Crestwood Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #85) reviewed for PASRR Level I screenings.The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #85. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included:Record review of Resident #85's face sheet, dated 01/05/2026, indicated she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including bipolar disorder, chronic kidney disease stage 4, and frontotemporal neurocognitive disorder. Record review of Resident #85's admission MDS assessment, dated 09/1520/25,…

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 laboratory services were obtained to meet the needs of 1 of 18 residents reviewed for laboratory services (Resident #9). The facility failed to obtain Resident #9's CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) every Monday for 4 weeks as ordered. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.Findings included: Record review of Resident #9's undated face sheet revealed he was an [AGE] year-old male that admitted on [DATE] with a readmit date of 12/3/25. Record review of Resident #9's physician's orders dated 1/7/26 indicated he had diagnoses that included: Dependence on Renal Dialysis (life-sustaining treatment for kidney failure that artificially filters waste products and excess fluid from the blood), End Stage Renal Disease (the kidneys can no longer filter waste and fluids effectively requiring dialysis or a kidney transplant for survival),…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control practices (Resident #60). The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care for Resident #60. She touched Resident 60's arm, gown, and leg with her dirty gloves. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #60's undated face sheet indicated she was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 1/7/26 indicated Resident #60 had diagnoses that included: Dementia (severe cognitive decline interfering with daily life),…

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 residents were informed orally, of their rights, for 6 of 6 residents interviewed during a group meeting (Resident #13, #14, #21, #32, #49 and #53). Residents #13, #14, #21, #32, #49 and #53 were not orally informed of their rights, during their stay in the facility. This failure placed the residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights. Findings included: During an interview on 10/15/2024 at 9:00 AM, Residents #13, #14, #21, #32, #49 and #53 said, the new AD has not reviewed resident rights with them or explained any resident rights to them, since she became the AD. During record review of resident council meeting minutes, for 10/09/2024, 09/03/2024, 08/02/2024, 07/02/2024, and 06/07/2024, revealed that resident rights were not reviewed over the past five months; October, September, August, July, and June 2024. During an interview on 10/16/2024 at 3:25 PM, the AD said she became the AD after receiving her certification in March 2024. She…

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 report to state agency emergency situations that pose a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected for 1 of 1 secured locked unit reviewed for physical environment. The facility failed to report to the State Survey Agency on 8/29/24 immediately but no later than 24 hours after becoming aware the facility's roof collapsed on the secured locked unit. This failure could place residents at risk of further potential abuse or neglect. Findings included: During observation of facility on 8/30/24 from 10:57am to 7:50pm a contract roofing company was working on the roof, the locked unit was taped off due to not in use because of the damages caused by the roof collapsing. All residents on 100 hall were relocated to the 200 hall and there was no visible bruising, skin tears or marks. Residents did not show signs of fear when interacting with staff. Record review of provider investigation report date 9/5/24 revealed: Date reported to HHSC - 8/3024…

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 an accurate MDS was completed for 12 of 18 residents (Resident #s 7, 9, 15, 18, 24, 32, 46, 49, 50, 51, 55, and 56) reviewed for MDS assessment accuracy. The facility did not accurately code Resident #s 7, 15, 32, 46, 49, 50, and 55's MDS for BIMS score (cognitive patterns), mood score, and daily routine and activity preferences. The facility did not accurately code Resident #s 9, 18, 24, 51, and 56's MDS assessment for BIMS score (cognitive patterns) and mood score. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #7's face sheet dated 08/23/2023 indicated Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, low back pain, high blood pressure, gastro-esophageal reflux disease (indigestion), fractures of first and fourth lumbar vertebrae, and muscle…

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 residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for resident (Resident #51) review for quality of life. The facility failed to provide Resident #51 with personal grooming for nail care These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Record review of Resident #51's admission record dated 11/2/2022 reflected Resident #51 was an [AGE] year-old male, diagnosis included full code with use of AED, Alzheimer's, unsteadiness on feet, history of falls, cognitive communication deficit, need for assistance with personal care, dysphagia, muscle weakness, attention deficit, dementia, anxiety disorder, repeated falls, hyperlipidemia (an excess of lipids or fats in your blood), migraine, hypertension,…

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 ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 2 residents (Resident #24 and #42) reviewed for oxygen therapy, in that: 1. The facility failed to ensure Resident #24's oxygen rate was set at 3-4 LPM (liters per minute) CONTINUOUS and not 2 LPM. 2. The facility failed to ensure monitoring of oxygen Saturation as ordered by the physician (maintain O2 saturation above 90%) 3. The facility failed to ensure there was an order for Resident #42 to receive oxygen. These failures could place residents who received oxygen therapy at risk for respiratory distress Record Review of Resident #24's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including emphysema,…

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.