Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thryve Of Crestwood during CMS and state inspections, most recent first.
Infection control failures involved a resident on contact precautions for C. diff and another resident who should have been on EBP for a G-tube and wounds. An RN entered the C. diff resident’s room without gown, gloves, or hand hygiene, then continued medication pass without hand hygiene. Housekeeping used non-sporicidal products for C. diff rooms, no C. diff-killing cleaner was initially identified, and soiled linen was found unsecured in the laundry chute and receiving bin. A second resident had no precaution sign or PPE setup despite an EBP order.
A cognitively impaired, non-ambulatory resident who required a mechanical lift for transfers was found on a floor mat after an unwitnessed fall and complained of right hip pain. An LPN assessed the resident, administered pain medication, and obtained a provider order for a STAT right hip X-ray expected to be completed and resulted within several hours, but the X-ray was never performed. The following day, the resident continued to exhibit pain, including facial grimacing and guarding of the right leg, and another LPN arranged transfer to the hospital due to unresolved right leg pain and the uncompleted STAT X-ray. At the emergency room, imaging showed a displaced comminuted intertrochanteric right femoral fracture, and the report notes that a reasonable person in this situation would have experienced psychosocial harm related to pain.
Multiple rooms and the dialysis area were recorded at temperatures above 81°F, with several residents reporting discomfort and using fans or makeshift methods to cool themselves. Staff confirmed that AC units were not functioning for several days, and temperature checks were not conducted overnight. Dialysis staff noted increased resident fatigue and fluctuating vital signs during treatments in the overheated room. Most residents were not proactively offered fans, and some were unaware they were available.
A resident with multiple health conditions, including neurogenic bladder and a sacral pressure ulcer, experienced four recurrent UTIs while having an indwelling urinary catheter. Despite ongoing complaints of discomfort and repeated infections, staff did not timely assess or consider removal of the catheter, and there was no documented outreach to the physician for reassessment. Facility policy requiring ongoing review and adjustment of care for residents with catheters and recurrent infections was not followed.
A resident with multiple complex medical conditions was admitted without a completed admission assessment, baseline care plan, or reconciliation of medications. Nursing staff did not administer medications or initiate G-tube feeding due to missing information and lack of follow-up with available resources, resulting in the resident not receiving necessary care until a code blue was called.
A facility failed to notify the attending physician about delays in urgent lab tests for a resident, resulting in a nine-hour delay. The resident, who had decreased food and fluid intake, was later hospitalized with dehydration, pneumonia, and a UTI. Incomplete documentation and lack of timely communication with the primary NP and physician contributed to the resident's deteriorating condition.
A resident with complex medical conditions, including end-stage renal disease, refused dialysis and was not properly monitored for fluid overload. The facility failed to notify the nephrologist of the refusal and abnormal X-ray results. The resident complained of shortness of breath and was later found unresponsive, leading to their death. Staff communication and adherence to policies were inadequate.
The facility failed to maintain adequate hot water temperatures in all shower rooms, affecting residents' ability to shower. The issue began when the Maintenance Director noticed dropping water temperatures, and a plumbing contractor was called. Despite efforts, the problem persisted, and residents had to use wipes or microwaved water for hygiene. Residents were not informed about repair progress, and documentation revealed inconsistencies in recording water temperatures. The deficiency highlights the facility's failure to provide a safe and comfortable environment.
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in shower rooms on multiple floors. The issue was identified on January 3rd, but delays in communication and approval processes, along with inadequate documentation and maintenance, prolonged the deficiency. A resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration was affected.
A resident with a history of dialysis and low potassium levels experienced an acute change in condition, including lethargy and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially stabilized the resident with oxygen, but the condition worsened, leading to a diagnosis of severe sepsis upon hospital admission. The delay in response and transport contributed to the deficiency identified in the facility's care.
Two residents were involved in a physical altercation in an elevator, where one resident, diagnosed with schizophrenia, struck another resident with a cell phone, causing injury. The incident occurred when the second resident attempted to enter the elevator, leading to a confrontation. Staff intervened, but the facility failed to prevent the abuse, resulting in physical harm.
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. A resident with severely impaired cognitive skills was assaulted by another resident, causing significant injuries. Staff failed to adhere to protocols requiring constant supervision and immediate reporting of abuse incidents.
A facility failed to supervise a resident with physical aggression and dementia, leading to the resident assaulting a peer. The injured resident sustained severe injuries, including multiple lacerations and a nasal bone fracture, requiring hospital treatment. The incident occurred in a locked unit left unattended by staff despite clear signage requiring constant supervision.
A resident developed an unstageable, necrotic pressure ulcer due to the facility's failure to identify, assess, and treat a change in skin condition. Despite being at risk for pressure ulcers, the resident's sacral wound was not addressed until it showed signs of infection, leading to hospitalization. Staff interviews highlighted the importance of early identification and documentation of skin changes to prevent such deterioration.
Two residents experienced verbal abuse from a CNA who used profanity and loud behavior during an interaction. Both residents, who have no cognitive impairments, confirmed the incident. The facility's investigation corroborated the residents' accounts, and the CNA admitted to the inappropriate conduct.
A resident's medications, specifically Adderall XR and Adderall, were not administered as ordered due to availability issues and documentation gaps. The resident was discharged to the hospital multiple times, and the nurse indicated that the facility's locked medication dispensing system required supervisor access, which hindered timely administration. The facility's policy for handling unavailable medications was not effectively followed.
Infection Control Failures With PPE, Cleaning, Linen Handling, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow infection prevention and control policies and procedures for residents on transmission-based precautions and enhanced barrier precautions. One resident admitted with diagnoses including gastrointestinal hemorrhage, ulcerative colitis, colostomy, and enterocolitis due to C. diff had a BIMS score of 6 and was documented as continuing on oral vancomycin for C. diff. The resident was observed on contact precautions with signage on the room door for both contact precautions and enhanced barrier precautions related to a Foley catheter. A unit manager stated the double signage could be confusing. A registered nurse was observed entering the resident’s room, pushing the medication cart to the door, not performing hand hygiene, assembling medications, entering the room without gown or gloves, administering medication, exiting without hand hygiene, and then proceeding to the next room and assembling medications without hand hygiene. The nurse stated that PPE should have been used. The resident’s room was also discussed with housekeeping staff, who stated that the room was cleaned with Neutral Cleaner 15 and Hospital Use Disinfectant-Cleaner 11, the same products used for all rooms, including rooms for residents with C. diff. The disinfectant label reviewed did not list C. diff, and a sales representative stated the product could not claim to kill C. diff because it had not been tested for that organism. Housekeeping staff also described an automated mixing system for cleaning solutions, and no sporicidal solutions were initially identified in the housekeeping closet during observation. Later, a micro-kill bleach product was mentioned by the housekeeping/laundry manager, but the housekeeper stated he had never seen those bottles and did not have them on his cart. In the laundry room, surveyors observed two opened bags of soiled linen in the laundry chute and one soiled blanket with a yellow stain in the dirty laundry receiving bin not placed in a plastic bag. The housekeeping/laundry manager stated the opened bags should have been tied shut to prevent spreading germs. Another resident with a G-tube, PICC line, active bacteremia treated with IV cefazolin, pressure ulcers, and an order for enhanced barrier precautions due to wounds and a G-tube was observed without any precaution sign or PPE setup at the room, and the infection prevention nurse stated the resident should have been on enhanced barrier precautions.
Failure to Carry Out STAT Hip X-Ray Order After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s STAT order for a right hip X-ray after an unwitnessed fall involving a cognitively impaired, non-ambulatory male resident who required a mechanical lift for transfers and was dependent for all ADLs. Following the fall, the resident was found on a floor mat next to a low bed by a CNA, who summoned the nurse. The LPN in charge performed a head-to-toe assessment, during which the resident complained of right hip pain. The LPN medicated the resident for pain and obtained a provider order for a STAT right hip X-ray, with an expectation that results would be available within 4–6 hours. The resident’s record later documented ongoing right hip pain, facial grimacing, and guarding of the right leg the following morning. Despite the STAT order and the provider’s and DON’s stated expectations that such X-rays be completed and resulted within hours, the ordered X-ray was never performed. The LPN who later transferred the resident to the hospital reported that the transfer occurred because the resident continued to complain of right leg pain and the previously ordered STAT X-ray had not been done. The resident was ultimately sent to a local emergency room approximately eighteen hours after the unwitnessed fall, where imaging revealed a superior laterally displaced comminuted intertrochanteric right femoral fracture. The report states that a reasonable person in the resident’s position would have experienced psychosocial harm related to pain, including facial grimacing and guarding of the right leg, as a result of the failure to carry out the STAT X-ray order.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures for residents, with multiple resident rooms and the dialysis room recorded at temperatures ranging from 82 to 85 degrees Fahrenheit, exceeding the recommended maximum of 81 degrees. Observations revealed that residents expressed discomfort due to the heat, with some using fans or fanning themselves with paper, and others requesting additional fans. Staff interviews confirmed that the air conditioning units were not functioning properly, and parts had to be ordered and replaced, resulting in several days of elevated indoor temperatures. The maintenance director reported that temperature checks were conducted hourly during the day but not overnight, and that fans were provided only upon request. Some residents were unaware that fans were available. Dialysis staff reported that residents undergoing treatment in the dialysis room, which was also affected by the heat, appeared more fatigued and had more fluctuating vital signs than usual. Staff provided cold water, popsicles, and monitored for signs of heat-related illness, but did not check on residents during dialysis sessions. The facility's temperature logs confirmed that room temperatures remained above 81 degrees for extended periods. The deficiency affected 53 out of 54 sampled residents, with both residents and staff acknowledging the uncomfortable and potentially unsafe conditions caused by the inadequate temperature control.
Failure to Prevent Recurrent UTIs and Timely Reassess Catheter Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident, who had multiple diagnoses including neurogenic bladder, sacral pressure ulcer, and chronic kidney disease, was admitted with a urinary catheter and experienced ongoing discomfort and recurrent UTIs. Despite repeated complaints of pain and discomfort related to the catheter, as well as multiple documented UTIs treated with antibiotics, there was no timely or appropriate assessment for the removal of the catheter. Observations and interviews revealed that the resident repeatedly expressed discomfort and requested removal of the catheter, but staff did not act on these requests until much later. The infectious disease nurse practitioner and infection prevention nurse both indicated that there was no documented outreach to the physician to consider discontinuing the catheter, and the attending physician confirmed that there had not been any prior attempt to reassess or remove the catheter before it was eventually dislodged and removed. The resident had been treated for UTIs on several occasions, with the same bacteria recurring, and the infectious disease nurse practitioner noted that improper cleaning and contamination from a sacral wound may have contributed to the infections. Facility policies required ongoing assessment and review of residents with indwelling catheters, especially in cases of recurrent infection, but these procedures were not followed. The lack of timely reassessment and failure to consider catheter removal contributed to the resident experiencing four UTIs during her stay, with ongoing discomfort and repeated antibiotic use.
Failure to Provide Necessary Services Upon Admission
Penalty
Summary
The facility failed to provide necessary services upon admission for a resident with multiple complex medical diagnoses, including diabetes, hypertension, chronic kidney disease, and obesity. Upon admission, there was no face sheet, initial admission assessment, or baseline care plan in the resident's medical record. Nursing staff documented that the resident was non-verbal, responsive only to painful stimuli, and on 7 liters of oxygen via trach collar. Although a head-to-toe assessment and vital signs were recorded, there was no documentation of height, weight, or blood sugar. The nurse who received the resident did not reconcile medications or obtain any orders, and the subsequent nurse did not administer any medications or initiate G-tube feeding, citing lack of information and inability to reach the physician for orders. Multiple staff interviews revealed that the feeding rate for the G-tube was not obtained from the hospital report, and the nurse did not connect the feeding or administer medications, waiting for a physician's response. The nurse did not seek assistance from the supervisor, and the supervisor was unaware that the resident had not received medications or feeding. The DON stated that urgent medications could be accessed from the facility's medication system and that the feeding rate was present in the admission papers. The nurse practitioner confirmed that alternative contacts and the dietician should have been involved if the physician was unavailable. The resident did not receive necessary medications or nutrition from admission until a code blue was called later that evening.
Failure to Timely Notify Physician of Urgent Lab Delays
Penalty
Summary
The facility failed to adhere to its policy for notifying the attending physician or nurse practitioner about urgent laboratory tests not being completed within the required 4-6 hour timeframe. This oversight affected a resident who was subsequently sent to the hospital and diagnosed with dehydration, pneumonia, and a urinary tract infection. The delay in obtaining laboratory results was over nine hours, which contributed to the resident's deteriorating condition. Interviews and record reviews revealed that the resident had a history of decreased food and fluid intake, which was documented by the certified nurse aide. The resident's condition worsened, showing signs of weakness, fatigue, and dehydration. Despite the urgent need for laboratory tests, there was a lack of timely communication with the primary nurse practitioner and physician, which hindered the management of the resident's care. The facility's documentation was incomplete, with missing records of the resident's fluid intake and bladder continence episodes. The resident's medical records did not show any urinalysis conducted before hospitalization, and the medication administration record lacked documentation of an administered inhaler. These documentation gaps, along with the delay in laboratory testing, contributed to the resident's hospitalization for dehydration, pneumonia, and a urinary tract infection.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, resulting in a critical incident. The resident, who had a complex medical history including chronic respiratory failure, morbid obesity, congestive heart failure, and end-stage renal disease, refused dialysis treatment and was not adequately monitored for fluid volume overload. Despite the resident's refusal to go to the hospital as ordered by the nephrologist, the facility staff did not notify the nephrologist of the refusal or the abnormal chest X-ray results, which showed signs of fluid overload. The resident complained of shortness of breath and requested to go to the hospital, but the facility staff only provided education on breathing techniques and did not perform a thorough assessment or take further vital signs. The resident was found unresponsive later that day and expired in the facility. Interviews with staff revealed a lack of communication and follow-up on the resident's condition, with several staff members unaware of the resident's complaints or the significance of the missed dialysis treatments. The facility's policies on refusal of treatment and notification of change were not followed, as the attending physician and nephrologist were not properly informed of the resident's condition and refusal of care. The facility also failed to ensure timely completion and review of the STAT chest X-ray, which was not performed within the expected timeframe, and the results were not communicated to the physician in a timely manner. This series of inactions and communication failures contributed to the resident's deterioration and eventual death.
Removal Plan
- All current dialysis residents were assessed for potential fluid overload, intervention in place as appropriate.
- Licensed nurses were educated by the Director of Nursing on the need to assess and implement interventions related to fluid volume overload when residents miss dialysis treatments.
- Dialysis assessment orders were updated per their physician. Their assessment order reads: Monitor for signs and symptoms of fluid volume overload, edema, bloating, headache, weight gain, shortness of breath, elevated blood pressure, JVD, lung sounds with crackles or wheezing, abdominal distention, or tachycardia. This assessment will be completed every shift and PRN.
- Licensed nurses were educated by the Director of Nursing on the importance of notifying the Attending physician and if unable to reach him/her notifying the resident's Nephrologist.
- Licensed nurses were educated by the Director of Nursing if STAT radiology orders are not able to be completed within the recommended timeframe the provider will be notified for additional instructions.
- Licensed Nurses will not work until they have been educated.
- Radiology company (All-Stat) has been notified of the expectation of timely notification of abnormal radiology results.
- Licensed nurses were educated to review their electronic health records to check and communicate the results of the radiology report.
- An additional email notification system has been implemented with the radiology company. This ensures all nursing managers receive results as they are uploaded into the electronic health record.
- All nursing managers were educated on the additional notification system.
- The Director of Nursing will audit all residents who refused dialysis to ensure they have been assessed, appropriate interventions are implemented, and that the physician was made aware.
- The Director of Nursing will complete audits to ensure any STAT radiology orders were completed within the recommended timeframe, and if the physician was notified.
Facility Fails to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain adequate hot water temperatures in all six shower rooms, affecting five residents. The issue began when the Maintenance Director noticed dropping water temperatures on January 3rd, 2025, and a plumbing contractor was called immediately. Despite the contractor's efforts, the problem persisted, and residents were unable to take showers due to the cold water. The Maintenance Director reported that the water temperatures were below the desired range of 100-110 degrees Fahrenheit, and staff were instructed not to use the showers until further notice. Residents expressed dissatisfaction with the situation, as they were unable to take showers and had to resort to using wipes or microwaved warm water for personal hygiene. Several residents reported not being informed about the progress of the repairs or when the hot water would be restored. The Assistant Administrator was notified of the issue on January 4th, 2025, and the Site Manager was informed on January 6th, 2025. The plumbing company identified a malfunctioning heat exchanger as the cause of the problem, and a new part was ordered, but the repairs were delayed due to approval and cost issues. The facility's documentation revealed inconsistencies in recording water temperatures, with no records of the temperatures during the period when they were below the acceptable range. The Loss of Hot Water Guideline outlined procedures for managing such situations, but there was a lack of communication and timely action to resolve the issue. The deficiency highlights the facility's failure to provide a safe and comfortable environment for residents, as required by regulations.
Failure to Maintain Hot Water System
Penalty
Summary
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in the shower rooms on the second, third, and fourth floors. The issue was first noticed by the Maintenance Director on January 3rd, when the water temperatures began to drop. A plumbing contractor was called immediately, and it was identified that the heat exchanger was malfunctioning. Despite efforts to address the issue, including cleaning the heat exchanger and replacing copper piping, the water temperatures remained below the required range for several days. The Assistant Administrator was informed of the hot water issue on January 4th, and the Site Manager was notified on January 6th. However, there was a delay in communication and approval processes, which contributed to the prolonged period of inadequate water temperatures. The Site Manager expressed concern about not being informed sooner and emphasized the need for timely communication to approve necessary repairs. The plumbing company was unable to complete the repairs promptly due to the facility's not-to-exceed limit on service costs, which required further approval. Throughout this period, water temperatures were inconsistently documented, and the Maintenance Director was unable to provide maintenance logs for the water heater system. The lack of scheduled maintenance and documentation, combined with delayed communication and approval processes, led to the deficiency in maintaining adequate hot water temperatures for the residents, including a resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration.
Delayed Transport of Resident with Acute Medical Condition
Penalty
Summary
The facility failed to immediately transport a resident experiencing an acute change in medical condition, which was identified during a review of the resident's care. The resident, who had a history of dialysis and was noted to have low potassium levels, exhibited symptoms of lethargy, shortness of breath, and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially assessed the resident and applied oxygen, which temporarily stabilized the resident's condition, but the resident's oxygen levels later deteriorated. The nurse practitioner was not initially aware of the resident's critically low potassium levels from previous laboratory results. On the day of the incident, the resident's condition worsened, with symptoms including hypoxia and tachycardia. The nurse practitioner ordered urgent laboratory tests and administered antibiotics intramuscularly. However, the resident's oxygen saturation continued to decline, necessitating the use of a non-rebreather mask and eventually leading to the decision to transport the resident to the hospital. The documentation revealed that there was a lack of timely communication and action regarding the resident's abnormal laboratory results and acute symptoms. The resident was eventually transported to the hospital with a diagnosis of severe sepsis, but there was a significant delay from the time the resident's condition was identified as critical to the time of transport. This delay in response and transport contributed to the deficiency identified in the facility's care of the resident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse involving two residents. Resident R4, diagnosed with schizophrenia and peripheral vascular disease, displayed erratic behavior by striking Resident R5, who has a diagnosis of malignant neoplasm of the lung, chronic obstructive pulmonary disease, and Parkinsonism. The altercation occurred when R5 attempted to enter an elevator already occupied by R4, leading to R4 striking R5 in the face and hand with a cell phone, causing a laceration and pain. The incident was documented in nursing notes, a police report, and a facility incident report. Staff interviews revealed that R5 asked R4 to move forward to make room for both wheelchairs on the elevator. When R5's wheelchair accidentally bumped R4's, R4 became physically aggressive, hitting R5 with a closed fist and a cell phone. Staff intervened to separate the residents, and R5 sustained a scratch on the face and pain in the finger. The facility's care plans and assessments for both residents indicated that R4 was at risk for inappropriate responses due to schizophrenia, and R5 was at risk for abuse due to residing in a skilled facility. Despite these assessments, the facility's failure to prevent the altercation resulted in physical harm to R5, which was classified as physical abuse according to the facility's abuse prevention policy.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. Resident R4 entered R1's room and physically assaulted R1, causing significant injuries including multiple lacerations, swelling, and a nasal bone fracture. R1, who has severely impaired cognitive decision-making skills, was transported to the hospital for treatment. The incident occurred despite signage in the men's village indicating that staff must be present at all times, and staff failed to adhere to this requirement. On the day of the incident, V4 CNA was working in the men's village and encountered combative behavior from R4. V4 attempted to redirect R4 but eventually left the men's village unattended to seek assistance from V3 LPN, who did not immediately respond. During this time, R4 entered R1's room and assaulted him. V4 and V3 only responded after hearing screams from the men's village, by which time R1 had already sustained injuries. V4 was unaware of the requirement to report the incident to the abuse coordinator. The facility's abuse prevention policy mandates staff training on assessing, preventing, and managing aggressive residents, and requires immediate reporting of any abuse incidents. However, the staff failed to follow these protocols. Additionally, R4's care plans related to his psychiatric diagnoses were not documented until after the incident, despite his history of visual delusions and hallucinations. This lack of adherence to the facility's policies and procedures contributed to the failure to prevent the assault on R1.
Failure to Supervise Aggressive Resident Results in Severe Injury
Penalty
Summary
The facility failed to effectively supervise and monitor a resident with a diagnosis of physical aggression and dementia, resulting in the resident physically assaulting a peer. This incident affected two residents, with one resident sustaining severe injuries including multiple lacerations, a swollen eye, ear redness and swelling, and a nasal bone fracture. The injured resident required hospital treatment and sutures to repair facial lacerations. The incident occurred in a locked unit known as the men's village, which was left unattended by staff for a period of time despite clear signage indicating that staff must be present at all times. On the morning of the incident, a CNA reported that a resident was being combative and attempted to redirect him. The CNA left the unit to get supplies, leaving the residents unattended. The CNA informed an LPN at the nurses' station about the combative resident, but the LPN did not immediately respond. Approximately ten minutes later, the CNA and LPN heard screaming and found the injured resident bleeding in his room. The injured resident and his roommate both reported that the aggressive resident had attacked him. The facility's Director of Nursing and Administrator were unaware that the men's village had been left unattended until after the incident occurred. The aggressive resident had a history of physical aggression and hallucinations, and his care plan included interventions to report all instances of alleged abuse. However, these measures were not effectively implemented, leading to the severe injury of a resident.
Failure to Identify and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to identify, assess, and treat a change in skin condition for a resident, leading to the development of an unstageable, necrotic pressure ulcer. The resident, who was dependent on staff for toileting hygiene and required maximal assistance for movement, was admitted to the facility without any pressure ulcers. However, the resident was at risk for developing pressure ulcers as indicated by a Braden skin risk assessment. Despite this, the resident developed an unstageable pressure ulcer on the sacrum, which was first identified by the wound physician on November 22, 2023. The wound was initially documented as having moderate exudate, 20% slough, and 80% eschar, with no signs of infection. However, by December 6, 2023, the wound had declined, showing 100% eschar and signs of infection, including odor, necessitating hospitalization for further evaluation and treatment. Interviews with facility staff revealed that the certified nursing assistants (CNAs) are expected to report any skin changes to the floor nurse, who would then assess the resident's skin and notify the wound care nurses. However, the wound care nurse/coordinator acknowledged that the wound should have been identified before becoming necrotic. The wound care physician confirmed that the worsening of the sacral wound, with 100% eschar and possible infection, required surgical debridement and further evaluation. The registered nurse and CNA emphasized the importance of early identification and documentation of skin changes to prevent the progression to pressure ulcers. The failure to identify and address the skin condition in a timely manner resulted in the resident's wound deteriorating and requiring hospitalization.
Verbal Abuse Incident Involving Two Residents
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a staff member. On a specific date, a resident reported that a CNA entered their room and used profanity when the resident requested a specific size diaper. The resident's roommate confirmed the incident, stating that the CNA responded aggressively when asked to stop. Both residents involved were assessed to have no cognitive impairments, indicating they were aware of the situation and its impact. The facility conducted an investigation following the incident, which confirmed the CNA's use of profanity and loud behavior. The CNA admitted to using inappropriate language and acknowledged being too loud. The facility's abuse prevention policy defines verbal abuse as the use of disparaging and derogatory language, which aligns with the behavior exhibited by the CNA. The investigation was documented, and the CNA was no longer employed at the facility following the incident.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, specifically concerning the administration of Adderall XR and Adderall. The Medication Administration Record for the resident showed multiple instances where the medication was ordered and then discontinued within a short period. The resident was discharged to the hospital on three separate occasions during this time frame. On two occasions, the medication administration was marked with a '9', indicating a need to refer to the nurse's notes. However, there was no corresponding nurse's note for one of these instances, leaving a gap in documentation. The nurse involved, identified as V6, stated that if a medication is not available, they follow up with the pharmacy. The facility has a locked medication dispensing system, but the nurse indicated they were unable to access it without a supervisor. The resident had complained about not receiving their Adderall, but the nurse explained that if the medication was not available, it could not be administered. The facility's Medication Administration Policy outlines steps to be taken if a medication cannot be located, including contacting the pharmacy or using the night box/emergency kit, but it appears these steps were not effectively followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crestwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Crestwood | 1.1 mi | ★★★★★ | 5 | 0 |
| Crestwood Terrace | 1.7 mi | ★★★★★ | 2 | 0 |
| Elevate Care Palos Heights | 2.2 mi | ★★★★★ | 3 | 0 |
| Aperion Care Midlothian | 2.8 mi | ★★★★★ | 3 | 0 |
| Belhaven Nursing & Rehab Center | 3.7 mi | ★★★★★ | 33 | 0 |
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