Deficiency Records for Crestwood Rehabilitation and Nursing
Updated as of March 01, 2024
A list of the most recent deficiencies for Crestwood Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-26 | 2023-08-18 | Y |
| 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 | 2023-01-04 | 2023-03-03 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-04 | 2023-03-03 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-04 | 2023-03-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-04 | 2023-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-04 | 2023-03-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-04 | 2023-03-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-04 | 2023-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-04 | 2023-03-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-04 | 2023-03-03 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-04 | 2023-03-03 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-25 | 2022-06-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-25 | 2022-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-25 | 2022-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-25 | 2022-06-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-25 | 2022-06-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-25 | 2022-06-10 | 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 | 2022-04-25 | 2022-06-10 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-25 | 2022-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-25 | 2022-06-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-25 | 2022-06-10 | N |
| Report COVID19 data to residents and families. | Health | 2022-04-25 | 2022-06-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-25 | 2022-06-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-25 | 2022-06-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-25 | 2022-06-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-25 | 2022-06-10 | Y |
| 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 | 2022-04-25 | 2022-06-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-06-10 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-04-25 | 2022-06-10 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-04-19 | 2022-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-19 | 2022-05-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-19 | 2022-04-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-19 | 2022-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-01-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-05 | 2022-01-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-04 | 2021-10-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-08-04 | 2021-10-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-08-04 | 2021-10-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-08-04 | 2021-10-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-04 | 2021-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-10-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-04 | 2021-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Meet other general requirements. | Fire Safety | 2021-08-02 | 2021-08-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-08-02 | 2021-08-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-09 | 2019-07-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-09 | 2019-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-07-26 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-05-09 | 2019-07-26 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-05-09 | 2019-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-09 | 2019-07-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-09 | 2019-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-09 | 2019-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-09 | 2019-07-26 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-05-07 | 2019-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-07 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-07 | 2019-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-07 | 2019-05-13 | N |
