A list of the most recent deficiencies for Crestwood Terrace. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-19 | 2023-12-04 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-09-20 | 2023-09-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-20 | 2023-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-15 | 2023-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-15 | 2023-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-18 | 2023-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-01 | 2023-04-14 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-11 | 2023-03-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-27 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-11-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-10-27 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-26 | 2022-09-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-08-26 | 2022-09-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-26 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-26 | 2022-09-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-26 | 2022-09-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-26 | 2022-08-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-30 | 2022-07-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-30 | 2022-07-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-30 | 2022-07-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-06-30 | 2022-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-07-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-30 | 2022-07-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-08 | 2022-06-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-06-25 | Y |
| Keep all essential equipment working safely. | Health | 2022-06-08 | 2022-06-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-04 | 2022-01-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-04 | 2022-01-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-06 | 2021-10-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-06 | 2021-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-06 | 2021-10-29 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-06 | 2021-10-29 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-26 | 2021-09-24 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-08-26 | 2021-09-24 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-07-21 | 2021-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-07-21 | 2021-08-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-21 | 2021-08-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-21 | 2021-08-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-21 | 2021-08-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-21 | 2021-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-21 | 2021-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-21 | 2021-08-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-21 | 2021-08-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-21 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-21 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-21 | 2021-08-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-07-21 | 2021-08-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-09 | 2021-07-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-21 | 2021-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-21 | 2021-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-21 | 2021-07-06 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-03-15 | 2021-03-25 | Y |
