Crimson Heights Health & Wellness

In the surveyor’s words

From the most serious findings on record at Crimson Heights Health & Wellness, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jul 21, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for Resident #1. The facility failed to update Resident #1's care plan to reflect she was a two plus person physical assist that resulted in an improper transfer on 07/15/2025. This led to Resident #1's, left shoulder fracture. An immediate jeopardy (IJ) was identified on 07/20/2025. The IJ template was provided to the facility on [DATE] at 10:39 am by the Investigator. […]

• Immediate jeopardy, isolatedF689Jul 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and assistive devices to prevent accident for Resident #1. On 07/15/2025, CNA D transferred Resident #1 unassisted using a stand and pivot method instead of a mechanical lift (a device used to aid in the transfer and movement of individuals especially those with mobility limitation) device as required by her care plan dated 12/06/2024. During the transfer there was audible pop from Resident #1's left shoulder. Resident #1 had pain and sustained a fracture. An immediate jeopardy (IJ) was identified on 07/18/2025. The IJ template was provided to the facility on [DATE] at 05:34 pm. […]

• Immediate jeopardy, isolatedF689Apr 1, 2024

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Residents #1) reviewed for adequate supervision. The facility failed to provide Resident #1 with adequate supervision and monitoring related to his wandering behaviors which resulted in an elopement to an apartment complex by EMS. Resident #1 was absent from the facility for approximately 7 hours before he was noticed by staff that he was missing. This failure could affect residents who and place them at risk for physical harm and or pain. An Immediate Jeopardy (IJ) was identified on 3/28/2024. […]

• Actual harm, patternF563Aug 13, 2025

  Based on observation, interview and record review, it was determined the facility failed to have written policies and procedures regarding the visitation rights of residents, including those setting forth any safety restriction or limitation and the reason for the safety restriction or limitation for 1 of 23 residents (Resident #67) reviewed for resident rights. The facility failed to have written policies and procedures regarding visitation rights of residents when Resident #67's family member was no longer allowed to visit the facility after 1/27/25. This failure placed residents at risk of inaccurate or incomplete information, decreased emotional wellbeing and diminished quality of life. […]

• Actual harm, isolatedF677Jun 13, 2024

  47772 Based on observations, interviews, and record reviews, the facility failed to assist with activities of daily life, for 2 of 8 residents (Resident #50 and Resident #98) who was observed for assistance with ADLs. The facility failed to: - Provide supervision, or touching assistance, for Resident #98 during food service. - Answer Resident #50's call light for 50 minutes after repeated verbalizations/request for help as he was soiled with urine and bowel movement subsequently making him feel helpless and neglected. This failure placed residents at risk of poor nutrition, dehydration, skin breakdown, and unintended weight loss. […]