Crestwood Wellness and Recovery Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to protect the rights of one out of four sampled residents (Resident 1) to be free from physical abuse by Resident 2 when Resident 2 hit Resident 1 in the face. This resulted in Resident 1 sustaining bruising to the right side of the face that lasted for 15 days. Findings: A review of the facility's policy and procedure (P&P) titled, Crisis Intervention Program, updated 6/1/25, indicated, facility staff would recognize early warning signs of crisis (notice changes in behavior, mood, or thinking). The P&P indicated staff would provide early intervention (action and support provided to the resident from staff) when a resident exhibited an increase in behaviors (acting out). A review of the Certified Nurse Assistant [CNA] Job Description, updated 10/30/25, indicated, the CNA would report all changes, including agitation (feeling anxious, worked up, or irritable) to the Shift Coordinator (SC) immediately. A review of Resident 1's admission Record, dated…

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 observations, interviews, and record reviews, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH, state agency dedicated to protecting and improving the health of Californians), the police department, and to the local Ombudsman [a person who worked to maintain resident rights] for one out of two sampled residents (Resident 3) when Resident 3 made statements about being sexually abused. This had the potential to negatively impact health status and psychosocial well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Client Abuse Prevention, updated 10/14/24, indicated, Staff will immediately and directly report to the Administrator any suspicions of client abuse, either witnessed or suspected. The P&P indicated, Due to the complexity of the clients being served by this facility (i.e., the seriously mentally ill), all reports of abuse will be initially screened by the Administrator or designee for the possibility 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.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food product bags after opening the bags for use. The open, unlabeled, and undated product bags contained frozen soy chicken patties, frozen fried eggs, and frozen soy beef patties. This failure had the potential for the food products to be used for meals in an untimely manner leading to bacterial or fungal growth resulting in food borne illnesses amongst residents. Findings: During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2020, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . During a concurrent observation and interview on 6/1/25 at 2:30 pm, with Food Service Supervisor (FSS), in the kitchen at the second freezer, a package of frozen fried eggs, a package of frozen soy chicken patties, and a package of frozen soy beef patties were observed open and unlabeled. FSS confirmed the bags were…

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 interview, and record review, the facility failed to ensure that one of 25 sampled Residents (Resident 56) was protected from verbal and physical abuse when Resident 38 yelled at Resident 56 calling him names and hit Resident 56 with a closed fist to his head, then continued to chase Resident 56 down the hall until staff could intervene. This failure resulted in increased anxiety, and the potential to result in emotional stress, anger, depression, feelings of neglect, and the potential for negative clinical outcomes for Resident 56. Findings: A review of the facility's policy revised 10/2024, titled, Client Abuse Prevention, indicated this facility will take all appropriate preventative measures to ensure that clients are not at risk for abuse. All Clients will be afforded the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, and misappropriation of client property. During a review of Resident 38's medical record, the Admisison…

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 the safety and security for one of two clients (Client 1) when: 1. The facility security door locking system malfunctioned and Client 1 eloped from the facility. 2. The Temporary-Office Assistant (TOA) did not recognize Client 1 as a client, when she passed through the front lobby and eloped out the front doors. 3. Program Staff (PS, an employee that does activities with clients), saw Client 1 outside the facility and made no inquiries as to why Client 1 was outside. This disregard for client safety allowed Client 1 to go missing from the facility and her whereabouts were unknown for 8 hours, which put Client 1 at risk for injury and exposure to cold weather and had the potential to negatively impact on Client 1's health, safety, and welfare. Findings: A review of the facility's policy titled, AWOL (absent without leave) updated 9/23/24, indicated, If a client goes absent without leave (AWOL), the proper authorities will be…

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 interview and record review, the facility failed to ensure that two of 20 sampled residents (Residents 3 and 82) were protected from physical abuse when: 1. On 6/12/24, Resident 84 struck Resident 82 in the face. 2. On 5/22/24, Resident 84 placed their hands around Resident 3's throat. This failure resulted in bleeding injuries to Resident 82, and had the potential to threaten the physical, emotional and psychological health and well-being of both residents. Findings: A facility policy, titled, Client (resident) Abuse Prevention, updated 4/5/22, was reviewed. The policy indicated clients should not have been subjected to verbal or physical abuse of any kind and clients should not have disciplined other clients. During pre-admission screening, all clients would have been assessed for history of poor impulse control, combativeness and assault to self and others. The interdisciplinary team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) would have…

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 store food in accordance with professional standards when they failed to label and date food containers/ product bags of frozen breaded fish, frozen fried eggs, frozen hashbrowns, frozen frenchtoast, pepperoni, and peeled garlic cloves with open dates after the packages were open and the products being used for meals. This failure had the potential to allow food products to sit an inappropriate amount of time after the packaging was open with no dating label adehered leading to bacterial or fungal growth causing food borne illnesses amongst residents if the product was served for meals and not used by an appropriate date following guidelines. Findings: During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2020, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . During a concurrent observation and interview on 6/17/24 at 11:18 am with [NAME] in the kitchen, multiple packages were…

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 maintain medical records that were complete and accurate for two out of two sampled clients (Client 1 and Client 2) when there was not a process in place for updating and maintaining the Personal Property Inventory sheet (PPI, a document that described what personal items a client had at the facility). This failure had the potential to inaccurately capture client personal property which could cause frustration for clients. Findings: During a review of the facility's policy and procedure (P&P) titled, Medical Records, updated 10/13/03, indicated, Clients' health records are current and kept in detail consistent with good medical and professional practice During an interview on 9/8/23 at 10:46 am, Client 1 stated when he had been admitted to the facility, he had an Xbox (video game system) and two cell phones that had been listed on his PPI. Client 1 stated he had previously sold the Xbox and was upset because the PPI was inaccurate and indicated he had an Xbox when he did not. During a concurrent interview and…

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 interview and record review the facility did not report a Clients allegation of rape to the California Department of Health as required. By not reporting the allegation of rape the facility created the possibility for ongoing abuse of the Client potentially causing mental anguish and physical injuries leading to adverse clinical outcomes. Findings: On 4/5/22 at 10:45 AM Client 50's medical record was reviewed. Client 50 was admitted to the facility on [DATE] with diagnosis that includes Schizoaffective Disorder, Bipolar Type (mental illness). On 2/24/2022 Client 50 reported to her Conservator (RP) (person that makes medical decisions) that she had been violated. The medical record does not reflect the facilities required reporting to the California Department of Public Health (CDPH) was completed. On 4/5/22 at 02:30 PM during an interview with the Director of Nursing (DON) regarding the rape allegation the DON stated, We found out about it when the police showed up. She has reported rape in the past.…

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 that one of one sampled residents had complete admission orders when Resident 185 had a urinary catheter (a tube that drains urine from the bladder) and there were no Physician's Orders that included the use of a catheter. This had the potential for Resident 185 not to receive the necessary care he needed to prevent malfunctioning of the catheter and avoid bladder infections. Findings: Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included; disorganized schizophrenia (disorganized behavior and speech and a disturbance in emotional expression), severe chronic kidney disease (kidneys do not filter waste from the blood), a neurogenic bladder (inability to drain the bladder) and bladder cancer. His most recent Minimum Data Set (MDS a standardized assessment tool used by all skilled nursing facilities), dated 1/4/22, showed that he was alert and oriented and used a urinary catheter. On 4/5/22 at 9:30am,…

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 that 1 of 22 sampled residents had Baseline Care Plans developed within 48 hours after admission. (Resident 185) This failure to identify Resident 185's immediate basic health and safety needs had the potential to negatively impact his physical and psychosocial well-being. Findings: Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included; disorganized schizophrenia (disorganized behavior and speech and a disturbance in emotional expression), severe chronic kidney disease (kidneys do not filter waste from the blood), a neurogenic bladder (inability to drain the bladder) and bladder cancer. His most recent Minimum Data Set (MDS, a standardized assessment used by all skilled nursing facilities), dated 1/4/22, showed that he was alert and oriented, had a urinary catheter and was taking psychotropic (alters mood and behavior) medications. On 4/5/22 at 11am, during an observation and interview, Resident 185…

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 develop comprehensive care plans for 3 of 22 sampled residents (Residents 185, 75 and 81) when: 1. Resident 185 had one care plan developed for his isolation problem but no other problems were identified or care planned. 2. Resident 75 did not have a care plan developed for his need to be straight cathed (insertion of a tube in the bladder to remove urine intermittently as needed, instead of having a permanent catheter in the bladder). 3. Resident 81's care plans did not identify medications, symptoms to monitor or report, or any non-pharmacological interventions. These failures had the potential for these Resident's needs to go unrecognized and untreated and negatively impact their ability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: 1. Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included; disorganized schizophrenia (disorganized behavior and speech…

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 interview and record review, the facility failed to ensure a post fall injury, including a bump on the head, was monitored according to facility policy, and a fall assessment done, upon readmission, was completed accurately, for one of two residents (Resident 48), with a history of falls. This had the potential to result in a delay in the recognition of a worsening injury and result in more falls with major injuries. Findings: The facility's Fall Prevention & Management policy, dated 4/3/20, was reviewed. It indicated, Upon admission, each resident is assessed using a Fall Risk Assessment Tool to determine possible risk for sustaining a fall. The procedure for responding to a fall included, Resident is to be placed on observation of vital signs, pain and other post-fall complications. Fall details, assessment findings, interventions & notifications are to be documented in the resident's clinical record & care plan updated accordingly. Continued monitoring is necessary, as symptoms may present at any…

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 interview and record review: 1. The facility's pharmacy consultant failed to identify drug irregularities which included duplicate therapy (more than one medication for the same purpose without a clear distinction of when one medication should be given over another medication), for one of six sampled residents (Resident 48) whose records were reviewed for unnecessary drugs. Resident 48 had orders, for two as needed (prn) medications, used to treat anxiety or agitation, without any direction from the physician, as to which medication to use first or why both medications were needed, on a prn basis. This had the potential to result in Resident 48 receiving unnecessary drugs with potential adverse side effects. 2. The facility failed to ensure their pharmacy consultant provided documentation for each resident when the medication regimen review was done on a monthly basis. There was nothing in each resident's medical record to indicate that a medication regimen review was done, if there were no drug…

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.