Thryve of Crestwood

In the surveyor’s words

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

• Immediate jeopardy, isolatedF698Jan 31, 2025

  Based on interview and record review, facility lacked an effective system to prevent fluid volume overload, assess and monitor fluid volume status, and notify the nephrologist of treatment refusals and abnormal radiology results for one (R8) out of three residents reviewed for dialysis in a total sample of ten. This failure resulted in staff failing to recognize R8's change in condition as fluid volume overload after R8 complained of shortness of breath, and R8 expired in the facility after being found unresponsive. The Immediate Jeopardy began on [DATE]. […]

• Immediate jeopardy, isolatedF600Jun 5, 2023

  Based on interview and record review, the facility failed to protect a resident from being sexually abused by another resident; the facility also failed to assess residents for abuse risk upon admission and failed to have effective interventions in place to keep residents free from abuse and/or abusing other residents. These failure applied to two (R1 and R2) of two residents reviewed for abuse and resulted in R1 being sexually assaulted by R2. R1 is not able to give consent for sexual activity due to cognitive impairment and was taken to local hospital and received prophylactic antibiotics. The Immediate Jeopardy began on 3/31/23 when R1 and R2 were found having non-consensual sex in R2's room. V1 (Administrator) was notified of the Immediate Jeopardy on 5/31/23 at 11:28 AM. […]

• Immediate jeopardy, isolatedF689Jun 5, 2023

  Based on interview and record review, the facility failed to have adequate supervision and effective interventions in place to monitor residents with impaired judgement/decision making skills, assessed as requiring staff supervision for all Activities of Daily Living (ADLs) and assessed to have wandering behaviors, who resided on the dementia/locked unit of the facility. These failures affected two (R1 and R2) of two residents reviewed for supervision and resulted in R1 having non-consensual sex with R2. The Immediate Jeopardy began on 3/31/23 when R1 and R2 were found having non-consensual sex in R2's room. V1 (Administrator) was notified of the Immediate Jeopardy on 5/31/23 at 11:28 AM. […]

• Actual harm, isolatedF600Aug 20, 2026

  Based on observation, interview and record review, the facility failed to ensure residents were free from physical and mental abuse. This failure affected two residents (R13 and R14) in a sample of three residents reviewed for abuse. This failure caused psychosocial harm to R14, as evidenced by R14 verbalizing feelings of emotional pain, and feelings of diminished self-worth; and caused psychosocial harm to R13 as evidenced by R13 verbalized feelings of fear. Applying a reasonable person concept due to the resident's cognitive impairment, a reasonable person would experience avoidable mood changes, agitation, anxiety, and being withdrawn/self-isolation.Findings include: On 8/18/2026 at 9:42 AM, V22 (Licensed Practical Nurse) affirmed V22 is assigned to care for R13 and R14. […]

• Actual harm, isolatedF677May 7, 2026

  Based on observation, interview, and record review the facility failed to follow policy procedures, failed to provide supervision/touching assistance for eating and/or failed to provide transfer assistance from the bed to wheelchair for four of 42 residents (R6, R14, R37, R131) in the sample reviewed for ADL (Activities of Daily Living) care. These failures resulted in R131's reported discomfort/feelings of uselessness and R37's reported frustration. Findings include: R6's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) of 15 indicating R6 is cognitively intact and indicates that R6 is dependent in chair or bed-to-chair transfers. […]