Crestmoor Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

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.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

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.

Environmental Deficiencies

Keep all essential equipment working safely.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

A survey for Incident #39978 was conducted on 6/17/25. One deficiency was cited. Based on record review and interviews, the facility failed to investigate allegations of abuse for one (#1) of five residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to complete a thorough and timely investigation after Resident #1 made abuse allegations that staff and other residents were trying to harm her. Findings include: I. Facility policy and procedure The Abuse policy, revised 2/29/24, was received from the nursing home administrator (NHA) on 6/17/25 at 12:46 p.m. It documented in pertinent part, "The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. "In addition to an investigation by the police department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents or family members who may have knowledge of the incident."II. Allegation of abuse A. Facility investigation The 4/17/25 alleged physical or verbal abuse occurrence packet was provided by the NHA on 6/17/25. The packet revealed Resident #1 was interviewed on 4/17/25 and said her granddaughter hired a certified nurse aide (CNA) to try to kill her. Resident #1 stated she felt safe at the facility because she was at the NHA' s office all day yesterday (4/16/25) and she was feeling better. The packet documented that eight additional residents were interviewed on 4/18/25 wit..

All items were corrected during surveyExtension cords in use throughout facility (CDS),Heater in office area (CDS) ,Sprinkler head obstructed in boiler room (CDS), Power Tap multi plug in outlet (CDS), Laundry room doors propped open (CDS)Egress doors to the kitchen are blocked, propped open, and items blocking the door are also blocking a fire extinguisher (CDS), Electrical panel in the Kitchen is blocked (CDS) Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Missing updated generator fuel report NFPA 1108.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruc.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazardous areas in accordance with NFPA 101 1. Seal penetrations in boiler room ceiling 2 .Rooms 102/103 storage, the doors need closers 8.4.2 Continuity.Smoke partitions shall comply with the following:(1)They shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as t.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Excessive stationary items in the corridor NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.NFPA 101, 19.2.1 General. Every aisle, pass.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with NFPA 101 1.Delayed egress door for dumpster exit needs 15 sec signage 7.2.1.6.1.1(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to t.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with NFPA 1011.Break room door needs latch, penetrations filled and the door stop wedge removed.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be co.. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. 1.Dryers need documentation of high altitude orifice installation NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used fo.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 101 and NFPA 251.Loaded sprinkler heads throughout facility2.Penetration and miss aligned sprinkler head outside of kitchen waiver placed3.Sprinkler: No documentation for inspection of annual visual inspection of sprinklers throughout facility5.2.1.1* Sprinklers shall be i.. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.The facility was constructed in 1964 and is a single story Type V (000) construction with a partial basement used for support services only. The basement has an exterior exit to grade level. The ..

A recertification survey with #CO37704, #CO38121, #CO38970, Incident #35623, Incident #36550, Incident #37061, Incident #38629 and Incident #38901 was completed on 2/3/25 to 2/6/25. Eleven deficiencies were ci.. An Emergency Preparedness survey was conducted from 2/3/25 to 2/6/25. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for three (#15, #69 and #64) of six residents reviewed for .. Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts.Specifically, the facility failed .. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infe.. Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for four (#26, #31, #15 and #54) of nine residents reviewed for accident hazards out of 47 sam.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, activities room, and two of two nourishment refrigerators.Spec.. Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#52) of four residents review.. Based on observations, record review and interviews, the facility failed to ensure two (#77 and #69) of eight residents reviewed for abuse out of 47 sample residents were kept free from abuse.Specifically, the facility failed to:-Protect .. Based on observations, record review and interviews, the facility failed to ensure two (#184 and #75) of seven residents reviewed for pressure ulcers out of 47 sample residents received the necessary treatment and services acco.. Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and c.. Based on record review and interviews, the facility failed to ensure one (#24) of one resident out of 47 sample residents were provided prompt efforts by the facility to resolve a grievance.Specifically, the facility failed to provid.. III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 8/16/23. According to the February 2025 CPO, diagnoses included anoxic brain damage, memory deficit following cerebral infarction, vascular dementia,..