actual harm, isolatedF600Jul 25, 2026

  Based on interview and record review the facility failed to follow their abuse policy and failed to protect a resident during an incident of resident-to-resident physical abuse. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R1 physically assaulting R2 by punching R2 in the head and face and pulling R2's hair. R2 sustained a closed head injury, neck and back pain, facial scratches, and psychosocial harm, including expressing fear that R1 would kill her; R2. Due to the injuries sustained, R2 was transferred to the hospital for further evaluation and treatment.Findings include:R1's and R2's FRI (facility reported incident), dated 7/22/26, documents, in part, Residents (R1 and R2) were involved in an altercation. […]

• Actual harm, isolatedF600Dec 27, 2025

  Based on observation, interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R3) from both physical and sexual abuse by R2. This failure affected one (R3) of seven residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for abuse. These failures resulted in R3 being physically and sexually assaulted by R2 and R3 also suffering psychosocial harm stating feelings of fear and nightmares. Findings include:R3's face sheet documents diagnose that include but are not limited to major depressive disorder and suicidal ideations.R3's Final Report titled, Final Investigation of Allegation of Abuse, dated 12/24/2025, documents, in part, R3 reported that on 12/20/25 she (R3) went into the shower room after breakfast to take a shower. […]

• Actual harm, isolatedF684Jul 22, 2025

  Based on interview and record review, the facility failed to follow hospital orders for a fluid restriction after a resident (R1) was hospitalized for low sodium and failed to complete additional laboratory work for a resident's (R1) low sodium levels for one out of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 suffering a syncopal episode twice within four days and needing to be hospitalized each episode for low sodium and bradycardia. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, type 2 diabetes, schizoaffective disorder, bradycardia, and syncope/collapse.R1 no longer resides in the facility. A Nursing note dated 5/ 31/ 25 document R1 was found lying on the floor in R1's room. […]