Crestwood Treatment Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF756Apr 13, 2023

  Based on interview and record review, the facility failed to ensure 56 of 56 sampled residents received a Medication Regimen Review (MRR, a pharmacist review of resident's medications to ensure safe and appropriate medications were prescribed by physician) for two months. This failure placed the facility's 56 residents at risk of side effects from psychoactive medications (medications used in the treatment psychiatric disorders and require monitoring for side effects), insulin (medication to treat high blood sugar and require monitoring to maintain normal blood sugar) and anti-coagulation medications (medications that prevent blood clots and require monitoring for excessive bleeding). […]

• No harm, potential for more than minimal, widespreadF880Apr 13, 2023

  Based on observation and record review, the facility infection prevention plan did not include a system or process to monitor for bacteria in the facility water system. The facility failed to develop or implement policies or procedures to ensure the facility water system was free of bacterial contamination including Legionella (the bacterium which flourishes in stagnant water and air conditioning and central heating systems and can cause disease). This failure had the potential to result in illness or death for residents exposed to contaminated water from ingestion or airborne exposure from ventilation systems. […]

• No harm, potential for more than minimal, patternF600May 22, 2026

  Based on observation, interview and record review, the facility failed to protect two of four sampled residents' (Resident 2 and 4) right to be free from physical abuse when:Resident 1 struck Resident 2 on the lip with closed fist in the television room.Resident 3 struck Resident 4 in the nasal area with closed hand in the television room.These failures resulted in Resident 2 sustaining skin tear to lower lip and Resident 4 abrasion on the bridge of nose. During a review of Resident 1's Annual Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 4/29/25, the MDS indicated Resident 1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Feb 27, 2025

  Based on observation, interview, and record review, the facility failed to follow proper food storage, sanitation, and food handling, when: 1. Kitchen pantry had two food items that were stored past their used-by dates; 2. Microwave was not cleaned routinely; 3. The lid of the ice machine was dirty; 4. Chopping boards had deep cuts and scratches. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 2/24/25, at 10:30 a.m., with Dietary Manager (DM), DM stated the kitchen pantry had food items that were stored past their used-by dates: - An unopened Sweet Pickle Relish gallon container with received date of 11/8/23 and used-by date of 11/8/24. […]

• No harm, potential for more than minimal, patternF814Feb 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure the garbage dumpster bin located outside the facility grounds had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest-related diseases for 58 residents out of a facility census of 58. Findings: During an observation on 2/24/25, at 9:00 a.m., outside the facility, there was a garbage dumpster bin located on the parking lot at the right side of the facility. The garbage bin had two panels of black-colored lids. The garbage dumpster bin had excess garbage inside which created gaps as both lids could not be closed. The gap between the lid and the bin on the left side was at least twelve inches. […]