PORT ANGELES, WA - State health inspectors documented significant violations across multiple areas of resident care at Crestwood Health and Rehabilitation Center during a July 2024 inspection, including medication management failures, food safety concerns, and inadequate monitoring of medical conditions.
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Critical Medication Safety Failures Documented
Inspectors found serious medication management violations that put residents at immediate risk. In the facility's East Medication Room, staff failed to properly date and discard expired medications, including an opened insulin pen that was undated and should have been discarded after 28 days per manufacturer guidelines.
The inspection revealed systemic failures in medication refrigerator temperature monitoring, with logs showing temperatures were recorded properly on only one day in May 2024 out of 31 days. June showed similar patterns with AM temperatures recorded just 3 out of 30 days and PM temperatures documented only 2 out of 30 days. This lack of temperature monitoring creates significant risks for medication effectiveness and resident safety.
Multiple expired medications were discovered on medication carts, including undated inhalers that expire one month after opening and 19 expired calcium acetate cards. These medication storage and monitoring failures violate fundamental pharmacy standards and place residents at risk of receiving ineffective or potentially harmful medications.
Medical Significance of Medication Violations
Proper medication storage and monitoring are critical safety measures in nursing home care. Insulin stored at incorrect temperatures or beyond expiration dates can lose potency, leading to inadequate blood sugar control in diabetic residents. Expired calcium acetate, used to control phosphorus levels in dialysis patients, can result in dangerous mineral imbalances that affect heart rhythm and bone health.
Temperature monitoring of medication refrigerators ensures medications remain effective. Many medications lose potency when exposed to temperatures outside their specified ranges, potentially rendering treatments ineffective and compromising resident health outcomes.
Dialysis Care Coordination Breakdown
A critical failure in dialysis care coordination was identified involving a resident receiving three-times-weekly dialysis treatments. The facility's own policy required regular communication with the dialysis center and incorporation of treatment information into care planning, but inspectors found the last documented communication occurred on July 5, 2024, despite the resident attending eight subsequent treatments.
This communication breakdown had serious consequences. While the facility recorded the resident's weight as remaining stable around 262-264 pounds, dialysis center records showed the resident had actually lost significant weight - from 258 pounds to 242 pounds over the monitoring period. This represented a 7.3% weight loss in 30 days and 17.1% weight loss over six months.
The facility's registered dietitian acknowledged that nursing staff should have been obtaining weekly communication records from the dialysis center and using post-treatment weights rather than facility measurements. The dietitian noted that when weight loss is identified, residents should be placed on alert for interdisciplinary team review and care plan modifications.
Impact of Dialysis Communication Failures
For dialysis patients, accurate weight monitoring is essential for determining fluid removal during treatments and assessing nutritional status. Significant weight loss can indicate malnutrition, inadequate caloric intake, or medical complications requiring immediate intervention. The facility's failure to recognize this resident's substantial weight loss delayed necessary nutritional interventions and medical evaluation.
Widespread Food Service and Temperature Control Issues
Multiple residents and family members reported serious food quality and temperature problems during the inspection. At a resident council meeting, residents complained that "hot food is cold and cold food is melted or warm," with ice cream consistently served melted rather than frozen.
One resident told inspectors, "Most of the food is garbage and that's being polite," describing meals as "served ice cold." During the inspection, investigators observed chocolate ice cream delivered as "brown soupy liquid" with only a small frozen portion remaining. Another resident's family member described facility food as "terrible," noting uncooked carrots and hard noodles.
The food service problems extended to serious food safety violations. Temperature logs for three facility refrigerators showed frequent readings above the safe 41-degree Fahrenheit threshold. The West Nurse refrigerator recorded temperatures as high as 59°F in May 2024, while the East Nurse refrigerator reached 58°F in April and July. These elevated temperatures occurred repeatedly across multiple months without proper corrective action documentation.
Food Safety and Health Implications
Food stored above 41°F enters the "danger zone" where harmful bacteria multiply rapidly, significantly increasing foodborne illness risk. For nursing home residents, who often have compromised immune systems, foodborne illnesses can lead to serious complications including dehydration, hospitalization, and in severe cases, death.
Poor food quality and unappetizing meals also contribute to malnutrition among residents. When meals are served cold, poorly prepared, or unpalatable, residents may reduce their food intake, leading to weight loss, weakened immune systems, and delayed healing of wounds or injuries.
Additional Safety and Care Concerns
Beyond these major violations, inspectors identified several other concerning issues. Safety equipment problems included a loose bed rail that moved "forwards and backwards and side to side," which a nursing assistant acknowledged could "absolutely" cause injury. The resident had positioned a commode against the rail to prevent movement, indicating awareness of the safety hazard.
Mental health service coordination failures affected residents requiring specialized psychiatric evaluation, with facility staff acknowledging missed follow-up on required assessments. One resident waited months for dentures that affected his ability to eat and enjoy food, with no evidence of proper referral coordination despite facility policies requiring such assistance.
Infection control violations included a registered nurse using scissors from her pocket during wound care without proper cleaning. The nurse later acknowledged the scissors "were considered dirty" and "should have been cleaned before proceeding to use them during wound care."
Assessment accuracy problems were also documented, with facility records incorrectly indicating a resident was on a prescribed weight-loss regimen when both the Director of Nursing and Registered Dietitian confirmed no such regimen existed.
Systemic Care Quality Implications
These violations collectively suggest systemic challenges in care coordination, staff training, and quality oversight. The combination of medication management failures, inadequate medical monitoring, food safety violations, and equipment maintenance issues indicates broader institutional problems that require comprehensive corrective action.
For nursing home residents, these combined failures create a cascade of risks affecting nutrition, medication effectiveness, safety from injury, and overall quality of life. Each violation represents a breakdown in the fundamental care standards that vulnerable nursing home populations depend upon for their health and wellbeing.
The facility must address these violations through comprehensive policy updates, staff retraining, and implementation of systematic monitoring procedures to ensure resident safety and care quality meet regulatory standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestwood Health and Rehabilitation Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
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