Crestwood Treatment Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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]. MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 09 meaning impaired cognition. MDS indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. - An unopened Thousand Island Salad Dressing gallon container with received date of 9/4/24 and used-by date of 12/4/24. DM stated the food items should have been thrown out as they were past the used-by dates. During an interview on 2/27/25, at 10:50 a.m., DM stated food items past the used-by dates may have salmonella and cause food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The gap between the lid and the bin on right side was at least six inches. On the ground, to the left of the dumpster bin, were at least ten plastic bags of garbage. During a concurrent observation and interview on 2/24/25, at 10:00 a.m., with Maintenance Director (MD), MD stated the two black-colored lids of the garbage bin could not be closed because of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 25 sampled residents (Resident 1, Resident 3, and Resident 12) received proper care in a manner to prevent the spread of infection during meal assistance. These failures to perform hand hygiene after each contact with Resident 1, Resident 3, and Resident 12, had the potential to result in transmission of pathogens (bacteria, virus, or other microorganisms capable of causing infection or disease) from one resident to the next and cause infection or disease. Findings: A review of Resident 12's admission Record, printed 2/27/25, indicated resident was admitted in 2007 with multiple diagnoses of dementia (memory loss; a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury, and hemiplegia (muscle weakness on one side of the body) affecting right dominant side. A review of Resident 12's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 11/20/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure open date/ use-by date was added to the insulin pen (a device which contains long-acting insulin used to help manage blood sugar levels in residents with high blood sugar levels) after it was removed from the refrigerator for administration to one of 16 sampled residents (Resident 35). This failure placed Resident 35 at risk for receiving the insulin beyond the use by date with the potential to result in unsafe and ineffective administration of the medication. Findings: During a record review of Resident 35's Order Summary Report (OSR), dated 02/2025, the OSR indicated, Resident 35 had an order to administer Basaglar KwikPen Subcutaneous Solution Pen Injector 100 unit/mL [milliliter, unit of measure] every morning) since 12/3/24. During a concurrent observation and interview on 2/24/25, at 10:16 a.m., with Licensed Vocational Nurse 1 (LVN 1) and Director of Nursing (DON), Resident 35's Basaglar KwikPen Insulin pen 100 unit/1 mL was stored inside Resident 35's medication tray in the Medication Room at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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). Findings: A review of the facility document titled, MDS Resident Matrix, dated 4/10/23, indicated the facility had 54 residents on psychoactive medications, six residents on insulin, and three residents on anti-coagulation medications. During a concurrent interview and record review, on 4/12/23, at 10:53 a.m., with the Director of Nursing (DON), the facility MRR binder was reviewed. The DON stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Findings: During an interview on 04/13/23, at 10:58 AM, with the Director of Nurses (DON) and Administrator (Admin), the Admin stated questions about facility water testing to rule out Legionella bacteria should be directed to the Maintenance Director (Main-D). During an interview and concurrent record review on 04/13/23, at 11:30 AM, with Main-D, the facility's maintenance records were reviewed. Main-D was unable to provide documentation of a facility water management plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Kitchen Pantry had multiple food items that were stored past its used-by dates. 2. Reach-in Refrigerator 1 had four trays of prepared jelly in cups that were not labeled and dated. 3. Walk-in Refrigerator had: - two boxes of iceberg lettuce that were discolored, wilted, and did not have received-by or used-by dates. - half a bag of breadsticks was hard, dry, and without a date or label. 4. Microwave was not cleaned routinely. 5. Chest freezer had ice build-up around the wall and freezer rim and did not have a thermometer or a temperature log monitoring system. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 4/10/23, at 10:30 a.m., with the Dietary Manager (DM), DM stated the kitchen pantry had food items that were stored past its used-by dates: - A half-full clear bin of sugar with received date 12/8/21 and used-by date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for two of two sampled residents (Resident 52 and Resident 44) when Licensed Vocational Nurse 1 (LVN 1) did not complete the 72-hour Neurological Check (a simple assessment tool used to check a person's level of consciousness [LOC], pupil reaction, speech, hand grasp, movement, and vital signs) on 4/11/23. This failure had the potential to result in inaccurate assessments of Resident 52 and Resident 44 and delay in the provision of resident care needs. Findings: A review of Resident 52's admission Record, dated 4/11/23, indicated Resident 52 was admitted in May 2023, with diagnoses of dementia (memory loss) and Schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). A review of Resident 52's Change of Condition Notes, dated 4/9/23, indicated Resident 52 was a recipient of physical aggression and obtained an abrasion (scrape) on middle of forehead and swelling around the left eye. Recommendations include medical charting times (x) 72 hours, Neuro…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage when the following were noted: 1. Two dietary staff did not have their hair fully covered; 2. In refrigerator #2, a tray of raw eggs were placed on top of prepared snacks, and a container labeled menudo had an use-by-date of 6/8/19; and, 3. There were two packages of mousse mix and one packet of whipped topping with expiration dates of 12/2018 in the dried storage area of the kitchen. These deficient practices had the potential to cause food-borne illnesses to residents receiving their meals in the kitchen of facility. Findings: During a kitchen observation with the Food Service Director (FSD) and concurrent interviews on 6/10/19 at 8:18 a.m., the Dietary Aide (DA 1) was observed with braided hair hanging down her back with her hair net covering only the top of her head. The DA 1 stated her braids were just done yesterday and that she could not figure out how to cover her braids/hair with a hairnet. DA 1 then stated, It still hurts to gather my hair up together. By…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of three sampled residents (Resident 59), the facility failed to ensure Resident 59 received treatment and services when Resident 59's eyes developed thick, purulent, sticky yellow drainage without assessment and initiation of treatment. This failure resulted in the delay of treatment and had the potential to result in complications. Findings: Review of Resident 59's admission Record on 6/10/19 indicated Resident 59 was admitted to the facility on [DATE] with multiple diagnoses which included unspecified dementia with behavioral disturbances (a brain condition that affects memory and other brain functions) and seborrheic dermatitis ( a common skin condition affecting the scalp and resulting in dry, scaly skin). During an observation on 6/10/19 at 12:54 p.m., Resident 59's eyes had thick, purulent, sticky, yellow drainage. Additionally, by continued observation, both of Resident 59's eyes had a brown, dried, crusty substance around them. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.