Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, review of a self-reported incident, staff interview, and policy review, the
facility failed to ensure residents were free from improper physician restraints. This affected one (#85) of
three residents reviewed for restraints. The facility census was 104.
Residents Affected - Few
Findings include:
Review of Resident #85's medical record revealed admission to the facility occurred on 01/05/24 with
medical diagnosis including subdural hematoma, alcohol abuse, stroke, seizures, and dementia.
Review of a self-reported incident (SRI) dated 03/09/24 at 11:44 A.M. identified Licensed Practical Nurse
(LPN) #214 observed LPN #220 place Resident #85 in a Broda chair (a type of chair use to help
positioning) at the nurses' station with a gait belt strapped around her waistline. The investigation identified
LPN #214 called the Director of Nursing (DON) to report the concern. The report identified the DON told
LPN #214 to send LPN #220 home, remove Resident #85 from the Broda chair, and take the gait belt off.
Interview with LPN #214 was completed on 04/02/24 at 7:39 A.M. The interview confirmed she witnessed
LPN #220 put Resident #85 in a Broda chair and secure her in the chair with a gait belt. The interview
confirmed Resident #85 was not in the chair for more than 10 to 20 minutes and she called the DON
because there was no physician orders for restraining Resident #85.
Interview with State Tested Nurse Aide (STNA) #225 occurred on 03/09/14 at 12:14 P.M. and confirmed she
was working in the facility on 03/09/24 when the incident occurred with Resident #85. The interview
confirmed LPN #220 told STNA #230 to take Resident #85 out in a Broda chair and strap her in the chair
with a gait belt. STNA #225 was asked to get the type of gait belt that was used to strap the resident into
the chair. STNA #225 obtained a belt that had a click closed secured latch. STNA #225 confirmed the gait
belt was around Resident #85 waist and around the chair so the resident could not stand up.
Interview with LPN #220 occurred on 04/02/24 at 2:28 P.M. and confirmed Resident #85 was crawling on
the floor and she was concerned the resident was going to hurt herself. LPN #220 confirmed she told
STNA #230 to put Resident #85 in a Broda chair and she had a gait belt, and confirmed she did not even
think about the gait belt being a physical restraint. LPN #220 confirmed Resident #85 was in the Broda
chair with the gait belt around her at the nurses' station so she could keep the resident safe.
Review of the undated facility policy for physical restraints revealed the definition referred to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365284
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Level of Harm - Minimal harm
or potential for actual harm
any manual method or physical or mechanical device, material, or equipment attached or adjacent to the
resident's body that the individual cannot remove easily which restricts freedom of movement or normal
access to one's body. Physical restraints may include, but are not limited to using devices in conjunction
with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the
resident from rising.
Residents Affected - Few
This deficiency represents non-compliance investigated under Master Complaint Number OH00151966.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation, staff interview, and policy review, the facility failed to maintain daily posted nurse
staffing data as required. This had the potential to affect all 104 residents residing in the facility. The facility
census was 104.
Residents Affected - Many
Findings include:
Observation of the front door of the facility on 04/02/24 at 1:15 P.M. revealed a message board with the
daily posted nurse staffing data dated 04/01/24 and 04/02/24.
During an interview with the Director of Nursing (DON) on 04/02/24 at 1:39 P.M. a request was made to
review the last two weeks of the facility's daily nurse staffing posting. The DON confirmed the facility had
been throwing away the daily posted nurse staffing data and not keeping them as required.
Review of the facility policy titled, Nurse Staffing Information, identified the facility will post the daily staffing
information for public viewing and maintain the data for a minimum of 18 months.
This deficiency was an incidental finding related to allegations contained in Master Complaint Number
OH00152382 and Complaint Number OH00151892.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure
medications were administered as ordered. This affected two (#14 and #110) of five residents reviewed for
medications. The facility census was 104.
Residents Affected - Some
Findings include:
1. Review of Resident #14's medical record revealed admission to the facility occurred on [DATE] with
diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary
disease.
Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely
alert and oriented.
Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication
to treat arthritis Humira subcutaneous (SQ) every 14 days.
Review of Resident #14's medication administration record (MAR) for [DATE] revealed Licensed Practical
Nurse (LPN) #232 documented on the MAR that Resident #14 received his Humira injection on [DATE].
There was no other documentation of the medication being administered during the month.
Interview with Resident #14 on [DATE] at 8:24 A.M. confirmed there was a nurse recently who came in to
administer the Humira injection and was not able to figure out how to do it correctly, so she threw the
medication in the trash. Resident #14 confirmed this occurred on [DATE] and stated he spoke with the
Director of Nursing (DON) regarding the situation.
Interview with the Director of Nursing (DON) on [DATE] at 10:46 A.M. confirmed LPN #232 did not provide
Resident #14 his Humira injection on [DATE] and signed off the [DATE] MAR as if she administered it. The
interview confirmed Resident #14 originally told the Social Services Director on [DATE] about what
happened and the facility started an investigation.
Interview with LPN #233 on [DATE] at 10:46 A.M. stated after identifying Resident #14 did not receive his
Humira injection on [DATE] another nurse gave Resident #14 his injection on [DATE]. The interview
confirmed there was no documented evidence Resident #14 received the injection on the [DATE] MAR or in
the progress notes.
2. Review of Resident #110's medical record revealed admission to the facility occurred on [DATE].
Diagnoses included dementia, chronic kidney disease and anxiety.
Review of Resident #110's nursing progress notes dated [DATE] revealed Resident #110 had a decline in
condition and the family gave consent for a hospice consult.
Review of a nursing progress notes for Resident #110 dated [DATE] at 4:30 P.M. revealed family was
notified of the continued health decline and Resident #110 was to be admitted to hospice in the morning.
Review of a nursing progress note dated [DATE] at 11:42 P.M. revealed Resident #110 was assessed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
with mottling to bilateral feet and uneven increased abdominal respirations. Further review of nursing
progress notes from [DATE] revealed Resident #110 was moaning and appear uncomfortable. The nurse
called the physician who ordered the narcotic pain medication morphine and/or the antianxiety medication
Ativan for comfort measures.
Review of Resident #110's medication administration record (MAR) for [DATE] revealed the resident was
ordered Morphine 20 milligrams per milliliter (mg/mL) to give 0.5 mLs by mouth every one hour as needed.
The order had a start date of [DATE] at 12:19 A.M. and ended on [DATE] at 1:07 A.M. The same order was
entered again with a start date of [DATE] at 1:33 A.M. and ended on [DATE] at 4:12 P.M. Further review of
the [DATE] MAR revealed Resident #110 received no morphine during the month.
Review of a nursing progress note dated [DATE] at 1:39 A.M. revealed the nurse was waiting on the
pharmacy to call back with authorization to pull morphine for Resident #110. The resident appeared more
comfortable and relaxed. Further review revealed Resident #110 expired on [DATE] at 1:55 A.M.
Review of a nursing progress note dated [DATE] at 5:14 A.M. revealed the pharmacist called the facility that
morning in regards to Resident #110's morphine order. The note identified the nurse informed the
pharmacist Resident #110 had expired and had waited for over an hour, and would be placed on a call back
list to receive authorization to pull the morphine from the facility's stock items. Further review of the note
revealed the pharmacist apologized and indicated it had been a long night and they had technical issues
that night and just was able to call the facility back.
Interview with Cooperate Registered Nurse #231 on [DATE] at 2:14 P.M. verified Resident #110 did not
received morphine as ordered when it was needed due to signs of discomfort.
Review of a facility policy titled, Medication Administration, dated 2013, revealed it was the policy of the
facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and
concerns of the residents. Medications should be administered only as prescribed by the provider.
This deficiency represents non-compliance investigated under Complaint Number OH00151892.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review, the facility failed to ensure
medications were stored in a safe and proper manner. This affected one (#17) of five residents reviewed for
medications. The facility census was 104.
Findings include:
Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with
medical diagnoses including subdural hemorrhage, kidney failure, and convulsions.
Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was assessed with severe cognitive impairment.
Observation on 04/02/24 at 9:31 A.M. in Resident #17's room revealed there was a cup full of medications
sitting on the bedside stand. Continued observation revealed Licensed Practical Nurse (LPN) #213 was
overheard telling Resident #17 she would leave the medications for him to take later, and LPN #213 was
then observed to moving the medication cart down the hallway away from the resident's room.
Interview with LPN #213 on 04/02/24 at 9:37 A.M. confirmed she left Resident #17's medications at the
bedside and did not observe him take the medications.
Review of the facility's undated medication administration policy revealed to remain with the resident until
medication was swallowed and do not leave medication at the bedside.
This deficiency was an incidental finding related to allegations contained in Master Complaint Number
OH00152382.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365284
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Care Center
225 W Main Street
Shelby, OH 44875
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and resident and staff interviews, the facility failed to ensure medication
administration was accurately documented in the medical record. This affected one (#14) of five residents
reviewed for medications. The facility census was 104.
Findings include:
Review of Resident #14's medical record revealed admission to the facility occurred on 06/13/19 with
diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary
disease.
Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely
alert and oriented.
Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication
to treat arthritis Humira subcutaneous (SQ) every 14 days.
Review of Resident #14's medication administration record (MAR) for March 2024 revealed Licensed
Practical Nurse (LPN) #232 documented on the MAR that Resident #14 received his Humira injection on
03/27/24. There was no other documentation of the medication being administered during the month.
Interview with Resident #14 on 04/11/24 at 8:24 A.M. confirmed there was a nurse recently who came in to
administer the Humira injection and was not able to figure out how to do it correctly, so she threw the
medication in the trash. Resident #14 confirmed this occurred on 03/27/24 and stated he spoke with the
Director of Nursing (DON) regarding the situation.
Interview with the Director of Nursing (DON) on 04/11/24 at 10:46 A.M. confirmed LPN #232 did not provide
Resident #14 his Humira injection on 03/27/24 and signed off the March 2024 MAR as if she administered
it. The interview confirmed Resident #14 originally told the Social Services Director on 03/28/24 about what
happened and the facility started an investigation.
Interview with LPN #233 on 04/11/24 at 10:46 A.M. stated after identifying Resident #14 did not receive his
Humira injection on 03/27/24 another nurse gave Resident #14 his injection on 03/30/24. The interview
confirmed there was no documented evidence Resident #14 received the injection on the March 2024 MAR
or in the progress notes.
This deficiency was an incidental finding related to allegations contained in Complaint Number
OH00151892.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365284
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F761 - Labeling of Drugs and Biologicals
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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the April 11, 2024 survey of Crestwood Care Center?
This was a inspection survey of Crestwood Care Center on April 11, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Crestwood Care Center on April 11, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.